Evidence to Practice A Bridge too Far

1
Evidence to PracticeA Bridge too Far ?

• Dr Branko Cesnik MBBS, MD, FACHI

2
Knowledge and Decision Support

• You cant write all that you say
• You cant say all that you know
• You often dont know what you know until you
  need to
• You often know how to find who does know
• Knowledge arises as much from interaction as from
  Evidence

3
Knowledge Management Components
Knowledge Management
4
Knowledge

• Im not quite sure what Knowledge is, but I have
  a fair idea of how it comes into being
• When Cognition and Experience are applied to
  reliable Information (cf data) what results seems
  to be knowledge
• Therefore context, expertise and experience
  allow information to become knowledge.

5
Knowledge Principles

• Analysis
• Comparison
• Representation
• Cognition
• Experience

Informs Service / Mngmt
Knowledge

• Accurate
• Timely
• Gathered
• Ordered

Information
Data
6
Definition of Decision Support

• Access to knowledge stored electronically to aid
  patients, carers, and service providers in making
  decisions on health care.

7
Levels of Decision Support

• 1 Base level categorized information that
  requires further processing and analysis by users
  before a decision could be arrived at.

8
Levels of Decision Support

• 1 Base level categorized information that
  requires further processing and analysis by users
  before a decision could be arrived at.
• 2 Trends of patients changing clinical status and
  alerts about out of range assessment results and
  intervention strategies.

9
Levels of Decision Support

• 1 Base level categorized information that
  requires further processing and analysis by users
  before a decision could be arrived at.
• 2 Trends of patients changing clinical status and
  alerts about out of range assessment results and
  intervention strategies.
• 3 Deductive inference engines, operate on some
  knowledge base and automatically generate
  diagnostic or intervention recommendations based
  on changing patient clinical condition and the
  knowledge and inference engines in stored the
  knowledge base.

10
Levels of Decision Support

• 1 Base level categorized information that
  requires further processing and analysis by users
  before a decision could be arrived at.
• 2 Trends of patients changing clinical status and
  alerts about out of range assessment results and
  intervention strategies.
• 3 Deductive inference engines, operate on some
  knowledge base and automatically generate
  diagnostic or intervention recommendations based
  on changing patient clinical condition and the
  knowledge and inference engines in stored the
  knowledge base.
• 4 Complex knowledge management and inference
  models.Self-learning capabilities, fuzzy set
  formalism, similarity measures, confidence level
  computation.
• 1/2 DSS are data/information driven 3/4 are
  knowledge driven.

11
Development
From the EDST taskforce report
12
Part of the problem
13
AORTA

• Vendors are often looked to for the instantiation
  of EDSS, including the requisite knowledge bases
• Industry is expected to take up the
  responsibility of currency of the computerised
  version once completed it is they who are
  expected to update the electronic system as
  evidence is gathered that alters what is
  currently considered best practice.
• Not only does this present a clouded governance
  model it also raises the difficulties of
  sustainability and intellectual property
  concerns.

14
Activity in DS

• Published work is usually around more
  sophisticated EDS research
• Actual projects are less sophisticated, less
  evaluated and poorly communicated
• Australia is spending approx 220 million on EDS
  work at present (very poorly tracked)
• Enthusiast vs Knowledge Organisation (EBM, NHMRC
  etc) vs In-House controlled development

15
Current status of EDSS in Australia
Project settings by location (Sintechenko et al.
2002)
16
Current status of EDSS in Australia
Knowledge sources used in EDSS development
(Sintechenko et al. 2002)
17
The Common Questions

• Can compliance with guidelines be improved by
  delivery via an EDSS (Evidence ?)
• Is there evidence that EDS systems dont work?
• Can healthcare processes (rather than best
  practice) be improved
• Have EDS systems been shown to improve health
  outcomes?
• What factors affect uptake?

18
Improved Compliance, Evidence

• Electronic decision support systems can improve
  the quality of medical care by helping clinicians
  comply with clinical guidelines and care
  standards
• (Dennis et al. 1993 Overhage, Tierney McDonald
  1996 Tierney McDonald 1996 Lobach Hammond
  1997 Harpole et al. 1997 Evans et al. 1998
  Birkmeyer et al. 2000).

19
Improved Compliance, Evidence

• In eight studies of systems designed to provide
  therapeutic and management advice, usually based
  on a set of published guidelines, increased
  compliance with the guidelines by physicians led
  to better practice, as well as more uniform
  standards of care amongst the participating
  physicians
• (Smith et al. 1999 Thomas, Dayton Peterson
  1999 Dayton et al. 2000 Emery et al. 2000
  Kellet 2001 Knab et al. 2001 Medow et al. 2001
  Lesourd et al. 2002).

20
Is there evidence that EDS systems dont work?

• Hetlevik et al. (1999 2000) implemented a system
  of clinical guidelines for diabetes mellitus in
  general practice, with a specific electronic
  decision support system as part of the
  intervention.
• They found no clinically significant change in
  doctors' behaviour or in patient outcomes between
  control and intervention groups.

21
Evidence that healthcare processes can be
improved (without greater adherence to
guidelines?)

• A study of an electronic decision support system
  designed to increase the appropriate use of
  fibrinolysis in 894 patients with myocardial
  infarction found no significant increase in the
  percentage of patients appropriately receiving
  fibrinolysis after the system was introduced
  (Kellet 2001).
• However, time between consultation and injection
  was significantly decreased after implementation,
  and this improvement was attributed to the
  system.

22
Is there evidence that EDSS can demonstrably
improve healthcare outcomes?

• Shiffman et al. (2000) found that the
  introduction of an electronic decision support
  system with the clinical guidelines for
  management of asthma changed patterns of care,
  resulting in increased measurements of peak
  expiratory flow rate, increased administration of
  nebulised beta2-agonists and longer
  consultations.
• This led to an increase in costs per visit, but
  had no measurable effect on immediate disposition
  or subsequent emergency department visits,
  hospitalisations, missed school, or carers'
  missed work, during the seven days post visit.

23
Is there evidence that EDSS can demonstrably
improve healthcare outcomes?

• In two randomised control trials in which
  electronic clinical guidelines were assessed as
  an intervention in management of hypertensive
  patients, neither found any significant
  difference between the blood pressures of the
  control and intervention groups (Hetlevik et al.
  1999 Montgomery et al. 2000).
• Although both studies used morbidity as a primary
  outcome, neither found a significant impact due
  to the electronic decision support system.

24
What factors influence the successful uptake of
EDSS?

• The consolidation of clinical guidelines for the
  priority health issues and the incorporation of
  this guidance within the systems at an early
  stage
• A reduction in adverse events and incorporation
  of the systems within electronic clinical order
  functionality and clinical pathways
• Improvements in workflow in order to free-up
  clinician time for what is seen as a
  time-consuming process at the point of care
• The use of standard terminology
• Incentive payments to encourage the use of the
  systems, for example in health prevention and
  chronic disease management
• High levels of system availability and access
  availability of initial and ongoing training.

25
What about the Internet?
26
ProcessNHS Professionals

• 58 of GPs and 34 of Practice Nurses have been
  approached by patients with Internet healthcare
  information. 65 of the information presented by
  patients was new to GPs.
• "Almost half of GPs would consider referring
  their patients to the Internet for further
  information about their condition."

Wilson SM. Impact of the internet on primary care
staff in Glasgow. J Med Internet Res 19991E7.
27
ProcessInformation for patients

• 45-51 of patients access the Internet
• 13-26 try to find out about their condition
• This is not their preferred information source
• In the twenty-first century, patients turn to
  their GP as the main source of health
  information.

Rokade A, Kapoor PK, Rao S, Rokade V, Reddy KT,
Kumar BN. Has the internet overtaken other
traditional sources of health information?
Questionnaire survey of patients attending ENT
outpatient clinics.Clin Otolaryngol
200227526-8. Larner AJ. Use of the internet
and of the NHS direct telephone helpline for
medical information by a cognitive function
clinic population. Int J Geriatr Psychiatry.
200318118-22. Tuffrey C, Finlay F. Use of the
internet by parents of paediatric
outpatients.Arch Dis Child 200287534-6.
Cargill A, Watson AR. Sources of information on
renal conditions used by families. Pediatr
Nephrol 200217648-51. Noll S, Spitz L, Pierro
A. Additional medical information prevalence,
source, and benefit to parents. J Pediatr Surg
200136791-4.
28
Information for patients

• Ask about Internet sites used
• Give alternative search strategies
• Since information from internet websites may
  shape health beliefs and expectations of patients
  and families/carers, appropriately or
  inappropriately, it may be important for the
  clinic doctor to inquire about these searches.
• Since most would use websites suggested by the
  doctor, a readiness to provide addresses for
  appropriate sites may prove helpful.

29
Internet Conclusions

• The main use of the Internet is for Information
• It is a minority activity for patients
• It is not their preferred method
• Find out what patients have looked at
• Suggest improved search strategies
• Develop user skills in information retrieval
• Become informed about knowledge management

30
Lessons in DS development

• What type(s) of DS are you targeting and why?
• Is there an approach for each of the components?
• How is Scalability and Longevity to be achieved?
• What are the appropriate Evaluation Methodologies
  to be applied / developed ?
• To what extent does DS development draw resources
  from other areas ?
• Good Project Management and Resources

31
Governance (broad)

• Who is responsible for what?
• Industry needs a valid Business Case to ensure
  sustainability
• Standards (development and application)
• This is not New Zealand ? - Roles for Government
  (State Cwlth)
• Resources and Equity to ensure maximal benefit
• Focus on the pragmatic and the common.

32
Is EDSS a Bridge too far?

• Only if we choose to make it so
• (I still want 1 and 2!)

33
Thank you