Evidence-Based Medical Information Technology: The Next Generation

US Health care is again in crisis. Our patients are stuck in a quagmire of worsening access to quality care (Fig. 1). The 2000 Institute of Medicine (IOM) report “To Err is Human” identified hospitals to be unsafe environments. Medical errors are rampant.1–3 By conservative estimates, these “errors of commission” are responsible for 44,000 to 98,000 deaths per year. In 2001, IOM published a second report entitled “Crossing the Quality Chasm”, which emphasized that despite our professed interest in providing evidence-based care, many patients do not receive proven therapies.4 A recent study assessed the frequency of these “errors of omission” by documenting 439 indicators of quality care for 30 acute and chronic health conditions in 12 US metropolitan areas and found that only 55% of patients received the appropriate therapies (e.g., β-blockers after an acute myocardial infarction).5 An inherent flaw of our system is that it takes 10 to 15 years for a proven therapy to become standard of care. In addition, this IOM report emphasized that we the providers (i.e., physicians and hospitals) are incapable of fixing these problems. In fact, current methods of reimbursement reward the status quo (e.g., we get paid for taking care of preventable complications). The IOM recommended legislation and regulations to insure that hospitals become safe environments (similar to the Federal Occupational Safety and Health Act). In addition, they recommended that the payers or patients be leveraged into choosing the providers that have a track record of delivering safe and evidence-based care that is customized to the individual patient’s desires. As a result of these two IOM reports, a number of external forces (with increasing recognized acronyms such as AHRQ, IHI, NQF, Leapfrog, SCIP, P4P) are merging their efforts with the intent of radically changing the way health care is practiced.6–8 Most physicians are now experiencing how pervasive this influence is on their day to day practices.Fig. 1.: The current crisis in our health care system.In June 2006, the IOM published three reports focused on access to emergency and trauma care. The one entitled “Emergency Hospital Based Care: At the Breaking Point” is most pertinent to our practices and nicely outlined the increasing frustration that I experienced during the last several years as Medical Director of a busy Level I Regional Trauma Center in Houston Texas.9 The basic tenet for reform is that inadequate hospital capacity and inefficient use of inpatient beds are causing an admission gridlock resulting in unacceptable emergency department (ED) overcrowding, diversion and poor care. Similar to the previous IOM reports, these 2006 reports will undoubtedly attract additional external forces that will mandate changes that we as trauma, emergency surgery, and surgical critical care providers will find unnecessarily intrusive. We need to seize the opportunity to exert leadership in arenas in which we have sufficient ownership to influence future development. Examples include (a) Trauma Systems should evolve to include all emergencies and designated levels of intensive care unit (ICU) care, (b) Acute Care Surgery should develop as a training and practice paradigm that insures ready access to high-quality emergency surgical care, (c) Surgical Critical Care should embrace creation of intensivist lead multidisciplinary ICU teams, and (d) evidence-based guidelines should be used to develop local protocols to deliver consistent, safe and high-quality care with documentable improvements in patient outcomes. This address will focus evidence-based guidelines and how medical information technology can be used to advance their implementation and refinement to improve patient outcomes. The discussion is broken into five parts: (1) evidence-based surgery and my early experience with bedside protocols, (2) evidence-based medicine, (3) evidence-based guidelines and the trauma surgeon’s leadership role in developing them, (4) “proof of concept” that computerized clinical decision support (CCDS) can implement and refine a complex ICU care processes, and (5) CCDS: why now. EVIDENCE-BASED SURGERY Training Evidence-based surgery was an important component of General Surgery training at the University of Colorado. When I started internship in 1979, I was given a book entitled “Surgical Decision Making” edited by Dr. Ben Eiseman.10 This book contained annotated algorithms to guide decision-making concerning management of common surgical problems based on the best available data and expert opinion. A similar book was published 1984 entitled “Critical Decisions in Trauma” edited by my brother Ernest “Gene” Moore and Ben Eiseman.11 I memorized many of these algorithms as a survival strategy for surgery Morbidity and Mortality conferences (M&Ms). During my career, I have authored many annotated algorithms (most for local patient care protocols) and firmly believe that this exercise is an excellent test of your true understanding of a clinical problem. As a resident, I also participate in a monthly “Parkland Series” journal club. Each month, we receive by mail a packet of the “Selected Readings in General Surgery” by Robert McClelland. This included an “expert opinion” type overview of the literature related to the selected topic plus reprints of the key articles. Each month was dedicated to a specific topic in General Surgery (e.g., peptic ulcer disease, diverticulitis, etc.) and these topics are recycled every 5 years. In our journal club, each resident was assigned one or two articles to critique and discuss with attending surgeon supervision. This was how I learned to critically appraise the literature, and by faithful participation during my residency, I was exposed to the best available evidence related to General Surgery. My third and most entertaining exposure to evidence-based surgery began in 1984 when Dr. Alden Harken (our new Department Chairman) started weekly Surgical Debates as part of the Surgery Department educational program.12 These were especially enticing when visiting professors were present. Dr. Harken would choose a focused question related to the visiting professors area of expertise (e.g., Dr. Shires: crystalloid resuscitation, Dr. Shoemaker: supranormal oxygen delivery, Dr. Cerra: branch chain amino acids, etc.). The resident chosen to argue the pro side would give background information and favorable review of available evidence (including key publications of the visiting professor). Next, the con side resident would provide a different negative review of the same available evidence and then the visiting professor would be invited to comment. This exercise was generally received well by the visiting professor. Because of their insight in the nuances of the debate, they could differentiate what we “do know” from what we “do not know” and identify the “gray zones” where they could best speculate on what was most likely true. Practicing Evidence-based surgery was an important component of my junior faculty development at University of Colorado. In 1986, I joined the faculty and was appointed Medical Director of the Surgical Intensive Care Unit (SICU) at the Denver General (DG) Hospital. One of my assignments was to develop protocols to standardize processes of care in the SICU. This was relatively easy at DG because there were already other protocols in place that standardized care in the ED and operating room. I recruited a clinical specialist in respiratory care (Jim Haenel RT), and we first focused on protocols to standardize mechanical ventilation. Over years, we refined a standardized approach (intermittent mandatory ventilation with pressure support with optimal positive end-expiratory pressure [PEEP]) with escalating use of unconventional interventions in patients who progressed into refractory acute respiratory distress syndrome (ARDS) (including inverse ratio pressure-controlled ventilation, permissive hypercapnia, tracheal gas insufflation, inhaled nitric oxide, and late steroids).13 Through these efforts, we learned a lot about mechanical ventilation, eliminated the need to consult pulmonologists, and improved outcomes.14–18 We attempted to same thing for other important care processes in the SICU.19,20 The most complex protocol that we implemented was shock resuscitation (SR).21 As one of Dr. Harken’s visiting professors, William Shoemaker visited DG on several occasions in the late 1980s. His concept that unrecognized flow dependent oxygen consumption was an important cause of multiple organ failure (MOF) was particularly enticing to our group because of DG’s long-term interest in this then deadly syndrome.22–24 The idea that oxygen delivery needed to be pushed to supranormal levels to eliminate the phenomenon made a lot of sense based on our understanding of the pathophysiology of shock. We pursued this project with great enthusiasm and with progressive protocol refinement exposed an inherent problem. As protocols become more complex, the bedside clinicians have a difficult time remembering what to do. We solved this problem by developing a bedside documentation form that depicted the algorithm on one side (Fig. 2) and a data collection sheet on the other side. Jim Haenel RT was available to help walk the PGY-2 residents through the protocol. It became an expectation that the resident would fill out the data sheets and present the resuscitation events on morning ICU rounds. This provided a fairly detailed record of what actually happened. We recognized different patterns of responses and used them to predict outcome.21 By collecting data in near real time, we gained new insights into the resuscitation process. We recognized with increasing frequency that these patients (especially those who had undergone liver packing) were at high risk of developing abdominal compartment syndrome (ACS).25,26 Also blood transfusions, a key component of resuscitation, were identified to be a strong independent risk factor for infections and MOF.27Fig. 2.: Shock resuscitation protocol; CI, cardiac index; DO2, oxygen delivery; VO2, oxygen consumption; PCWP, pulmonary capillary wedge pressure; HCT, hematocrit; R/O, rule out.EVIDENCE-BASED MEDICINE In 1972 Archie Cochrane, a Scottish epidemiologist, published a short but portentous monograph entitled “Effectiveness and Efficiency Random Reflections on Health Services”.28 He identified serious shortcomings in medical information. Standard of care interventions were incompletely tested and poorly analyzed. In addition, available information was badly organized and not readily available. He stressed the importance of randomized controlled trials (RCTs) in generating the most reliable information and proposed an institute (ultimately founded in 1992) that would prepare, maintain, and disseminate systematic reviews RCTs of the effects of health care.29 Each review explores the evidence for and against the effectiveness and appropriateness of treatments (medications, surgery, education, etc.) in specific circumstances. Cochrane reviews have become known internationally as sources of high-quality, reliable health information and are updated quarterly. Evidence-based medicine is a byproduct of Archie Cochrane’s legacy of using the best available data to make clinical decisions. The term was coined by the faculty at the University in in to a of training physicians for future clinical the in publications related to evidence-based medicine in the as it gained Evidence-based medicine and to A can be found in by in which based medicine is the and use of current best evidence in about the care of individual in evidence-based a pertinent clinical question is a of the literature is to identify these publications are and the evidence is based on quality and Level I Level with This in is used to make levels of A to The is implementation of into clinical can be through a of but as a recognized of this of articles with in in We Evidence-based guidelines have interest because they provide for health care there an in health related information. medical are in new proven therapies into bedside clinicians can be a in this despite and increasing health care there is an unacceptable and in the delivery of care. provide a to and eliminate care. can in care and provide a for identify the “gray zones” of clinical practice in which there are a of data on which to These future and this is expert decision is and it is to argue against the of evidence-based medicine, have by physicians for a of are as medicine that the expert in decision and the risk of in are of because we use to make decisions. In surgical are made with data through clinical to make is part of the surgical In addition, there is the that experienced surgeon’s are not and the in which they practice is not for It is how are to changing practices based on published data (e.g., early of after surgery, short of of use of etc.). Through training and clinical safe and practices and are to risk poor by changing the It is easy to especially those by or Because of a of there are Level I are with such as or be In addition, because of the of the made by the are to be by the most and on the same topic by different the same data can with This is an inherent risk of and is difficult to the real in a are included in the development there is a risk that these will the because they are in their these are then the not be because they do not the nuances of The of is is a but as with it can be to of expertise that many do not In addition, the of are only as as the data on which it is based (i.e., is a to a not The of is that is time and from development to to local implementation can years. In that time, the evidence have and to need to be updated and One recent this is the for to influence the by the development and using as an Trauma Trauma have in evidence-based surgery and have the concept for several trauma is a and by help care by practices and what to is an important part of a designated trauma can as for trauma have the of Trauma The first was published by the of on Trauma in and is now in This medicine many and as a for for a of trauma In address at for the Surgery of Trauma to a for developing and lead the trauma in this Dr. that these would be in developing local management protocols, but that they need to be by local to In local clinical management protocols is relatively but the real is He emphasized the need for a high and a that the from all bedside recognized that by quality and quality into the of implementation and of protocols an and In I was recruited to to become the Medical Director of Trauma at Hospital. At that time, care was increasing in the Houston health care and I was to make trauma at Hospital more Dr. in we a that was to a and in which protocols a role (a) how the trauma would and how it would with other of (b) standardized to ED management and (c) an intensivist lead multidisciplinary ICU that would care for the most patient using protocols that standardized common processes of care This approach to a and for (Fig. and of hospital (Fig. for the Trauma at Hospital. our improved quality of care related to protocol This time group into a that was by a clinical of our protocols were with the of review to data for ED ICU A per for for the Trauma of for Trauma this was a but we learned several it is important that that when a new protocol is it is likely not It should be in the of to what and what not The protocol is then updated and protocols are in (e.g., and a is identified to be the to when and is responsible for the group of new published information. other protocols or but need to be on a This can be by a of and then a for protocol A second we learned was that our protocol book not well in the Because of protocol we needed a way protocol We an trauma where we all of the the information readily available is of key importance for their and new need concerning the they have in a they will the This can be on ICU and multidisciplinary by to the protocols and their every opportunity to and that medicine clinicians to that the protocols are an component how the trauma not with a they are to be the topic on the for and get to the protocol. Decision My to When I to Houston in I was appointed Medical Director of the Shock Trauma ICU at the Hospital and became one of intensivist who the of the ICU after my I a patient on my who had refractory an with the ICU in which I the interventions that we I proposed a of for the my I was that I could not the because the patient was in an for mechanical ventilation of patients with and had randomized to I made a of the local and who that this was a safe and well tested that was to multiple as part of a study by from the for Health Care and and the Institute of General Medical for the and with in a I this was a and that I would support the clinical in the Shock Trauma We randomized of our patients into this I the patients and identified This protocol was at the University of Hospital and an bedside In the protocol used a of and strategy to was used and optimal was by a fairly blood gas and with standard mechanical were into the bedside and the medical would for how the should be and when to the patient (Fig. The RT with physicians could the but needed to why the was not appropriate of were improved and the patient was on ventilation trials were to mechanical support could be who were not randomized to were by the intensivist lead ICU critical care The in not improve patient patients were more as well as levels of and had with those of the patients by the ICU I was by the of to a complex of care in this critically patient oxygen by blood oxygen in in positive pressure; to positive pressure positive pressure; respiratory medical to and of In to the Medical Director of Trauma at Hospital I was recruited to the University of Houston Medical to develop a for Institute of General Medical Trauma I received a and a for a clinical project related to The of this project were (a) use to and refine the (b) develop a to how and patients responses to escalating interventions to patient and (c) use this information to for resuscitation that can be tested in the and (d) develop a well of critically patients in which to test basic for their clinical This project became the of a Trauma Center that was this I was to into my of General Surgery. we visited and at the hospital in we recruited one of their medical to We a group to the of developing for ICU We used the algorithm that we had at DG as a and flow for the for escalating interventions in The basic is depicted is in We used the Denver to risk that would be used as into the protocol. These included (a) of that in an (b) and (c) of blood or years with two of the previous risk patients with were these had of a pulmonary at ICU the was tested with at bedside with we had a on a that would be pushed to the bedside of patients when the protocol. specific data were then into the which then that the bedside could of were The protocol for This collection of data (a) patient (b) for (c) to (d) of and and every more data (including and These patients also had their clinical in a The basic strategy was to implement the the and then the protocol based on group In review we have (1) all patients by the ICU protocol emergency interventions or and in the ICU after ED (2) Most patients well to with and to blood (3) A of patients not well to escalating on to develop and and their clinical could be ICU (4) A to to cardiac is but risk of failure and (5) the from delivery to a more was with similar but with crystalloid and blood and of and is present in most patients at ED admission and in those who despite and ICU standard of care As a result of these we that changes are in the care of trauma patients who shock and a Standard of care resuscitation is is this of These patients can be identified after ED admission and they need a different management should be used protocols should be to insure ready of which should be with the first unit of is of importance and blood pressure should be this is ICU resuscitation an important to after the of resuscitation should be oxygen delivery with the of the and to provide them with an expert who out why they are not of resuscitation protocol. pulmonary blood oxygen delivery index; blood CI, cardiac index; by Trauma have strong for evidence-based care. The current evidence-based medicine provided with we have the The real is how we implement this best evidence into our by local refinement of to guide specific processes of care can in care and of best These can then be to improve patient outcomes. is a that these Our with mechanical ventilation of and are “proof of concept” that can processes of care. The opportunity now to health information technology to make available for many different processes of care. In the near the medical record and computerized will be implemented and provide the for We are to that access the hospital information to patient specific These data will be with clinical by bedside clinicians and into medical to the is by the bedside it will be implemented through include decision and these will be in the and will provide patient specific and at appropriate to the bedside clinicians in decisions. this is a but there are on to provide improved access to safe and high-quality care. can be especially for ICU clinicians who are for the patients and are with information is not an Evidence-based medical information technology is the in evidence-based care, and we need to seize the opportunity of this into our The would to many in the Surgery of the University of Health Center and the University of Medical of the result of the and that to Trauma

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