Learning Objective

  1. Describe the IT considerations for evidence-based medicine and clinical practice guidelines
  2. Describe the IT considerations for value-based payment models in medicine
  3. Describe the IT considerations for care coordination and PCMH

Evidence Based Care

Evidence Based Medicine is not exactly like this

When making medical decisions, good doctors rely on both their own clinical expertise as well as external evidence (such as medical research). Early on, evidence based medicine(EBM) was described as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of the individual patient.” Evidence-based practice provides clinicians with a methodology they can use to make sound decisions about patient care. In our current patient-driven environment, EBM is defined as decision-making using a combination of clinical skills, patient values, and research evidence. “Cookbook medicine” is an unfavorable nickname for EBM.

One way to disseminate evidence-based best practices is to generate clinical practice guidelines. In 1990, the Institute of Medicine, or IOM, published, “Clinical Practice Guidelines: Directions for a New Program.” They defined clinical practice guidelines as, “systematically developed statements to assist practitioners and patients making decisions about appropriate health care for specific clinical circumstances.

Think of EMB as a set of logical if-this-then-that actions based on research. In this example of evidence based guidelines , patients who come to the Emergency Department with heart attack symptoms should be given aspirin as soon as possible, and a 12 lead electrocardiogram test performed within 10 minutes of arriving. The results of the test (and other assessments) determine what additional tests and procedures should be done to the patient.

Health IT plays a large role in EBM, resulting from the vast increase of published EBM care plans as well as EBM adherence becoming a measure of quality. Evidence-based medicine can be implemented by using clinical decision support and the electronic health record system to guide the provider’s decisions. Clinical decision support is a part of the EHR that helps health professionals make clinical decisions to enhance patient care. Clinical decision support systems are active knowledge systems that use two or more items of patient data to generate care-specific advice in real time (while the provider is with the patient).

Using the acute angina heart attack example above, as soon as a nurse, EMT, or physician documents the symptom of angina, a notification could be sent to the attending physician to click one button that immediately orders aspirin and the 12 lead ECG for the patient.

Personalized Medicine is the term used to describe EMB that relies on more unique individual characteristics such as genetic markers and the patient’s personal microbiome.

Value Based Care

Dr. Piggy got payed more for having better quality measures.

If Evidence-Based care is the optimal way to treat patients, it follows that high value care adheres to EBM guidelines. Insurance companies may want to incentivize high value care by paying more money if a provider adheres to EBM practices most of the time, or less money if the provider does not adhere to EBM practices. Models that financially incentivize providers to give better quality care (e.g. by risk of lower payments) are called value based care payment models.

Quality (as it pertains to Value Based Care) may be defined a number of ways. Quality indicators may describe processes– for example, percent of patients prescribed aspirin at hospital discharge after myocardial infarction–or outcomes, for example, in-hospital mortality rate for patients admitted for myocardial infarction. The electronic health record is important in improving quality, not just acting as a vehicle for data collection, but also providing the data required for analysis.

Care Coordination and PCMH

A Patient-centered medical home (PCMH) is a model of care where patients have an engaged relationship with a primary care provider who coordinates a cooperative team of other healthcare professionals and is responsible for the collective care provided to the patient. The critical component of an effective PCMH is the primary care doctor’s ability to coordinate the care the patient receives outside of the PCPs office.

Healthcare IT, particularly a provider’s ability to view and share patient records with other providers (called Health information exchange) plays an important role in care coordination. However, health IT has not yet satisfied the the requirements of PCMH. HIMSS reported that HIT products, especially the initial EHRs, do not provide robust enough care coordination features.