The evidence-based advantage: the proper use of EBM in CPOE can enhance physician decision-making and improve patient outcomes

Health Management Technology, March, 2008 by Donald Denmark

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In 2001, the senior administration at NorthBay Healthcare Group decided to convert from a paper-based healthcare system to one that, as much as possible, was completely electronic. One of the foundation principles in the strategic plan was to make the choice between "best of breed" and an "integrated health record." We chose the latter and invited nine to 10 vendors to submit proposals. The steering committee reviewed each and weeded out the interfaced electronic health record systems (EHR) from the truly integrated EHRs, and, after much due diligence, chose one for installation.

The fully integrated EHR improved our ability to track physician activity for recredentialing purposes, documentation and completion of medical records. It also improved workflow and turnaround time for results. And, everyone appreciated the elimination of the notorious cursive handwriting and subsequent need for interpretation.

We now have 30 applications implemented, including five patient management systems and 25 patient care systems, and are continuing to implement more systems, such as PACS and CPOE.

CPOE and EBM

The NorthBay Healthcare System includes two hospitals--the 140-bed NorthBay Medical Center (NBMC) and the 50-bed VacaValley Hospital, a fully-accredited regional cancer treatment center (medical and radiation oncology)--occupational health services, the NorthBay Center for Pain Management, three primary care centers, and several specialty practices and other ancillary services for the community.

As the implementations proceed, we are preparing for one of the final clinical applications--computerized physician order entry (CPOE). In our approach to this phase, the physicians evaluated our current state and made significant decisions regarding our future state and the tools we would use to develop our order sets.

The decision making related to the inclusion of evidence-based medicine (EBM) and standardization/evidence-based management (EBMgt), organizational governance, CPOE vision, future state model, CPOE deployment priority, CPOE deployment approach, communication and change management.

Decisions in the respective areas would become foundational positions for moving ahead in the project. Achieving optimal patient outcomes and optimal resource utilization through the use of EBM and EBMgt was set as a priority.

David L. Sackett, M.D., and his colleagues from McMaster University, defined EBM as: "The conscientious, explicit and judicious use of the current best evidence in making decisions about the care of individual patients. The practice of EBM means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. By best available external evidence we mean clinically relevant research, often from basic sciences of medicine, but especially from patient-centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative and preventive regimens."

The application of outdated clinical evidence is a discredit to the patient and the unfiltered use of even the best clinical evidence in the absence of clinical experience and expertise generates potential risk to the individual patient.

Content and Context

EBM has at its core a voluminous body of refined clinical content that has been critically evaluated from three aspects that combine the art and science of medicine.

In the first instance, the science of EBM comes from the rigorous, objective and academic evaluation of the medical literature synthesizing relevant original clinical research and meta-analysis study results into refined, usable clinical evidence. The criteria for evaluation of the various sources have been formalized and outlined in a series of articles published in several sources and are also available online.

Secondly, we must be addressing a properly formatted clinical question for which we need an answer such that the appropriate evidence has clinical relevance. In this context the physician has identified the clinical context in which the patient presents with a defined problem requiring an intervention with an expected outcome.

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The art of medicine comes into the third component of the clinical application. The physician, through critical thinking, must decide if the EBM application is appropriate for his or her patient in the present clinical setting.

We need to look at the available evidence in the context of the patient and make sure that we are applying a recommendation that will result in making a positive difference in the outcome for the patient without increasing risk. This is the integration of EBM and EBMgt, or the integration of content and context, to maximize the use of resources in decision making and care provision for the patient.