eHealth: Innovations and Issues

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eHealth Innovations and Issues

• Lecture 10
• Online Information Resources
• for eHealth
• Norm Archer

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Agenda

• Uses of medical data
• Evidence based medicine (EBM) for clinical
  decision making
• Sample EBM study
• Impact of EBM on professional confidence
• Impact of EBM on quality of care
• Information resources for public health

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Uses of Medical Data

• Creates the basis for historical records
• Supports communication among healthcare providers
• Anticipates future health problems (e.g.
  screening for risk factors)
• Records standard preventive measures (e.g.
  immunizations, etc.)
• Identifies deviations from expected trends (e.g.
  normal growth development of children)
• Provides a legal record
• Records providers examination results
• Records actions taken (medications prescribed,
  referrals, etc.)
• May be used to support clinical research
• Digital versus paper records??

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Evidence Based Medicine for Clinical Decision
Making

• The term and concept of EBM came to the fore in
  the early 1990s and is now a well known concept
  in many national healthcare systems.
• Originated at McMaster University
• Defined as "the integration of best research
  evidence with clinical expertise and patient
  values" (Sackett, 2000).

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EBM

• Best possible evidence from medical literature
  that can be used in decision making
• Possible approaches
• Exclusive use of original literature (huge waste
  of time for clinicians)
• Review articles (many such articles do not review
  the literature exhaustively)
• Systematic reviews (identify all clinical trials
  ever done, and perform a meta-analysis if
  appropriate)
• Sources of systematic reviews
• Cochrane Collaboration (12 centres around the
  world, including University of Ottawa McMaster
  has a neonatal review group as part of this work)
• 13 evidence based practice centres in North
  America one is at McMaster

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EBM

• Central to the practice of EBM by practicing
  physicians
• Clinical findings - history and physical
  examination
• Etiology - causes of disease including iatrogenic
  (due to action of physician or therapy
  prescribed) forms
• Clinical manifestations - how often and when a
  disease causes clinical manifestations
• Differential diagnosis - possible causes (likely,
  serious and responsive to treatment)
• Diagnostic tests - selection and interpretation
  of tests to confirm or exclude a diagnosis
• Prognosis - likely clinical course and possible
  complications
• Therapy - appropriate treatments
• Prevention - risk factors and screening
• Patient experience and meaning - empathy with the
  patient's situation
• Continuing self-improvement.

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Sample EBM Study (Vermeire et al 2005)

• Standard format for Cochrane Reviews (Abstract
  only follows)
• Background Research suggests adherence to
  treatment recommendations is low. In type 2
  diabetes, which is a chronic condition slowly
  leading to serious vascular, nephrologic,
  neurologic and ophthalmological complications, it
  can be assumed that enhancing adherence to
  treatment recommendations may lead to a reduction
  of complications. Treatment regimens in type 2
  diabetes are complicated, encompassing life-style
  adaptations and medication intake.
• Objectives To assess the effects of
  interventions for improving adherence to
  treatment recommendations in people with type 2
  diabetes mellitus
• Search strategy Studies were obtained from
  searches of multiple electronic bibliographic
  databases supplemented with hand searches of
  references. Date of last search November 2002.

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Sample EBM Study

• Selection criteria Randomized controlled and
  controlled clinical trials, before-after studies
  and epidemiological studies, assessing changes in
  adherence to treatment recommendations, as
  defined in the objectives section, were included.
• Data collection and analysis Two teams of
  reviewers independently assessed the trials
  identified for inclusion. Three teams of two
  reviewers assessed trial quality and extracted
  data. The analysis for the narrative part was
  performed by one reviewer (EV), the meta-analysis
  by two reviewers (EV, JW).
• Main results Twenty one studies assessing
  interventions aiming at improving adherence to
  treatment recommendations were included

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Sample EMB Study

• Authors' conclusions Current efforts to improve
  or to facilitate adherence of people with type 2
  diabetes to treatment recommendations do not show
  significant effects nor harms. The question
  whether any intervention enhances adherence to
  treatment recommendations in type 2 diabetes
  effectively, thus still remains unanswered.

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Example Measures of EBM Effectiveness
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Impact of EBM on Professional Confidence
(Westbrook et al 2005)

• Online evidence can help clinicians find answers
  to clinical questions. The relationship between
  confidence in answers and correctness is complex.
• Objective of the study To examine the impact of
  online evidence retrieval on clinician
  decision-making confidence and to determine if
  this differs for experienced doctors and nurses.
• A sample of 44 doctors and 31 clinical nurse
  consultants answered 8 clinical scenarios (600
  scenario answers) before and after the use of
  online evidence resources. Clinicians rated
  their confidence in scenario answers and in the
  evidence they found using the information system.

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EBM and Professional Confidence

• Prior to using online evidence, 37 of doctors
  and 18 of CNCs answered scenarios correctly.
  These clinicians were more confident (56 very
  confident or confident) in their answers than
  those with incorrect (34) answers. Doctors with
  incorrect answers prior to searching rated their
  confidence significantly higher than did nurses
  who were incorrect. After searching, both groups
  answered 50 of scenarios correctly.

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EBM and Professional Confidence

• Conclusions
• Clinician confidence increases after searching
  when they already know the right answer. It is
  difficult to know when they have found the
  answer, when searching from a position of
  ignorance.
• Doctors are more confident in their knowledge
  than nurses, but this results in overconfidence
  in wrong answers. Although doctors placed more
  confidence in the evidence they found than
  nurses, the online evidence system resulted in
  similar numbers of scenarios answered correctly
  for both professional groups.

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Impact of EBM on Quality of Care (Gosling et al
2002)

• Research study of how clinical information
  systems can be diffused and applied successfully
  to improve healthcare.
• Objective of the study To investigate the
  association between clinical team functioning and
  diffusion (awareness, use, and impact) of an
  online evidence retrieval system. To examine the
  relationships between clinical team
  characteristics and the adoption of the online
  evidence system.
• Involved 18 clinical teams in three Australian
  hospitals
• Organizational, psychological, and sociological
  research within the health care system has
  consistently identified the importance of factors
  such as hierarchy, professional subcultures,
  local communication networks, and clinical team
  functioning.

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Impact of EBM on Quality of Care

• Online Information Resources Available to
  Clinical Teams
• Medline
• Harrisons Online (textbook)
• Psychinfo
• Cochrane database
• CINAHL
• Micromedex
• EMBASE
• Interactive ECG tutorials
• Healthstar
• Full Therapeutic Guidelines
• 38 full text journals (including JAMA, BMJ, NEJM)
• CMI (consumer medicines information)
• Australian Medicines Handbook

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Impact of EBM on Quality of Care

• Findings
• Clinical team functioning was not related to
  awareness or use of the online evidence retrieval
  system.
• However, clinical team functioning was
  significantly associated with the impact of
  online evidence in terms of reported experience
  of improved patient care following system use.
  Clinicians in small teams ( 15 members) had
  higher levels of system awareness compared to
  large (gt 15) teams.

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Information Resources and Public Health
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Information Resources for Public Health

• Public health focuses on health of populations
  versus individuals
• Prevention of disease or injury by altering
  conditions or environment that puts populations
  at risk
• Explore potential for prevention at vulnerable
  points in causal chains leading to disease,
  injury, or disability
• As a societal function, supported and managed by
  government agencies

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Public Health

• Surveillance function
• Early detection of epidemics, localized outbreaks
  of disease, bioterrorism, or impacts of
  environmental pollution
• Must use constantly updated data
• Difficulties in collecting data from healthcare
  data silos with no interoperability
• Concerns about security, privacy, confidentiality
• Epidemiologists must be able to analyze and
  interpret incoming data
• Rapid response to warning signs or spikes in
  reports of diseases or conditions

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References

• Gosling, A. S., Westbrook, J. I., Braithwaite,
  J. (2003). Clinical team functioning and IT
  innovation A study of the diffusion of a
  point-of-care online evidence system. Journal of
  the American Medical Informatics Association,
  10(3), 244-251.
• Vermeire, E., Wens, J., Van Royen, P., Biot, Y.,
  Hearnshaw, H., Lindenmeyer, A. (2005).
  Interventions for improving adherence to
  treatment recommendations in people with type 2
  diabetes mellitus. Cochrane Reviews(2).
• Westbrook, J. I., Gosling, A. S., Coiera, E. W.
  (2005). The impact of an online evidence system
  on confidence in decision making in a controlled
  setting. Medical Decision Making, 25, 178-185.

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eHealth Innovations and IssuesEnd Lecture 10
Online Information Resources for eHealth Norm
Archer, Ph.D.archer_at_mcmaster.cExt. 23944