Practice Guidelines and EHRs

Standardized clinical practice guidelines (CPGs) are evidence-based algorithms that doctors and other providers use to precisely follow patients to ensure that they receive the best possible care. The goal is to standardize care around guidelines that are most beneficial to the patient. CPGs seem like a good idea to me. It moves medicine to a higher scientific level where treatment plans are based on what has been firmly established to yield the most desirable clinical outcomes. However, as with most things, CPGs, while great in theory, have some practical constraints.

For example, a recent study published in The Journal of the American Medical Association (JAMA) determined that of the 619 cardiac guideline recommendations promulgated between 1998 and 2007, only 495 remained unaltered in 2013. Mark D Neuman, MD, MSc, of the Perelman School of Medicine in Philadelphia, and colleagues examined CPGs and concluded that there is a need for frequent re-evaluation of guideline recommendations.

Why is this? Well, there are several reasons. But, I will discuss two. One, it has to do with how the sample of patients were selected on which the research is based. It is not a simple thing to draw up a representative sample of patients from which generalizations can be made to a larger group of patients. Most research takes place in tertiary hospitals and is often lead by researchers of medical schools. That is fine and appropriate. But, the patients are often dissimilar to those seen in a primary care setting. For example, some CPGs do not take into consideration comorbid conditions.

Another reason for frequent reevaluation—in my simple way of putting it is--things change. New drugs are developed and new technologies emerge. I interpret this to be the process of continuous improvement and a good thing. A CPG cannot be “adopted and forgotten.” These guidelines need to be continuous reevaluated in light of how patients are responding to treatments and new developments in the field.

But, here is something exciting, CPGs can be integrated into the electronic health record (EHR) and its computerized physician order entry (CPOE) feature. The EHR can prompt clinicians to either adopt recommendations or indicate why they chose an alternative plan. The physician actually directing the care should always have the right to explain why they prefer an alternative method of care and to choose that care. From the EHR then we can do “big data” type studies and see what approach really does work best and continuously improve CPGs. An example of the cycle of plan/do/check/act (or adjust.) Exciting times, indeed.