Rx for Health Care Reform

7. The Limits of Evidence

95 7 The Limits of Evidence Consumer-driven care is not just about giving consumers incentives to use health care services more judiciously. Its proponents also seek to create a market in which consumer choices will force physicians to change how they practice. In this sense, it complements pay for performance, which is designed to influence physician and hospital behavior. Both pay for performance and provider report cards rely on performance measures drawn from a set of “best practices.” In the past, these “best practices” might have been based on expert opinion. But today, health plans, employers, and politicians expect physicians to practice in accordance with “evidence-based medicine,” which they regard as a body of generally accepted scientific principles. If doctors followed “evidence-based guidelines” with the help of information technology, these parties maintain, practice variations and inappropriate care would vanish, and quality and efficiency would go through the roof. Arnold Milstein, MD, medical director of the Pacific Business Group on Health, believes that someday, all physicians will follow step-by-step, computerized guidelines. In the regimented system he envisions, physicians would provide better, less expensive care by making fewer medical decisions. “Think about a world in which treatment selection and application is prompted by structured, computerized workflow, where over time the doctor begins to play less and less of a role in these decisions,” Milstein says. “You begin to have something more analogous to Big Blue playing chess. In the 1950s, when you said to a chess master, ‘The computer’s going to take over and outplay the chess masters,’ he’d say, ‘Get real, no way that’s going to happen.’ But by 1985, not even Bobby Fischer could beat Big Blue. That’s my prediction as to what’s going to happen in medicine.” 96 Rx for Health Care Reform Some large physician groups are already moving in this direction. At the Park Nicollet Clinic in Minneapolis, for example, the doctors depend on their electronic health record to help them adhere to guidelines created by the Institute for Clinical Systems Improvement, a consortium of the state’s major groups and health plans. In an affiliated hospital, the physicians all order the same tests and drugs for each medical condition. “If a patient is admitted with acute myocardial infarction [AMI, heart attack], we create a standardized order set based on what patients with AMI should be receiving,” David Abelson, MD, the group’s vice president of strategic improvement, says. “So the patient automatically gets the best care.” To accelerate quality improvement and reduce waste, Abelson and other Park Nicollet executives have even attended Toyota “lean production ” workshops. But Abelson admits that this industrial approach can be applied in health care only to a limited extent. “The Toyota lean production system doesn’t help decision-making in the face of uncertainty,” he says. “It doesn’t help in understanding individual preferences.” Neither does evidence-based medicine. While it can be a powerful agent for change, it’s no more of a silver bullet than electronic health records are. To harness evidence-based medicine properly as part of health care reform, we need to understand what it can and cannot do. Three-Part Definition According to the Centre for EvidenceBased Medicine at the University of Toronto, evidence-based medicine is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine requires the integration of individual clinical expertise with the best available external clinical evidence from systematic research and our patient’s unique values and circumstances.”1 This approach represents a departure from the traditional concept of the physician as an omniscient expert who can be relied on to provide the best care. But it’s also far from the interpretation of payers who view evidence-based medicine as the robotic application of rigid guidelines. Not only does it require physicians to pay more attention to patient preferences but it also retains a role for “clinical expertise”—the fruits of experience in treating many different patients with various diseases and co-morbidities. We certainly should expect physicians to practice in conformity with the latest scientific knowledge. But even if they could always do so—and The Limits of Evidence 97 that’s a big “if,” considering the difficulty of keeping up with the everchanging medical literature—adherence to the best evidence faces...