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EPS Focus Report Date [Title] Evidence-based medical practice in the 21st century An Focus Report January 2006 Focus Report > Multiclient Report > R&C Report > Contents Executive Summary ........................ 2 www.epsltd.com Introduction................................... 5 Drivers for change .......................... 6 Early adopter case studies ............. 15 • Partners Healthcare • Adventist Health System The commercial landscape ............. 18 Expert • • • • Interviews Clin-eguide ........................ Dr J A Muir Gray ................. Theradoc ........................... Zynx................................. 35 39 40 42 Previous EPS Focus Reports ........... 44 “Publishers will undoubtedly move into the area of clinical decision support, integrating their content into the workflow of the clinician. The value of reference-based content from the clinician’s perspective is falling because of the clear value-add offered by clinical decision support services.” Scott Weingarten, CEO, Zynx David Bousfield Ganesha Associates Kate Worlock Director, EPS Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Executive Summary Introduction This EPS Focus Report describes how knowledge, data and information technology are being fused together to make the process of practicing medicine simpler, more transparent and above all, more effective. The scope will include both: o the process of gathering information and identifying best practice (Evidence Based Medicine, EBM, in its strictest sense); o the methods used to present this knowledge to support decisions made by the clinician and patient (Clinical Decision Support - CDS). Drivers for change The increasing complexity of healthcare and cost of the underlying technologies needed to deliver these benefits, coupled to a prejudice that ‘latest means best’, has become the major driving force. Medical errors are now one of the leading causes of death. Based on the findings cited by a study from the US Institute of Medicine (IOM), medical errors kill some 44,000 people in US hospitals each year. The IOM emphasized that most medical errors are systems-related and not necessarily attributable to individual negligence or misconduct. The key to reducing medical errors then is to focus on improving the systems of delivering information - healthcare professionals are simply human and, like everyone else, they make mistakes – and repeated research studies have shown that system improvements can reduce the error rates and improve the quality of healthcare. Today, the sheer volume and complexity of new medical information greatly exceeds the capability of the human brain to assimilate it – either by writing about or memorizing it. This means that the gap between what doctors might do (based on an evidencebased consensus informed by best clinical practice guidelines, costs and patient outcomes) and what they actually do is wide, variable and growing. Even if information is available at the point-of-care, its usefulness and relevance is conditional on an increasingly complex data stream from the individual patient, e.g. gender, weight, age, co-morbidities, comedications, allergies and pre-operative history, plus a host of genetic and environmental factors. The replacement of healthcare systems reliant on paper-based medical records or generally localized clinical information systems by very large scale health information infrastructures centred on interoperable electronic patient record systems is now underway in many western countries. These national programs, all established within the last few years, are so extensive that they will precipitate a healthcare revolution in each country where they have been announced. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 2 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century The Electronic Health Record (EHR) seems to be the ideal point-of-care solution for most clinicians to simultaneously improve quality and enhance operational efficiency. However, for various reasons, EHR adoption has been slow in the US and in the UK, particularly for physicians in small practices. Early adopter case studies Partners Healthcare Partners’ information systems budget was $92.3m in 2002, monies that have been used to develop a number of knowledge assets, such as a suite of medication decision support systems which include expert systems for tailoring drug dosage regimens to specific patient groups such as the aged or cases of renal insufficiency, order sets for radiology, and outpatient decision support. Partners sees its current challenges as largely being driven by interoperability, knowledge management and performance issues. To combat these problems, Partners is investing in the development of a knowledge management system. Adventist Health System (AHS) AHS’ motivation for undertaking its ‘evidence-based practice’ program has been the improvement in quality of outcome and reduction of costs. Using Cochrane Library material, speciality medical Society consensus views and data from the national guideline clearing house (Agency for Healthcare Research ad Quality - AHRQ) as a starting point, medical literature surveys are carried out in-house to identify best practice, but the resource intensive work of structuring this information into clinical pathway guidelines and order sets has been outsourced to Zynx. The commercial landscape Publishers and software developers have reacted to the opportunities presented by healthcare informatics by developing a range of products that provide support across a range of applications: o Simple tools for linking and aggregating existing reference materials (e.g. Thomson’s InfoButton provides a simple link from an electronic health record to reference material stored in its MicroMedex database system); o Sources of reference to evidence-based medical practices (e.g. PatientKeeper, Infotriever, ClinicalResource@Ovid); o Adaptation of EBM sources to specific point-ofcare applications (e.g. the Cochrane Library, Clinical Evidence, InfoPOEMS, Bazian, Zynx, Clin-eguide, TheraDoc); o Adaptation of EBM sources, outcome and cost information to create higher level management Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 3 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century tools (e.g. Thomson’s Logic Modules (MLMs). Micromedex Medical The changing shape of the marketplace Healthcare should be an information-driven business, but until now this has not been the case. As articulated by J A Muir Gray, founder of the Centre for Evidence-based Medicine (CEBM) in Oxford, ‘The application of what we know will have a bigger impact on disease than any drug’. And yet there can a 20year gap between scientific discovery and the routine application of those discoveries in clinical practice (AHRQ, 2001). The investment in networked healthcare systems is now a national priority in many countries of the world. This alone will bring about significant reductions in the cost and improvements to quality. But the force for transformational change will be the large-scale implementation of the evidence-based practice of medicine. Drug information and order sets will commoditise most rapidly. Most of the core information is within the public domain already and as formularies and clinical best practice become determined by efficacy and cost rather than habit, there will be little scope for differentiation other than on speed of update, comprehensiveness and functionality. The creation of national networks of linked EHR repositories (the US National Health Information Network, NHIN) and the UK’s NPfIT Connecting for Health Spine) will create an enormous opportunity for further commercial development when integrated with the prescription and payer information. Expert interviews Clin-eguide: Carol Leighton, Director, Editorial & Product Manager Dr J A Muir Gray, Programme Director of the NHS National Electronic Library for Health (NeLH) and founder of the Centre for Evidence-Based Medicine Theradoc: Stan Pestotnik, CEO Zynx Health: Scott Weingarten, President and CEO Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 4 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Introduction: what is evidence-based medicine and why is it important? “Medicine used to be simple, ineffective yet relatively safe. Now it is complex, effective and potentially dangerous”1. It has also become increasingly expensive and threatens to gobble up an increasingly large fraction of GDP in many develop countries. In the closing years of the last century several governments sought to tackle these emerging problems by investing heavily in IT development programs designed to rationalize the healthcare process and make it more accountable to the taxpayer and the consumer. This EPS Focus Report describes how knowledge, data and information technology are being fused together to make the process of practicing medicine simpler, more transparent and, above all, more effective. Key to the success of these initiatives will be the consolidation of evidence-based medical processes and guidelines, and the structuring of this information so that it can be easily integrated into workflow to provide automated clinical decision support. The report takes a broad view of the definition of evidencebased medicine – the scope will include both the process of gathering information and identifying best practice (EBM in its strictest sense) and the methods used to present this knowledge to support decisions made by the clinician and patient (CDS). The overlap is clear from popular definitions of the two terms: ‘Evidence-based medicine (EBM) is a medical movement based upon the application of the scientific method to medical practice, including longestablished existing medical traditions not yet subjected to adequate scientific scrutiny. According to the Centre for Evidence-Based Medicine, “evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”’ ‘Clinical decision support (CDS) refers broadly to providing clinicians or patients with clinical knowledge and patient-related information, intelligently filtered, or presented at appropriate times, to enhance patient care. Clinical knowledge of interest could be simple facts and relationships for managing patients with specific disease states, new medical knowledge from clinical research and many other types of information.’ Implicit in our interpretation of these definitions is the fact that both EBM and CDS systems are created within a healthcare system that is run to a budget – which will influence the choice of drugs, procedures and care available to an individual patient – and that choices will in future be driven by the consumer. In other words, these definitions are still evolving in response to a number of market forces. The purpose of this report is to highlight and describe the changes that have had and will in future have a bearing on commercial opportunities (and threats) for STM publishers. 1 From Sir Cyril Chantler’s Hollister Lecture at Northwestern University, Illinois in 1999 Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 5 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Drivers for change Background All is not well with many western healthcare systems. The most visible symptom, as observed through the lens of newspaper headlines, is that costs are increasing much faster than inflation. For example, by 2010 it has been projected that healthcare costs will account for over 18% of US national income, and yet over 50m citizens (about 16% of the population) will still remain uninsured. Figure 1: Per capita health expenditure and GDP As Figure 1 shows, the per capita expenditure is lower for most OECD countries than it is in the US, but other statistics show that the rates of increase in health spending, as a percentage of GDP, are comparable to the US. Why is this happening at a time when medical knowledge and technological know-how are at an all-time high? Costs, errors and information overload It is true that cost increases are in part caused by the successes of modern medicine in extending our longevity and consequently the length of time for which we shall each require healthcare. However, it is the increasing complexity of healthcare and cost of the underlying technologies needed to deliver these benefits, coupled to a prejudice that ‘latest means best’, that has become the major driving force. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 6 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Figure 2: US health costs by source Source: Centers for Medicare and Medicaid Services More disconcerting perhaps, and certainly less well ‘advertised’ by the news media, is the impact of this complexity on clinicians’ performance. A report published by the US Institute of Medicine (IOM) in 1999 found that medical errors were one of the leading causes of death. Based on the findings cited by this study, medical errors kill some 44,000 people in US hospitals each year. Other surveys reviewed by IOM put the number much higher at 98,000. Even using the lower estimate, more people die from medical mistakes each year than from road accidents, breast cancer, or AIDS. Subsequent reports have confirmed that neither is the problem getting smaller, nor is it restricted to North America. Not surprisingly, the customers are revolting. For example, a new international survey supported by The Commonwealth Fund found that one-third of US patients with health problems reported experiencing medical mistakes, medication errors, or inaccurate or delayed lab results – the highest rate of any of the six nations surveyed. While sicker patients in all countries reported safety risks, poor care coordination, and inadequate chronic care treatment, with no country deemed best or worst overall, the US stood out for high error rates, inefficient coordination of care, and high out-of-pocket costs resulting in forgone care. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 7 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Rising costs and falling quality – is informatics part of the solution? At the dawning of the scientific method Sir Francis Bacon was able to declare that, ‘Reading maketh a full man; conference a ready man; and writing an exact man. And therefore, if a man write little, he had need have a great memory.’ Today, the sheer volume and complexity of new medical information greatly exceeds the capability of the human brain to assimilate it – either by writing about or memorizing it. This means that the gap between what doctors might do (based on an evidence-based consensus informed by best clinical practice guidelines, costs and patient outcomes) and what they actually do is wide, variable and growing. Many factors contribute to this situation. Doctors are inundated with new, often poorly evidence-based and sometimes conflicting clinical information. This is particularly serious for a generalist working in primary care, with over 400,000 articles added to the biomedical literature each year. Indeed, a recent medical study has shown that on average it takes as many as twenty years for new medical knowledge to be incorporated into clinical practice2. Figure 3: Translational medicine – from bench to bedside in 20 years Source: Balas and Boren (see footnote) 2 E. A. Balas & S. A. Boren. Managing Clinical Knowledge for Healthcare Improvement. Yearbook of Medical Informatics 2000, 65-70 Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 8 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Another study warns that many claimed research findings amount simply to accurate measures of the prevailing bias or are otherwise incorrect3. Even if this information were available at the point-of-care, its usefulness and relevance is conditional on an increasingly complex data stream from the individual patient, e.g. gender, weight, age, co-morbidities, co-medications, allergies and preoperative history, plus a host of genetic and environmental factors. The availability of laboratory tests, drugs and clinical procedures will be limited by a hospital’s formulary, or by the patient’s level of health insurance. The main drivers for healthcare reform are costs, the quality of medical care and the patient or consumer’s perception of value. Stated more simply, there is currently no basis for the patient, physician, healthcare provider or payer to make informed choices based on knowledge of outcomes, performance or cost. In other words, ‘evidence-based medicine’ must currently be regarded as something of an oxymoron. That said, this is precisely why governments across the world are investing in the transformation of healthcare financing and installation of national infrastructures for informatics support. We all want the best healthcare, but can we afford it? The world’s healthcare systems can be categorized on their financial basis into four main groups4. National health schemes such as those found in Britain or Sweden cover everybody and have a single payer who pays for the care at a salaried or capitated5 rate. In The Netherlands, Australia, Canada, and France, national schemes cover everybody and there is a single payer but payment is in the form of a fee for each service provided. Mandatory insurance (as in Germany, Brazil, Japan, Malaysia, and Singapore) again covers everybody but has multiple sickness funds or insurance carriers and provides care through a mixture of salaried public providers and private providers paid a fee for each service. Voluntary insurance (as in the United States or South Africa) does not offer cover to everybody and has many payers and providers and different systems of payment and delivery. Even the best of these systems are essentially ‘open loop’, in that payers receive little feedback about the quality of care they are purchasing and consequently allow consumer demand and technological innovation to drive spiraling costs. Few schemes manage to aligned physician payment incentives in a way that effectively delivers a consumer-driven healthcare system. However, there are strong signs that this will happen over the next 5-10 years. ‘Managed care’ was introduced in the US in the early 1900s as an alternative to indemnity insurance, and was one of the first attempts to build a more balanced business model. Managed care is a broad term and encompasses many different types of organizations, payment mechanisms, review mechanisms and 3 Ioannidis JPA (2005) Why Most Published Research Findings Are False. PLoS Med 2(8): e124 Richard Smith, BMJ 1997;314:1495 5 The method of payment in which the provider is paid a fixed amount for each person served no matter what the actual number or nature of services delivered. 4 Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 9 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century collaborations, but in essence it provides a gatekeeper function between payers, providers and patients by creating tools with which to review medical necessity, create incentives to use cost-effective providers, and manage individual cases over time so that outcome/cost benefits can be used more effectively to shape future best practice. In its initial form, managed care struggled to achieve significant market share, but during the presidency of Ronald Reagan government support enabled managed care to become, albeit briefly, a means to control Medicare payouts. Indeed, the new approach spread fairly quickly to the health insurance industry in the private sector. The rise of managed care has been credited with the lessened rate of medical inflation seen between 1993 and 2000 in the US, which during these years was little more than inflation. However, this effect has ended and US medical inflation is once again two or three times the rate of overall inflation. ‘Disease management programs’ and ‘consumer-directed health plans’ are just two of the new strategies being used in the US and in some European countries to combat increasing costs and to insert some rules of economics between supply and demand. Managed care plus - more management and more care Disease management is a strategy for healthcare service delivery employing interdisciplinary clinical teams, real-time data analysis, and well-defined, cost-effective technological procedures to improve the health outcomes in patients with specific diseases. Unsurprisingly, the successful implementation of disease management programs requires sophisticated decision-support systems which can encapsulate precise guidelines reflecting current clinical best practice, and which can adapt to patient-specific needs such as the existence of co-morbidities whilst simultaneously capturing the detailed cost information needed for reimbursement purposes. Even this still doesn’t completely close the feedback loop – the consumer needs to become more aware of the costs of medical treatment. Consumer-directed health plans are currently an experiment in the US, but provide a clear signpost to government thinking about the consumer’s future financial responsibility and involvement in healthcare choices. These health plans can take the form of a two-part health insurance program consisting of a high-deductible health insurance policy and a tax-free medical savings investment account (MSA) set up to fund medical costs not covered by the policy. MSAs benefit individuals with low healthcare costs, who can take advantage of the low-premium, high-deductible insurance policies, but other multi-tiered schemes are emerging to meet a wider variety of needs. In addition to creating financial incentives to encourage patients to make cost-conscious choices, new information tools are emerging to provide consumers with comparative quality information about hospitals and physicians and outcome statistics associated with specific diseases and conditions6. 6 See http://www.hospitalcare.hhs.gov and http://www.chooseandbook.nhs.uk/ Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 10 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Together with disease management, consumer-directed health plans create an environment where cost and performance can and will drive the rapid evolution of healthcare practices over the course of the next decade. In particular it is likely that insurers will increasingly move away from the old capitated schemes in which the healthcare provider was paid a flat fee per member per month, to these that capture more of the individual patient’s circumstances and pay for performance. This stratification of consumers will eventually result in the demise of mutual insurance schemes for healthcare funding and place a strong onus on the customer to keep fit and knowledgeable about their health. Investment in IT infrastructure – a cure for all ? Since the original IOM study in 1999, there has been much analysis of the failings of health systems and the need for reform. From a US perspective, Blackford Middleton, Director of Clinical Informatics R&D at Partners Healthcare in Boston MA, has summarized some of the main issues arising: Medical error, patient safety, quality and cost issues 1 in 4 prescriptions taken by a patient are not known to the treating physician; 1 in 7 admissions result from missing ambulatory/outpatient information; 1 in 5 lab and x-ray tests are ordered because originals can not be found; 40% of outpatient prescriptions are unnecessary; Patients receive only half of recommended care. Providers have incomplete knowledge of their patients Patient data was unavailable in 81% of cases in one clinic, with an average of 4 missing items per case. 18% of medical errors are estimated to be due to inadequate availability of patient information. Figure 4: Where adverse events originate Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 11 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century In the UK, an analysis of the NHS has shown that during 200304, 885,832 adverse incidents and near misses were recorded. A later follow-up survey found that for 2004-05 there were around 974,000 reported adverse incidents and near misses. The IOM emphasized that most medical errors are systemsrelated and not necessarily attributable to individual negligence or misconduct. The key to reducing medical errors then is to focus on improving the systems of delivering information healthcare professionals are only human and, like everyone else, they make mistakes – and repeated research studies have shown that system improvements can reduce the error rates and improve the quality of healthcare. A common focus for these studies is the point at which a clinician makes a decision to prescribe a drug, or order a diagnostic test, increasingly via some form of PDA. The collective acronym for this activity is ACPOE (ambulatory computerised physician order entry) and the results of one such study are shown in Figure 5. Figure 5: Cost savings estimated for Ambulatory Computerized Physician Order Entry The replacement of healthcare systems reliant on paper-based medical records or generally localized clinical information systems by very large scale health information infrastructures centred on interoperable electronic patient record (electronic health records, EHRs) systems is now underway in many western countries. Some countries are well-advanced in the implementation of electronic patient records and national network infra-structures - particularly in Denmark, Finland, Norway and Sweden,but most are just getting off the ground. Governments in France, Canada, Australia, England, New Zealand and the USA have only recently committed to deliver national electronic networks and medical record systems to support healthcare delivery for their populations, typically by the end of the current decade. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 12 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Figure 6: Healthcare informatics technology networks Source: McKesson’s electronic health record roadmap whitepaper Impact of national programs These national programs, all established within the last few years, are so extensive that they will precipitate a healthcare revolution in each country where they have been announced. In 2004, the European Commission took a lead in publishing an action plan for a European e-Health Area. The plan specifies a sequential set of actions to be taken by EU member states over the period 2004-2010. The investment committed in at least one case (the NHS in England on its wholly publicly-funded Connecting for Health program) is unprecedented. Some other countries, including France, are also funding their programs exclusively with public money. Other governments, including Australia and Canada, are promoting collaborations between the private and public sectors. Finland's FinnWell program, whose principal goal is to improve healthcare, is also designed to promote healthcare technology development and create opportunities for Finnish business and research especially in the telemedicine sector. The Electronic Health Record (EHR) seems to be the ideal point-of-care solution for most clinicians to simultaneously improve quality and enhance operational efficiency. However, for various reasons, EHR adoption has been slow in the US and in the UK, particularly for physicians in small practices (see Figure 7). Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 13 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Figure 7: EHR adoption rates across the US healthcare system The reasons behind this slow adoption include cost; immature technology; difficulty with assessing product quality and appropriateness for a particular practice; incomplete interoperability with other necessary systems; a misalignment of incentives (providers bear the costs and others reap the benefits). However, within the past year, the rate of adoption has begun to increase. Figure 8: International EHR adoption rates Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 14 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Early adopter case studies – Partners Healthcare and Adventist Health Partners HealthCare Partners HealthCare was founded in 1994 by Brigham and Women's Hospital and Massachusetts General Hospital in Boston. A not-for-profit organization, Partners is an integrated healthcare system that offers patients a continuum of coordinated high-quality care. The system includes primary care and specialty physicians, community hospitals, the two founding academic medical centres (Harvard Medical School and the Dona Faber Cancer Institute), specialty facilities, community health centres, and other health-related entities. Partners has 3,200 beds, 135,000 admissions and 2.3m outpatient visits per year. It is one of the most active organizations in the innovative use of informatics in healthcare in the world. Partners’ information systems budget was $92.3m in 2002, monies that have been used to develop a number of knowledge assets, such as a suite of medication decision support systems which include expert systems for tailoring drug dosage regimens to specific patient groups such as the aged or cases of renal insufficiency, order sets for radiology, and outpatient decision support. Partners also hosts the Research Patient Data Registry, comprising over two million health records collected since the mid-1990s which incorporates not only stored data from lab tests, but also details of medicines prescribed (IDX billing records) and precise definitions of the illnesses diagnosed (ICH-9 disease classification codes). Partners sees its current challenges as largely being driven by interoperability, knowledge management and performance issues. It has seven home-grown and two commercial ambulatory computerized physician order entry (ACPOE) systems. Clinical knowledge capture is limited, and coding of these data is often of a proprietary, non-scaleable nature. Updating and maintenance processes are poorly developed and resource-constrained. Figure 9: Partners knowledge asset management strategy Source: Partners Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 15 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century To combat these problems, Partners is investing in the development of a knowledge management system. This system will: facilitate organisational control and improvement as judged by a series of quality and safety metrics; support the analysis of clinical performance data in order to understand where knowledge deficits are preventing the achievement of performance goals; provide support for asynchronous authoring and links to key internal as well as commercial and academic reference sources; support the collection and integration of clinical data sets both from a patient-centric and populationcentric (epidemiological) perspective; incorporate the full gamut of gene diagnostic data which is rapidly becoming the norm and which will enrich the clinical understanding of inter-patient variability considerably. Adventist Health System Adventist Health System (AHS) is the largest Protestant healthcare organization in the US and has hospitals in 13 states, 42,000 employees and a total revenue of $4.1 billion (2005). With its 6,234 inpatient beds and 6,634 physicians, AHS sees four million patients annually. AHS’ motivation for undertaking its ‘evidence-based practice’ program has been the improvement in quality of outcome and reduction of costs. Like Partners, the program focuses heavily on physician involvement from the start. Using Cochrane Library material, speciality medical society consensus views and data from the national guideline clearing house (AHRQ) as a starting point, medical literature surveys are carried out in-house to identify best practice, but the resource intensive work of structuring this information into clinical pathway guidelines and order sets has been outsourced to Zynx (Zynx was interviewed for this Focus Report – see page 42). Adventist Health took great care to involve staff from the outset in developing the systems and incorporating the implementation process into key management practices. Beginning in 2000, each hospital CEO had specific clinical accountabilities associated with the scheme included as a component of their overall corporate performance-related objectives. For 2000-2004 this component amounted to 10% of total and in 2005 this had increased to 25%. Throughout the implementation period there was a commitment to collect and measure severity-adjusted outcomes and share this data with physicians on a regular basis. It is claimed that this approach has been crucial in winning over the physicians and dispelling the ‘cookbook’ stigma often associated with evidence-based practice. The improvements in care and outcome have been well documented – see Figure 10. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 16 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Figure 10: Improvement in outcomes for pneumonia patients using proprietary pathway guidance tools as compared to controls Source: Ann. Epidemiol (Elsevier). 2004, 14, 669-675 Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 17 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century The commercial landscape The concepts of evidence-based medicine and clinical decision support are brought together in the graphic below created by Tonya Hongsermeier, Corporate Manager of Clinical Decision Support and Knowledge Management, at Partners HealthCare. This spectrum can be used to distinguish between different vendors and their products on the basis of where their products are embedded into the healthcare workflow and the types of functionality they support. Figure 11: Levels of complexity and function in evidence-based medical practice The left of the spectrum is dominated by companies that acquire, aggregate and initiate the consolidation of knowledge. The middle ground is dominated by companies that take evidence of best practice and structure it into order sets, clinical guidelines and care pathways using a fairly rigid rule set to shape and confine decision-making. Finally come the developers of expert systems which combine evidence, real time patient data and flexible logic to create diagnostic support systems. Some specific examples of these different approaches are reviewed later in the report. Blackford Middleton, also from Partners and source of much of the evidence for cost savings derived from healthcare informatics, has shown how these cost savings increase dramatically as the complexity and sophistication of clinical decision support for prescribing and diagnostic performance is increased – see Figure 12. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 18 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Figure 12: Savings derived from basic, intermediate (INT) and advanced (ADV) support for prescribing (Rx) and diagnosis (Dx). ADE = adverse drug event reduction Source: Blackford Middleton A growing hierarchy of increasingly sophisticated EBM/CDS tools Publishers and software developers have reacted to the opportunities presented by healthcare informatics by developing a range of products that provide support across the spectrum of applications described by Hongersmeier and Middleton. This product range includes: Simple tools for linking and aggregating existing reference materials; Sources of reference to EBM practices; Adaptation of EBM sources to specific point-of-care applications, such as: o Order sets7 used in ambulatory computerized physician order entry; o e-prescribing;8 o Clinical guidelines used to assist diagnosis and the management of a specific condition.9 Adaptation of EBM sources, outcome and cost information to create higher level management tools, such as: o Clinical, careflow or workflow pathways;10 o Disease management support;11 7 Definition: An order set is a predefined list of actions that has been utilized in the standard care of hospitals for many years typically on admission or after diagnosis. 8 Covered in the recent EPS Focus Report on Drug Informatics 9 Definition: Clinical guidelines briefly identify, summarize and evaluate the best evidence and most current data about prevention, diagnosis, prognosis, therapy, risk/benefit and cost/effectiveness. Then they define the most important questions related to clinical practice and identify all possible decision options and their outcomes. Thus, they integrate the identified decision points and respective courses of action to the clinical judgment and experience of practitioners. Many guidelines place the treatment alternatives into classes to help providers in deciding which treatment to use. 10 Clinical Pathways (aka Careflow or Workflow Pathways) are structured, multidisciplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management, clinical audit and also financial management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc) with a specific condition over a given time period, and include progress and outcomes details. Clinical Pathways aim to improve, in particular, the continuity and co-ordination of care across different disciplines and sectors. 11 Disease Management is a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant. Disease management Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 19 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century o Predictive tools and disease. What follows is a brief description of a series of products arranged along this scale of increasing sophistication and complexity. Some specific examples Linking InfoButtons (a generic term) take the context of a clinician’s user session in a clinical information system (e.g. the task context such as review of lab results) and link this to the main concept of interest (medications, problems, lab tests), placing this in the patient context which includes factors such as age or gender to identify a textual answer within a content reference resource of some sort. Figure 13: Thomson InfoButton linking an EHR to MicroMedex Source: Thomson For example, Thomson’s InfoButton provides a simple link from an electronic health record to reference material stored in its MicroMedex database system. Elsevier uses a similar functionality in its iConsult product linking with MDConsult, as emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies, and evaluates clinical and economic outcomes on an ongoing basis with the goal of improving overall health. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 20 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century does Wolters Kluwer for Skolar. HL7, an organization charged with the development of informatics-driven process standards across healthcare, is now chairing negotiations between healthcare providers including Partners HealthCare, Intermountain Health, Cedars Sinai and Columbia, software vendors including IDX, Epic and Eclipsys, and publishers including Thomson, Elsevier, Wolters Kluwer and Hearst, aimed at creating a common programming interface so that content from each of these sources can be integrated into a single display when linking out from an electronic health record. Aggregators You don’t need to create content to be a player. Several content aggregators play a prominent role in the EBM/CDS market place. Access to clinical references, such as drug guides, dictionaries, drug interaction guides, evidence-based medicine modules, clinical guidelines, and calculators, can all help physicians make more informed clinical decisions. Much of the value in having access to such sources can be generated by providing seamless interoperability between the different content sources. An example of this is PatientKeeper which has developed a suite of products which combine patient information with the wealth of clinical knowledge available in medical reference material from a wide variety of third party sources, and delivers the search results to a PDA. Figure 14: PatientKeeper’s basic architecture Source: PatientKeeper A second example, recently purchased by Wiley, is Infotriever. This service also offers a mix of proprietary and third party content sources, but includes its own current awareness service, InfoPoems. Claiming to be the only database system of filtered, synopsized, evidence-based information, the Infotriever search engine allows the user to simultaneously search, via keyword, the following databases and reference sources: InfoPOEMs, synopses of recent research; Cochrane Database abstracts; Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 21 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Evidence-based Practice Guideline summaries; Clinical Decision Rules; Diagnostic test calculators (unique combinations of symptom -> disease -> test); H&PE (Haematocrit & Partial Exchange Volume) calculators (unique combinations of symptom -> disease -> test); The complete 5-Minute Clinical Consult Summaries; The complete 5-Minute Clinical Consult Photos; ICD-9 lookup tool, most commonly used disease classification codes. ClinicalResource@Ovid is another aggregated resource which provides one-click access to important clinical resources ‘recommended by physicians for physicians’. Assessable knowledge resources include: Clin-eguide (evidence-based diagnosis and treatment guidelines); 5-Minute Consult Database; Ovid MEDLINE; Drug Facts and Comparisons; A to Z Drug Facts; Review of Natural Products; MedFacts (English and Spanish patient handouts); National Guideline Clearinghouse; McKesson Patient Handouts. From these three examples it is clear that, from the perspective of the end-user, there is still much that can be done to facilitate the broader integration of sources beyond the normal proprietary boundaries. Given that there is also much redundancy across the reference products cited here, a process of selection-of-the-fittest will occur – the evidence-based approach leaves little opportunity for the survival of diversity. User interface design will also be a key factor in making sense of search results channelled from so many different sources. It will be interesting to watch development of InfoButton technologies alongside these more traditional aggregator services. Thomson has perhaps the strongest links with the US standards bodies, but Wolters Kluwer has a wider range of assets in this area. Strong alliances with EHR vendors (to secure sales channels) and the development of consumer branding will also be factors that will influence the distribution of market share between the major players in this field: Thomson, Wolters Kluwer and Hearst. Tertiary content providers: No one can keep up-to-date with the relevant evidence in their field of interest. The major bibliographic databases cover less than half the world's literature and are biased towards English language publications. Of the evidence available in the major databases, only a fraction can be found by the average searcher – incidentally providing a niche for specialist search technologies and services, such as Bazian. Textbooks, editorials and reviews which have not been prepared systematically may be unreliable. Much evidence is unpublished, but unpublished evidence may be important. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 22 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century More easily accessible research reports tend to exaggerate the benefits of interventions12. There is therefore an important role to be played by publishers expert in distilling and publishing evidence-based consensus reviews of medical practice and progress. Figure 15: Reviews and protocols published by the Cochrane Database of Systematic Review Source: Cochrane The Cochrane Library, now published by Wiley, is probably the leading brand in this field - though there are still many contenders who will vie for this position in the coming years. Published on a quarterly basis and made available both on CDROM and online, it is the most comprehensive source of reliable evidence about the effects of health care and is frequently cited as the major component for many derivative products such as BMJ’s Clinical Evidence, also available via NHS Direct branded as Best Treatments13. The five steps involved in creating EBM reviews are: convert information need into answerable questions; track down the best evidence to answer the question; critically appraise the evidence for its validity and usefulness14; integrate appraisal results with clinical expertise and patient values; evaluate outcomes. Those who prepare the reviews are mostly healthcare professionals who volunteer to work in one of Cochrane’s many Collaborative Review Groups, with editorial teams overseeing the preparation and maintenance of the reviews, as well as the application of the quality standards. 12 See for example, Ioannidis JPA (2005) Why Most Published Research Findings Are False. PLoS Med 2(8): e124 13 http://www.besttreatments.co.uk/btuk/home.html, see also http://www.nelh.nhs.uk/ 14 See http://www.cebm.net/levels_of_evidence.asp#levels for details as the methods used to assess evidence. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 23 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Other players in this field15 include Clinical Evidence (BMJ), the journal Bandolier (CEBM), InfoPOEMS (Wiley), FirstConsult and Bazian. Figure 16: The Bazian product pipeline Source: Bazian Clinical Evidence and Bandolier aim to cover common or important clinical conditions seen in primary and hospital care. To decide which conditions to cover they review national data on consultation rates, morbidity and mortality, take account of national priorities for healthcare such as those outlined in the UK National Service Frameworks and in the US Institute of Medicine reports, and take advice from generalist clinicians and patient groups. InfoPOEMs (Patient Oriented Evidence that Matters) point out valid, relevant research via daily e-mail synopses each working day. InfoPOEMS editors review more than 1,200 studies monthly from 100+ medical journals, presenting only the best as InfoPOEMs - only about 1 in 40 studies qualifies. Bazian is also a leading global provider of evidence-based healthcare solutions. Their branding is based on quality – they claim to assess, analyse and synthesize clinical research from around the world to reveal what works and what doesn’t with an accuracy and clarity previously unavailable thus enabling their clients do ‘what was previously almost impossible’. There is the emergence of an industry here which is generating evidence-based reviews, but the reality is that access (or rather lack of it) to the primary content is what prevents the group from consolidating to a single high quality supplier. The editorial process is highly skilled (but not irreproducible) and the volume required for reasonably comprehensive coverage (say 10-20k core articles) not hugely onerous to maintain provided the content can be re-used in a variety of spin-off products. Access via vendors to the major distribution channels will again be an important variable in the equation for survival. Equally important will be investment in metadata standards which enable evidence-based content to be re-used in a wide variety of applications, such as order sets and clinical guidelines. The point about evidence-based practice is that there is only needs to be one version of the text. This is not the case at present, but the future will be about function as content value per se becomes commoditized. The principal user of EBM/CDS products need not be a clinician – and consumer branding of evidence-based products is a new frontier to watch. For example, when patients, caregivers and 15 See http://www.openclinical.org/ebm.html for a full list of alternative sources Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 24 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century providers face critical treatment choices, NexCura, a recent Thomson acquisition, can deliver the timely, targeted, evidence-based and personally relevant knowledge they need. This individualized information is made available through the NexProfiles treatment option tools. These tools are available for over 30 specific conditions, including various types of cancer as well as cardiovascular and pulmonary conditions. As hospitals increasingly market themselves in terms that address consumers’ concerns about treatment quality, Intel Inside branding may become a marketing tactic used by leading EHR vendors and EBM publishers. Order sets, clinical guidelines and care pathways Order sets provide a highly structured set of decision points to be completed by a nurse or physician on admission, during the process of diagnosis and treatment of a particular disease, and on discharge. In essence, order sets distil a well-characterized set of actions and considerations that apply to a well-defined patient population. Order sets usually take the form of a simple list with links back to supporting evidence and details of exceptional circumstances. They can be easily customized to allow a healthcare provider to choose common orders for a particular disease state or circumstance according to best practice or other local criteria. The EHR itself may recommend order sets using a simple set of rule-based conditions or as the result of other clinical information being entered into the EHR. Alternatively, the order sets may simply be available for use as a passive check list by the ordering physician or nurse. Zynx, recently purchased by Hearst from Cerner, is a leader in this field. Zynx begins by developing clinical summaries and distil best practices based on rigorous reviews of the peerreviewed literature much in the same way as described earlier in this section. Within each order set module, evidence synopses cover a range of topics from performance improvement, to treatment, to discharge planning. Each synopsis includes a clinical recommendation, rationale statements, and complete references with links to abstracts and full-text articles (when available) for more comprehensive literature reviews. In some cases, clinical evidence may satisfy topic inclusion criteria but cannot be directly translated into order items, so a reminder item is embedded into the order set, and a hyperlink to the evidence page is provided. For example, a topic regarding the use of a prediction rule to guide triage decisions for patients with community-acquired pneumonia cannot be translated into an order item, but an order set reminder item can serve as a timely evidence-based reminder to the physician at the point of care. Reminder items are created only for topics that are presented in the evidence. Order set section names are internally standardized healthcare concepts that are used to group order items into the following top-level organization: Condition, Vital Signs, Activity, Nursing Orders, Diet, IV Fluids, Medications, Laboratory, Diagnostic Tests, Specialty, Consults, and so on. Sections are often divided into subsections for the purpose of grouping similar concepts. The ontology of sections, order items, and reminder items within Zynx default order sets can be rearranged and Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 25 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century renamed during customization in the Zynx AuthorSpace editing environment. Wolters Kluwer’s Clin-eguide Clinical Knowledge System is a similar clinical decision-support system designed to fit neatly into the clinician’s workflow. The Clin-eguide Clinical Knowledge Base of structured diagnostic, management and treatment recommendations, referenced to the primary literature, is the cornerstone of the system. The two products generated from this database, Clin-eguide Clinical Reference and Clin-eguide Order Sets, are accessed via a web browser or integrate with a clinical application such as Skolar MD – see interview on page 36. TheraDoc's products (see interview on page 40) take this theme and develop it around very specific applications such as the administration of antibiotics, painkillers and infection control. For example, Antibiotic Assistant augments clinical decision-making by providing the decision-maker with enriched disease-specific recommendations for antibiotic treatments, tests and referrals based on individual patient profiles. This particular module integrates patient data with coded clinical data, global medical knowledge, institutional protocols and epidemiological factors, so that the software can be used to assess all possible ways in which an infectious disease could be managed, eliminating those options that are contraindicated due to factors such as allergies or neutropenia as well as patient attributes such as height, weight, and age. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 26 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Prediction and disease management Clinical guidelines and pathways take this process further by introducing decision points within the process. Clinical pathways are structured, multidisciplinary plans of care designed to support the implementation of clinical guidelines and protocols. They are designed to support clinical management, clinical and non-clinical resource management, clinical audit and also financial management. They provide detailed guidance for each stage in the management of a patient (treatments, interventions etc) with a specific condition over a given time period, and include progress and outcomes details. Figure 17. A schematic of Isabel’s algorithm for the management of meningococcal disease Source: Isabel Healthcare Clinical pathways aim to improve, in particular, the continuity and co-ordination of care across different disciplines and sectors. They can be viewed as algorithms in as much as they offer a flowchart format of the decisions to be made and the care to be provided for a given patient or patient group for a certain condition in a step-wise sequence. See guideline logical overview for the management of meningococcal disease taken from Isabel Healthcare above. In a similar vein, Thomson’s Micromedex Medical Logic Modules (MLMs) integrate data into a clinical information system ‘rules engine’ to support advanced clinical decision making. MLMs are written using a standard rule-based system, Arden Syntax. For example, the hypertension MLM is designed to remind the clinician of appropriate treatment recommendations for Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 27 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century patients with hypertension, thereby reducing the risk of serious complications from uncontrolled hypertension, i.e., stroke, heart attack, etc. To achieve this, the rules engine event monitor detects the entry of a patient’s blood pressure made during an office visit, prompting the physician to gather other data from the patient’s record. These data would include risk factors such as smoking, diabetes, age greater than 60 years, etc. The MLM then calculates the patient’s blood pressure stage and risk group based on, in this instance, the US national guidelines, and returns a treatment recommendation based on all of these factors. Using software to add more value – prediction and disease management Predictive tools can take this process of sophistication one stage further. For example, Advanced Biological Laboratory’s TherapyEdge uses abstracted clinical knowledge and diagnostic feedback data to assess the effectiveness of a cocktail of antiretroviral drugs being used to treat an HIV-positive patient. At the heart of TherapyEdge is an algorithm called ViroScore which was developed by and licensed from Stanford University. This calculates the drug resistance indication and all other relevant mutation information, enabling the clinician to prescribe the most appropriate HIV anti-retroviral drugs and to design a new optimized cocktail which can anticipate the developing resistance as new viral strains emerge. Some vendors are beginning to offer solutions that integrate several of the types of product described so far, but centred on providing overall support around a specific disease. For example, Delphi Diabetes Manager is a point-of-care system that applies best practice knowledge to automate, manage, and deliver patient care from the early identification and intervention for patients at risk, to methodologies that help to prevent or defer the progression to chronic disease and the expensive medical complications. Not only is the functionality much broader than the earlier products described, so is the customer base. For example, Delphi software provides documentation for all major Pay-For-Performance quality improvement initiatives for physicians, insurers, employers and governments. These products are well liked, especially by patients because of their emphasis on follow-up and monitoring of disease progress. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 28 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Figure 18. An overview of the Delphi disease management module Source: Delphi TheraSim has developed a range of clinical simulation technologies to support the training of physicians, nurses, medical students and pharmacists in the diagnosis and treatment of chronic and infectious diseases. At the core of TheraSim products is a Therapy Simulation Engine (TSE) that analyzes a patient treatment path against an extensive knowledgebase of best practices and pharmacokinetic data. Figure 19: TheraSim knowledgebase organization Source: Therasim Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 29 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century This knowledgebase is distilled from various information sources such as: clinical best practices for various diseases; clinical information on patient metabolics; pharmacokinetic databases; drug prescribing information; published, peer-reviewed clinical research; expert advice and review from the TheraSim Clinical Advisory Panel. The clinical data in the system is rigorously validated and reviewed by a panel of medical experts prior to publication of new TheraSim Simulations. Most simulation products on the market cope with the nearly unlimited clinical choices for diagnosis and treatment that face a clinician in any patient encounter by limiting those choices to just a few. This ‘multiple-choice’ approach severely limits the clinical relevance of these products as the clinician user is always presented with the correct answer, but the TSE technology can be extended beyond education into clinical decision support systems. Entelos, for example, has developed a number of large-scale computer models of human disease. Called PhysioLabs, each provides a framework for integrating data (including genomic, proteomic, physiologic, and environmental) in the context of a disease, with a focus on understanding and determining clinical responses to potential treatment. PhysioLab systems are built and customized using thousands of peer-reviewed papers, the expertise of world-class advisory boards, and the proprietary information from industry collaborators. Within the virtual research environment of a PhysioLab, clinicians can simulate experiments in silico (in computer) that could take months or years to do in the lab or clinic. In silico R&D can be used to: Identify and characterize novel pathways and genes; Prioritize and evaluate new drug targets and candidates; Plan and optimize clinical trials and experiments; Assess the clinical impact of therapeutic approaches on different patient populations; Relate genomic, proteomic, and in vitro data to clinical outcomes. But isn’t this beginning to blur the boundary between informatics for health and informatics for drug development? Precisely, and it is a major part of the NIH’s recently announced Roadmap initiative in translational biology and medicine – scientific research programs design to accelerated the integration of bench findings into clinical practice. i2b2 (Informatics for Integrating Biology and the Bedside) is an NIH-funded National Center for Biomedical Computing based at Partners HealthCare. The i2b2 Center is developing a scalable informatics framework that will bridge clinical research data and the vast data banks arising from basic science research in order to better understand the mechanistic bases of complex diseases such as hypertension, diabetes and Huntington’s chorea. The expectation is that this knowledge will facilitate the design of targeted therapies for individual patients with many common diseases having complex genetic origins. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 30 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century “Providing high quality and efficient health care isn’t possible anymore without a sophisticated marriage of information technology and state-of-the-art science,” says John Glaser, CIO at Partners Healthcare. “But bringing them together to inform patient care is a tremendous undertaking. i2b2 is about harnessing all the possibilities afforded by the full array of new information provided by genomic research – and making it real for doctors and patients.” And, according to Isaac Kohane, Director of Informatics at Harvard Medical School – Partners Healthcare Center for Genetics and Genomics, the distillation and publishing of this information will be managed internally – a possible clue to the future branding strategy of leading-edge healthcare consortia such as Partners. Figure 20: i2d2’s project data model Source: i2d2 Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 31 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Through a glass, brightly - the changing shape (and size) of the marketplace Globally, healthcare is a multi-trillion dollar business. Yet, challenged by error and care quality issues that result in thousands of injury and deaths each year, it is one of the most dangerous and inefficient industries in the world. Healthcare should be an information-driven business, but until now this has not been the case. As articulated by J A Muir Gray (see interview p.39), founder of the Centre for Evidence-based Medicine (CEBM) in Oxford, ‘The application of what we know will have a bigger impact on disease than any drug’. And yet there can a 20-year gap between scientific discovery and the routine application of those discoveries in clinical practice (AHRQ, 2001). “I conclude that though the individual physician is not perfectible, the system of care is, and that the computer will play a major part in the perfection of future care systems.” Clem McDonald, MD NEJM 295:1355, 1976 “Current practice depends upon the clinical decision making capacity and reliability of autonomous individual practitioners, for classes of problems that routinely exceed the bounds of unaided human cognition” Dan Masys, MD IOM Annual Meeting (2001) The investment in networked healthcare systems is now a national priority in many countries of the world. This alone will bring about significant reductions in the cost and improvements to quality. But the force for transformational change will be the large-scale implementation of the evidencebased practice of medicine. There are currently over 40,000 hospitals of a significant size worldwide. These units will increasingly become grouped as consortia or similar collaborations in order to better leverage purchasing decisions. Software (EHR) vendors such as Cerner, EPIC, GE Healthcare and McKesson will play a dominant role in shaping market access for publishers such as Hearst, Thomson and Wolters Kluwer and vendors of specialised knowledge-based systems such as Delphi and TheraSim. Some vendors such as Cerner may chose to play in both fields but they will be in the minority. It seems likely that close alliances will form between publishers and vendors as the pecking order amongst the vendors becomes clearer. The geographical and political heterogeneity of the global market will ensure that there will be space for perhaps half a dozen software vendors for the foreseeable future, but there will be far greater pressure to differentiate and add value within both the traditional and the new entrant publishers. The formation of alliances between the vendors and the publishers will be key to ensuring sales and will influence product specification (interoperability), marketing (software/content value perception) and pricing (subscription/maintenance revenue split). An excellent example of this is Hearst’s negotiation of a letter of understanding with vendors in the UK’s National Program for Health IT, (NPfIT) to be sole supplier of drug information. Where now is Haymarket’s MIMS, once the desk-top bible of all of the UK’s GPs? Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 32 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Drug information and order sets will commoditise most rapidly. Most of the core information is within the public domain already and as formularies and clinical best practice become determined by efficacy and cost rather than habit, there will be little scope for differentiation other than on speed of update, comprehensiveness and functionality. The winner in this sector will be the player who manages to integrate drug information into a richer selection of linked services such as guidelines, pathways and predictive tools. However, initially, in terms of the development of market access, the advantage may go to companies such as Hearst (First Data Bank and Zynx) who focus only on these areas – simply because they are generic. Currently each physician practises medicine differently. These differences stem from multiple sources, such as source and recency of education, marketing influence of pharma companies, the availability of new technologies and so forth. Evidence-based medicine and clinical decision support will reduce this variability to focus on known facts and measured outcomes, a language the consumer and the physician can both understand. The branding of trustworthy sources of information will be key to the survival for the suppliers (such as Bazian) of what will otherwise be largely undifferentiated content. Software vendors are today’s pioneers, but what of tomorrow? In the future, the main variable in the practice of medicine will be the patient and, based around a variety of preventative options, ability to pay, pharmacogenetics and individual differences in the molecular pathology of disease. This will place increasing pressure on content providers to structure their offerings so that they can react to patient-specific details embedded in their health record. GE Healthcare’s purchase of IDX, one of the leading software vendors, provides it with a solid foundation in the EHR marketplace. The earlier acquisition of GeneticXchange and its discoveryHub information management technology plus its already dominant position in imaging and diagnostic systems provide it with a clear opportunity to play in the more sophisticated knowledge management market as this matures. The prescription of a drug will be based upon its efficacy, not the amount of money spent on its promotion. The treatment of a disease will be based on a knowledge of measured outcomes, tempered by a knowledge of genetic and environmental variables peculiar to the patient. Where will this leave direct-to-customer (DTC) advertising, direct-to-physician (e-detailing), and pharma marketing strategies generally in the future? Finally, the creation of national networks of linked EHR repositories (the US National Health Information Network, NHIN, and the UK’s NPfIT Connecting for Health Spine) will create an enormous opportunity for further commercial development when integrated with the prescription and payer information - currently a market very much dominated by IMS. Amongst many benefits, these databases will provide government, payers and providers with a resource which can be used retrospectively to conduct virtual clinical trials, judge Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 33 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century outcomes from a cost perspective and manage in real time the implementation of evidence-based medical practice. Thomson’s MedStat is well positioned to take advantage of this opportunity, but Wolters Kluwer’s acquisition of NDC provides it with some of the data-handling skill sets needed in this area. EBM and Open Access The National Institutes of Health (NIH) is the largest funder of medical research in the world, and the largest funder of nonclassified research in the U.S. federal government. Its budget for fiscal year 2005 was $28 billion. To date, its open access policy has been to provide free online access to full-text, peerreviewed journal articles arising from taxpayer-funded research. Currently the NIH asks every scientist who receives an NIH research grant, and who publishes the results in a peerreviewed journal, to deposit voluntarily a copy of the article in PubMed Central (PMC). PMC will then provide free online access to its copy some time after the article is published in a journal – until recently the length of the delay was a matter of debate. Introduced on December 14th 2005 by Senators Joe Lieberman and Thad Cochran, the bipartisan Cures Bill is intended to expedite development of new therapies and cures for lifethreatening diseases. Among the requirements of this bill is the establishment of free public access to articles stemming from research funded by agencies of the Department of Health and Human Services (DHHS), including NIH, the Centers for Disease Control and Prevention (CDC), and the Agency for Healthcare Research and Quality (AHRQ). “The Cures Bill is exactly the medicine that’s needed,” says Heather Joseph, Executive Director of the Scholarly Publishing and Academic Resources Coalition (SPARC) and a leader of the Alliance for Taxpayer Access. “It goes right to the heart of the case for unfettered access to publicly funded research. Senators Lieberman and Cochran took a close look at how best to speed development of treatments for diseases. Among their conclusions is that it’s time we ensure the research we’re already conducting is available to all potential users.” Pat Furlong, executive director of Parent Project Muscular Dystrophy comments, “It recognizes how important the sharing of information is to speeding research and translating new knowledge into cures. In the age of the Internet, it makes no sense for the results of taxpayer-funded research to be hidden away.” The bill calls for DHHS-funded research to be made available on PMC within four months of publication in a peer-reviewed journal. NIH estimates that less than five percent of eligible research is currently making its way into PubMed Central under its current policy. The Cures Bill would require deposit of refereed articles and reach beyond the NIH. It would also provide access sooner than the current NIH policy. Making evidence publicly available will be a boon to EBM publishers such as Bazian, but a threat to larger content providers such as Elsevier. The future of this marketplace will depend very much on how players respond to the Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 34 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century commoditisation of base content and to the need to retain access to EHR software vendor distribution channels and to create knowledge-based software products which are interoperable and easily updated. This will require investment and strong alliances with the software vendors and the major agencies driving standards such as ONCHIT, HL7, HIMSS. This view would favour Thomson, Hearst and Wolters Kluwer as future market leaders in evidence-based medical publishing. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 35 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Expert Interview Clin-eguide Carol Leighton, Director, Editorial & Product Manager, Clin-eguide, Wolters Kluwer Health Carol Leighton is Director of the Clin-eguide product from Wolters Kluwer Health. Clin-eguide Clinical Reference and Clin-eguide Order Sets provide evidence-based knowledge to the point of care and can be integrated with vendor or hospital clinical systems. The reference product can also be accessed through the Clinical Resource@Ovid platform. How do you define evidence-based medicine? We started looking at evidence-based medicine (EBM) around five years ago, at a time when it was not as well accepted as it is now. We evaluated how we could provide evidence-based content that would be consistent across all medical specialties, and developed a methodology that provides the user with the best possible evidence and grades it according to the strength of the evidence. A systematic review would be graded A1 to indicate that it is very strong evidence, and other types of evidence such as case studies would be graded lower, according to a sliding scale, down to expert opinion. We evaluate evidence from a wide spectrum of resources to ensure we can answer clinical questions encountered during practice. The important thing is to provide transparency, so that when a statement is made it is clear to the user what the evidence is behind it. We developed our methodology after attending a course at MacMaster University in Canada, and now have 450 topics that are evidence-based. At the beginning, we received quite a few sceptical comments from users, (for example calling it ‘cookbook medicine’), but there were some who understood it and liked it. The sceptics have become far fewer over the years and the majority of physicians now find evidence-based content useful, especially in areas of controversy or outside their fields of expertise. The feedback we have received from users is that where there isn’t a definitive answer to their question the best approach is to provide what evidence there is and label it clearly. Who do you see as the key players in the marketplace? There are a number of different companies that provide evidence that compete with Clin-eguide. These include FirstConsult, part of Elsevier’s MDConsult, The American College of Physicians Journal Club, PIER and InfoPOEMs, recently acquired by John Wiley & Sons. Clin-eguide users also perceive UpToDate as a competitor, even though it provides expert-based guidelines rather than evidence-based content. A lot of evidence-based content is still stuck in the library and getting it to the point of care, and into the workflow where a physician needs it most, is a challenge. We have partnered with Electronic Medical Record (EMR) providers such as Cerner and Eclipsys, so that Clin-eguide is now integrated into their systems and available from within the patient’s EMR. For example, one way we have done this is through our new Clin-eguide order sets. When physicians do their rounds, they have to order certain medications, laboratory and diagnostic tests etc depending on the working diagnosis of the patient. The order sets provide evidence-based lists of these orderables. If the physician has a patient Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 36 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century with a heart attack for example, the physician will now be able to retrieve a list of orders for this condition that can be accessed from within the patient’s EMR. This is intended to prevent clinical errors, provide consistent medical care and allows us to provide content right at the point of care. There are also links from the order set lists to our evidence-based guidelines. The order sets also contain alerts and rules that serve to remind the physician of any medications that may have been missed or tests that are outstanding. This is an excellent way to improve and measure key performance indicators within an institution. Nearly all the large EMR vendors are looking to provide order sets that link to evidencebased guidelines. What role do publishers currently play? It is important to provide robust and synthesized material, and the onus is on us to make it practical, remove the barriers to access and make it easy to use. At Clin-eguide we have physicians and pharmacists writing all the material to ensure we get it presented in the right format. Unless we do it well customers will simply choose to leave EBM out of their workflow. Integrating evidence-based content into workflow is the biggest challenge publishers face – and yet its utility is radically limited when in the library. Our strategy at WKH is to provide evidence plus best practice with input from physicians, and then partner with EMR vendors in order to get this content to the point of care. How do you see this role changing over the next few years? We will look at the breadth of our content across a number of different clinical specialties, because EBM can be used across a range of disciplines, not only physicians. The content will need to be consistent between clinical specialties, so that nurses, physicians and pharmacists are all receiving consistent guidance. We will also provide increasing levels of assistance with documentation and provide what customers need in their workflow. Publishing for this market is now about three things, the content, the technology and the services to help customer implementation. Working within the EMR environment will be crucial - 13% of US hospitals currently have an EMR, but this number will increase by 2008 to 3040%. This will mean a big culture change for physicians and we need to ask how we can best assist them with this. Allowing customisation of our content will be very important, because it makes it more applicable to a specific institution and more acceptable to physician end users. What are the key trends evident in the launch of new products and services for this market? Acceptance of EBM is growing. Customers increasingly want content based on evidence-based methodology, and more integrated content that they can use as templates. We are therefore more involved with hospital informaticists and working with CIOs, CTOs, and CMOs. What are the drivers of change in this market? The incidence of medical errors is a key driver. The US is very litigious and there is a need for physicians to be able to point to the content they used to make a decision. There is so much information available today that physicians need to know how to navigate it. Evidence-based content can be useful even for a senior physician operating outside their area of expertise. Physicians are increasingly saying ‘I need to know more than my patient’. Patients can now go on search engines such as Google and find information about medical conditions. There are a number of government initiatives on what types of content physicians should have access to and also incentives to utilize EMRs. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 37 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Hospitals are also finding that their own content (guidelines and order sets) is difficult to maintain and to update. A lot of this content is paperbased and not consistent across different departments within the same institution. As a result institutions are turning to publishers and asking them to provide and update these guidelines and deliver them in electronic form. What do you believe are the future trends in evidence-based medicine? We will see a lot more evidence integrated into workflow, particularly as by 2010 we will have a large proportion of institutions with EMRs. There will be features such as information buttons for particular diseases integrated within the EMR, and semantic networks between different content sets. Technology will allow us to link co-morbidities and infer best treatment strategies for example, first-line treatment for a pregnant patient with diabetes mellitus and heart disease. We are starting to turn content into real knowledge and will see a bi-directional flow of knowledge between the EMR and the physician. A physician will have access to very granular information that is clinically relevant for the patient they have in front of them. Rules and reminders are here today and will increase over the years as the technology allows us to provide more focused content. However it is very important to say that we know we can never replace physicians. We are not trying to challenge their role as the decision makers, rather to provide evidence to help the process along, because ultimately they are the ones with the patient knowledge. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 38 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Expert Interview Dr J A Muir Grey Dr Muir Gray is Programme Director of the NHS National Electronic Library for Health (NeLH) and has been in the vanguard of the UK’s evidence-based health movement, establishing the Centre for Evidence-Based Medicine at Oxford. He runs a web and wireless service about health knowledge – www.soundshealthy.org Who do you see as the key players in the marketplace? All the major publishers now have offerings in this area, as it has become a key area of growth for them. However key evidence-based medicine players include Bazian, Zynx, EMed Group, and UpToDate. What role do publishers currently play? Publishers have been active in this market so far without adding a great deal of value to the information available to medical professionals. This is because it is the quality of the content published in their journals that is the real issue and one that has yet to be solved. The peer review process is hopeless as a means of providing sufficient quality, so most journals are too inaccurate for clinicians and patients to use. The answer to this problem lies in the increased use of systematic reviews by bodies such as the Cochrane Collaboration who can provide a check on the validity of the content published. Journals also need to use standards, such as CONSORT, to improve how they report research. How do you see this role changing over the next couple of years? I would hope that publishers would worry less about evidence-based medicine and concentrate more on the quality of the books and journals they produce. What are the key trends evident in the launch of new products and services for this market? We will see increasingly rigorous scrutiny of the quality of published content in scholarly journals and a growing need to be explicit in what the updating procedures for these are. It is clear that peer review is flawed and pressure will grow for ways of improving the system. What are the drivers of change in this market? A key problem is that there is too much information of too low quality available to clinicians, and there is a need to look for ways to both improve its quality and help doctors navigate it effectively. Meanwhile the limits of finance, as hospitals and surgeries struggle to balance and make the most of limited budgets, are driving a need to increase the value derived from resources. Bound up with both these trends is a growing awareness of the need to improve patient safety by reducing medical errors, which is a very strong driver of developments both in the US and here in the UK. Alongside these factors there has been a growth in consumerism amongst patients, who are increasingly arriving at consultations having already used the web to research their health conditions. Doctors must be on top of all the latest evidence to deal effectively with well-informed patients. What do you believe are the future trends in evidence-based medicine? We will see the growth of better knowledge management, to address the issues stemming from the mass of information available to medical professionals, and better systems of care that will look to reduce medical errors. We can also expect increasing levels of patient involvement. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 39 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Expert Interview TheraDoc Stan Pestotnik, Chief Executive Officer and co-founder TheraDoc was founded in 1999 and is based in Salt Lake City, Utah. It is a medical informatics company that creates and markets software designed to help physicians deliver evidence-based care. How do you define evidence-based medicine? We define it based on the Cochrane Collaboration standards; we grade the evidence and we analyse control trials or observational trials. How is this being developed at the moment? We have an in-house editorial staff of physicians and pharmacists who collate the literature and then, using the template for grading, grade it and build our knowledge bases. But we let people know what the rules, guidelines and the evidence behind this knowledge base is. Is there any scepticism with regards to EBM? Well, I think it depends - there can be. The way you get around that is how the technology marries that evidence base with individual patient data. If you are able to take the evidence base, and bring that into the context of patient care and patient data, then I think you get away from that criticism because I think what you are doing is taking that evidence base and turning into actionable knowledge at both the time and the point of care. Who do you see as the key players in the marketplace? In my opinion, the current leader in the evidence-based space is going to be Zynx, a division of Hearst Corporation. In the whole content arena there are other legitimate players – Clin-eguide being one, another being UpToDate, Skolar and Healthgate. The larger players are going to have to take a more pro-active in healthcare information technology and workflow solutions. Their content – their evidence base – is quickly becoming a commodity and eventually will just become a commodity. What role do publishers currently play? The role they play right now is – and I think this will continue to be a major role – is that they act as collators or aggregators of this knowledge. They are the ones who are the repositories, and they need to be able to take that knowledge and get it into the context of patient care workflow – that’s where they are struggling right now. We are seeing this with the recent announcement that Wolters Kluwer just bought a company at the end of the year (a documentation company). What remains uncertain in my mind is whether or not they are going to be able to execute on their vision. Giving a selfish reason, I think companies like TheraDoc are going to be the ones that are going to do that. The EMR vendors and the HIT vendors talk a good story about this, but they haven’t been successful in doing this either and I think it’s too specialised a niche for them. They have too much more to try to accomplish in creating the electronic health record or electronic medical record as well as refining the transaction base. Trying to get into the knowledge space is a difficult proposition for them. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 40 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century How have you approached this issue? One of the things we have been able to do with our technology is that we have a platform that the knowledge integrates with and that platform is designed to create the interoperability and connectivity with the patient data. It also provides interoperability connectivity with the knowledge or evidence base so it is within that platform that the technology (which is proprietary) draws on the strength of expert systems technology and on the knowledge bases that contain the evidence. It is this expert system platform where this happens. That’s how we are unlike the publishers. What we are working diligently on is establishing relationships with publishers like Zynx, Clin-eguide, and the Micromedex because I think what we bring to the table is the ability to take that rich content and integrate it into workflow which they have not been able to do to date. Do you think the growth of EBM is largely pegged to the growth of electronic medical records? The next wave you are going to see is when we empower the consumer of healthcare to use these technologies to be able to get access to the evidence base in conjunction with whatever their particular issue is. Where we are going with this in the industrialised nations is shared medical decisioning. One of the only viable answers in addressing escalating healthcare costs is to make the patient part of the decision-making on the best treatments. The way to do that is to give them proper information that is graded and in a format that they can understand and they can discuss with their physicians. We are years away from that, but I think it will be one of the great flatteners. WebMD has something like this too, but it will end up with the healthcare providers like the NHS in Britain or some of the larger carers in the United States. The movement is evident within some of the large insurance carriers in the US, which are trying to create these so-called portals that will connect patients with their doctors and their hospitals - they are now trying to figure out how to bring the evidence base into the whole mix. What growth rate are we likely to see with regards to hospitals using EMRs? One figure we have is 30-40% of US hospitals using EMR by 2008. I think that’s pretty accurate. It’s going to continue to grow because of the many national initiatives – whether it be in the UK or the US or other places – for this. I think it is now a political issue, at least in the US. It is also now the lay-person who is talking more about this because they are exposed to it. With the presidential elections in 2008, health records, shared medical decision-making and escalating healthcare costs are all going to be major political issues. I see the healthcare, IT and EBM sectors continuing to grow. What are the drivers of change in this market? The number one drivers at the moment are regulatory requirements, at least in the US, to do with quality and safety. You are also seeing, at least in my view, the explosion of medical knowledge. It is impossible for an individual to keep abreast of the information they need to be competent in their area of expertise, and then you couple that with the manpower shortages that are uniformly seen with physicians, pharmacists and nurses. All of these things couple and will push for EBM and IT adoption. What I keep trying to tell publishers is that their content is a commodity and it is going to continue to be a commodity unless they change. Can old-world publishers, to use a worn-out phrase, change their stripes and move into the digital age? It’s all about workflow. They are going to have to have workflow solutions. To just sit the content in a library is not going to help anyone. It has to be at the point of care. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 41 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Expert Interviews Zynx Health Scott Weingarten, President, Chief Executive Officer, and cofounder Zynx Health was founded in 1996 as part of the Cedars-Sinai Medical Center Division of Health Services Research. It became a subsidiary of the Hearst Business Media division of The Hearst Corporation in 2004. The company delivers its services to almost 1000 hospitals, largely in the US. Zynx creates clinical decision support content using peer-reviewed scientific literature. How do you/your organisation define evidence-based medicine? Zynx defines evidence-based medicine as the process by which scientific evidence from peer-reviewed scientific literature is used to inform clinical decisions. The goal of evidence-based medicine is to ensure that clinicians are informed of all of the relevant scientific evidence to enable them to take better patient care decisions. Who do you see as the key players in the marketplace? Lots of different organisations are involved in this sector, although Zynx believes that it has little direct competition with evidence-based clinical information that can be integrated with clinical information systems. Other organisations involved in evidence-based medicine include the Cochrane Collaboration, an international not-for-profit organisation, providing up-to-date information about the effects of healthcare. Its major product is the Cochrane Database of Systematic Reviews which is published quarterly – this therefore is a very different model to that employed by Zynx which delivers continuously updated information to the clinician at the point-of-care. The Health Information Research Unit at McMaster University has also done a lot of work in this area. Zynx has found that some healthcare institutions believe that they can use staff members to develop their own evidence-based medicine clinical information. What role do publishers currently play? At present, the role played by publishers in developing evidence-based clinical information that can be integrated with clinical information systems is still in its fairly early stages. Some publish evidence-based medicine journals and books, but there is less activity in the area of integrating evidence-based medicine into healthcare information technology to improve clinical decision makings at the point of care. These technologies allow rapid access to context-specific evidencebased medicine information very quickly. How do you see this role changing over the next few years? Publishers will undoubtedly move into the area of clinical decision support, integrating their content into the workflow of the clinician. The value of reference-based content from the clinician’s perspective is falling because of the clear value-add offered by clinical decision support services. What are the key trends evident in the launch of new products and services for this market? Clinical decision support tools are driving the recognition that referential sources are difficult for time-pressured clinicians to use consistently and effectively Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 42 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century What are the drivers of change in this market? In addition to this recognition, healthcare organisations are moving down the road of adopting much more healthcare information technology which evidencebased medicine services will be able to feed into. Examples of these types of technology include electronic health records, computerised physician order entry systems, and handheld devices. What do you believe are the future trends in evidence-based medicine? Evidence-based medicine is intended to improve levels of patient care, but it is challenging to practice evidence-based medicine without clinical information systems. The development of these products and services however will enable them to be used by clinicians to practice medicine on a daily basis. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 43 EPS Focus Report January 2006 Evidence-based medical practice in the 21st century Previous EPS Focus Reports 2005 December November October September August July June April/May February/March January 20 to watch in 2006 STM Publishing in Asia The future of reference publishing Drug informatics – where are the opportunities for STM publishers? The Mobile Content Market: Drivers, trends and technologies Business Publishing in China Online Corporate Recruitment Activities: How is the recruitment landscape changing? Google and Publishers: assessing the impact of the Googlesphere Outsourcing and offshoring: Can it work for publishers? Innovation in e-learning: Expanding the realm of the possible 2004 November/December: October: September: July/August: June: April/May: March: February January: ELT content: What does the future hold for this market? Humanities and social sciences publishing: attitudes, challenges and innovations Business models for online content: balancing the bucks The Transformation of Healthcare in the US Digital Rights Management: gaining real value from implementation STM Book Publishing: A Sector in Crisis? The road ahead for digital and online newspapers Classifieds Online: Where Now? Where Next? DOI in 2004: Where are the tipping points? 2003 November/December: October: September: July/August: June: May: April: March: February: January: Publishing and the Investment Community Future-gazing: projects and technologies for the content industry to watch E-Textbooks: their place in the undergraduate content mix Healthcare Publishing: a model for other markets Aggregating Content for the Corporate User Integrating Content With Workflow: Learning from the pioneers E-learning 2003: lessons from the marketplace Profitable Publishing Architectures Digital publishing in the UK schools market Open Archives Initiative: Market revolution or hot air? All EPS Focus Reports are available in HTML and PDF to EPS Market Intelligence and Advisory Service clients at www.epsltd.com. We are happy to e-mail PDF versions to clients on request. Executive summaries of EPS Focus Reports are free of charge to guests, and are available at www.epsltd.com. Electronic Publishing Services Ltd, 7-15 Rosebery Avenue, London EC1R 4SP Tel: 020 7837 3345 · Fax: 020 7837 8901 · [email protected] · www.epsltd.com 44