October 15, 2007

Just the Facts, Ma’am: Evidence-based Medicine in Action
By Aggie Stewart
For The Record
Vol. 19 No. 21 P. 10

Evidence-based medicine—the idea of providing care and treatment to a patient based on the best and most current clinical research—hardly sounds like a new or radical idea. After all, isn’t that how medicine has been historically taught and practiced? Well, yes and no—but mostly no. According to the Institute of Medicine, it can take 15 to 20 years for new discoveries about care and treatment to become part of mainstream medicine. And even when the information makes its way into the mainstream, its application remains uneven.

Channeling new clinical information into mainstream clinical practice presents challenges far beyond the mere publication of research findings. An increasing number of new and traditional media outlets are pumped with research on a daily basis, making availability and access minor issues by comparison. The more major issues include the ability of clinicians to stay current with the sheer volume of clinical research and then associate it with specific patients when it’s needed—daunting issues to say the least.

Not so much for cardiologist Lonny Reisman, MD, and his team of clinicians at New York City-based ActiveHealth Management. Reisman saw an opportunity for clinical decision support technology to help enhance a clinician’s ability to employ the most current evidence-based clinical information for a specific condition in the care and treatment of one particular patient. As Reisman and his team applied it, that clinical decision support technology evolved into software known as the CareEngine System.

Now in its second generation and used by health plans, employers, and government payers, CareEngine compares continuously updated patient data on ActiveHealth’s more than 15 million members against the latest findings in evidence-based clinical literature to hone in on gaps in care, medical errors, and other quality issues. When this comparison identifies an opportunity to improve care or prevent a medical error, CareEngine sends a patient-specific clinical alert, known as a Care Consideration, to the patient and his or her treating physician. Among other enhancements, the second generation of CareEngine more easily integrates in real time with personal health records (PHRs), electronic medical records (EMRs), and health information exchanges, such as regional health information organizations and the nationwide health information network.

According to ActiveHealth Chief Medical Officer Greg Steinberg, MD, the patient data component of CareEngine distinguishes it, in part, from other clinical decision support software products. While most “decision support systems have access to [administrative] data, we currently utilize not only administrative plan data—procedure codes, diagnostic codes, drug data—we also have access to actual lab data, and not just whether a patient had a particular lab test, but the actual lab values from the test. It is my understanding that these data, by and large, are not available to most clinical decision support systems,” Steinberg explains.

The uniqueness of CareEngine’s patient data doesn’t stop here. Additional patient data also come directly from members via other ActiveHealth software products, such as its disease management program and online PHR. “This gives us data that we cannot get through other sources, mainly things like over-the-counter medications, allergies, height, weight, and smoking cessation status,” says Steinberg.

Another supplemental stream of patient data flows into the system from participating physicians. “When we send [Care Considerations] to physicians, we solicit feedback from them about the information we sent; mainly, do they agree with it or not, and if they don’t, why they don’t. When it’s relevant, that information is entered into our system,” explains Steinberg.

CareEngine’s clinical intelligence is created in daily meetings of ActiveHealth’s Clinical Development Center, a 20-person team consisting of 17 board-certified physicians, two doctorate-level clinical pharmacists, and a clinical nurse who systematically review medical literature to identify potential sources for new rules, modifications to existing rules, and justification to delete rules. According to Steinberg, the rigor of the rules is high; that is, they produce specific messages and not merely sensitive messages.

“Since we present our information to physicians, we wanted to avoid false-positive messaging,” says Steinberg. “We made a decision early on that the quality of the messages they would get from a specificity perspective would be very high, that we would not be dealing with medical issues that were controversial, that we would only deal with medical issues around which there was strong medical consensus about the fundamental validity of the issue from a clinical perspective. This makes the rigor and clinical integrity of these rules somewhat unique.”

This rigor was recently lauded by Harvard Medical School faculty physicians, who gave the clinical content of Care Considerations and ActiveHealth’s application of the evidence in the medical literature a thumbs-up review.

Steinberg describes the technology’s rules as clinically comprehensive due to the number of rules that respond to more esoteric or rare clinical issues, such as celiac disease, for which there is high-quality medical evidence for diagnosis and treatment. “The clinical comprehensiveness of the rules we have developed goes above and beyond the standard diabetes, asthma, heart failure, and coronary artery disease that most clinical decision support systems claim they have,” notes Steinberg.

For a healthcare organization such as Nashville, Tenn.,-based Vanderbilt Primary Care Group, partnering with ActiveHealth around CareEngine’s “different offering” has helped it positively impact the quality of patient care by learning how to perform tasks in new ways. Not least among these has been the way the technology has helped Vanderbilt Primary Care promote more rapid adoption of new evidence-based guidelines and better serve the more than 17,000 employees covered by Vanderbilt University’s health plan.

“We believe there’s value in a company whose core competency is to look out there and identify evidence-based medicine and vet that for a huge variety of conditions and stay on top of that,” says Jim Jirjis, MD, MBA, medical director of Vanderbilt Adult Primary Care. “It makes much more sense for one company to do that than for every single hospital to do that. So one of the values of [CareEngine] is that instead of us getting all of our ducks in a row around just one clinical condition such as diabetes, we can have hundreds and hundreds of Care Considerations that use administrative data to identify potential gaps in care.”

Vanderbilt’s partnership with ActiveHealth involved customizing CareEngine to be seamlessly integrated into Vanderbilt’s primary care workflow. Rather than both the patient and the patient’s physician receiving a Care Consideration, CareEngine sends all Care Considerations for Vanderbilt Primary Care patients to a nurse who reviews each one against the patient’s EMR to determine whether the recommendations for the patient make sense. Those that do—roughly 60% to 70%, according to Jirjis—are sent to the patient’s physician, while those that don’t are sent back to ActiveHealth.

Vanderbilt Primary Care receives more than 100 Care Considerations in monthly batches and adjudicates each batch within one week of receipt. Each batch is entered into an electronic database that feeds into the work queue of the nurse responsible for their adjudication. The nurse flags actionable Care Considerations and, for each one, contacts the applicable physician via Vanderbilt’s electronic messaging system. The physician is asked to implement the recommendation or return a message indicating why the recommendation cannot be implemented. These responses are entered into the Care Consideration database and sent back to ActiveHealth. Actionable Care Considerations are also documented in the respective patient’s EMR, as is the physician’s response.

Vanderbilt’s more than 150 physicians and residents have made a commitment to implement actionable Care Considerations. Since March, when the group began using CareEngine, it not only has made measurable improvement in the quality and safety of the care it provides but also acted on opportunities to bring its physicians up-to-date with new evidence-based guidelines, a result that Jirjis believes would have been difficult to achieve without the software.

Adopting new evidence-based guidelines recommended through Care Considerations has not been without its challenges for the group. Its experience, however, has been that the Care Considerations draw attention to evidence-based medicine issues that physicians either don’t know about or disagree with, forcing a dialogue that can actually change the practice of medicine within the group. For example, a recent debate over a Care Consideration recommending the prescription of cholesterol medication to people with diabetes, regardless of their low-density lipoprotein cholesterol level, prompted much disagreement. The group decided to hold a journal club meeting to examine and discuss the study. “Our belief is that a lot of people began to change their practice as a result,” says Jirjis.

Changes prompted by CareEngine aren’t restricted to clinical practice alone. System use has also enabled Vanderbilt Primary Care to change its process for care delivery, moving from visit-focused care to population-focused care. “Visits are only part of the care delivered to patients,” says Jirjis. “We need to move away from the idea that we have to focus our [care] processes around the visit only, because a lot of [patients] don’t come in, so you have to structure your processes around the population.”

While the use of CareEngine has inspired changes in practice and the process of care delivery, it hasn’t disrupted physician workflow, a factor contributing to physician acceptance. “We like to call this the ‘physician-engaged model’,” explains Jirjis, emphasizing that the organized and engaged physician extracts the full value from the software’s offerings. According to Jirjis, this is because Vanderbilt Primary Care makes sure all Care Considerations are adjudicated correctly and only those that have potential meaning for a specific physician’s patient are brought to his or her attention.

Nonetheless, physician acceptance didn’t occur without some initial resistance. Jirjis says the idea that “someone was telling [doctors] how to practice” was not well-received. He met the resistance by describing CareEngine as a tool that brought the most current evidence-based medicine practices to their attention, leaving it up to them to decide how to act on the information. He also presents quarterly data on the system’s specific impact on physician care delivered, such as showing care delivered that may not have been delivered otherwise or demonstrating improvement on measures of care that the group knows to be evidence-based.

And the numbers speak for themselves. “Every single target we’ve gone after, we’ve hit 90% to 95%,” says Jirjis. “Going from a 50% to 55% actual implementation of evidence-based medicine to 90%—routinely—is worth looking at.”

— Aggie Stewart is a freelance writer and editor, specializing in HIM and HIT. She also serves as consulting editor of Health Information Management Manual, 2nd edition. She can be contacted at sps_01@verizon.net.