Clinical practices that don't add value

The initiatives that warn of clinical practices that don’t add value or that contributes very little, are an advanced product of evidence-based medicine. This culture, which has the force of reason, often conflicts with several limitations to influence the actual practice of medicine. The first lies in the ‘original sin’, since most clinical trials leave out the very elderly and the multi-pathologies, the second has to do with the difficulties of adapting clinical practice guidelines to the actual circumstances surrounding each patient and the third is the influence of other factors, such as industry or popular culture, for example, when it comes to influencing clinical decisions.

This matter of little practical value is one of the most unclear of which I have addressed on the blog, and so I want to explain my opinion of the three main sources that today feed us information.

"Do not do” recommendations from NICE

This initiative stems from the futility that NICE experts have made of their own clinical practice guidelines. This is a list of quiet thousand recommendations including all specialties. Clearly they aren’t prohibited, but instead the prestigious agency experts warn that these practices don’t have sufficient scientific support.

To illustrate how these recommendations work, I have chosen five examples of the questions that NICE believes should not be posed:

• Indicate hysterectomy as a first choice in cases of even strong bleeding
• Prescribe antipyretics to prevent febrile seizures
• Prescribe bevacizumab as first line in cases of metastatic colorectal cancer
• Shaving the skin in surgical preparation
• Hospitalising women with gestational hypertension

Mayo Clinic: lessons on management and governance

The Mayo Clinic is a network of non-profit health services based in Rochester (Minnesota). Mayo is essentially a group medical practice that has 3,800 doctors, researchers and over 50,000 employees. There are two features that identify this group: integrated clinical practice (especially in addressing complex cases), and research. The Mayo Clinic has been top of the U.S. News magazine for 20 years in a row and is among the one hundred best companies to work for, according to Fortune magazine.

In 1892 a group of doctors, led by brothers Will and Charlie Mayo, created a group of clinical practices, that from the start, had the vision to grow whilst retaining the essence of a cooperative and integrated medical practice, which, together with an early willingness to do research and teach, has earned them the prestige that they deserve today. If we consider the history of the Mayo Clinic in context, we can see the value of having defended the concept of a top-level project of professional services as it has survived the aggressive, speculative market of private medicine in the U.S.

The spirit of the Clinic

Take note of the values ​​that the Mayo brothers entrenched in the DNA of the organisation over one hundred years ago:

• Continuing pursuit of the ideal of service and not profit
• Continued primary and sincere concern for the care and welfare of each patient individually
• Continuing interest by every member of the staff in the professional progress of every other member
• Continuing effort towards excellence in everything that is done
• Continuing conduct of all affairs with absolute integrity

Tino Martí generated model

This series concludes (for now) and to end we rely on the participation of Tino Martí, health economist and technologist who has focused his career in the field of health management, innovation and new technologies, particularly in primary care. Together with him we have worked on a conceptual model of innovation in clinical practice.

The model recognises that health care is currently provided in three stages: the health centre, the home and the cloud. The emergence of this third stage together with the possibility of remote assistance from the health centre is facilitating the emergence of new models of care that are challenging clinical practice by questioning the need for physical presence.

The main innovation is the digitisation of medical records and the ability to exchange information between systems. The electronic medical record acts as a platform for both the physical presence in clinical practice and the virtual by allowing the patient to access a subset of data represented by the personal health record and through the glue of services (patient portal). Alongside the systems of informed decisions, these services provide information to the patient and enable them to play a more active role.
The virtual consultation via email, telecare (videoconferencing) and monitoring using cloud connected computers (telehealth), form the communication layer of this model.
Finally, and with a promising yet unpredictable future, we have the patient’s social networks that contribute a relational layer to the model.

Infographic: Virtual Clinical Practice Model (T. Martí, J. Varela)

Not all components are present in all systems (a long way to go), nor is there a standard configuration for virtual clinical practice. Depending on your goals and the technology available, each practice must design and configure the elements that help to complete the personal assistance services or develop substitutes.

Reviewing experiences has provided us with various levels of evidence for effectiveness and efficiency represented below in the coloured bars in each chart element. It’s reasonable to use the existing evidence in evaluating the introduction of innovations in healthcare, especially in a time of scarce resources, but these circumstances should not obscure the fact that innovation is born from experimentation. The existing assessments of the models tend to focus on one element and not the system; therefore we evaluate tools in isolation instead of new models of care.

The introduction of new technology doesn’t usually prioritise on the cost effectiveness ratio, but rather the improvement to the quality and safety of care and the satisfaction of the participants.

As you have seen, we have only hinted at the innovation available from the current vogue of mobile technology and it deserves a separate chapter that we hope to cover in a near future post.

Personal Health Record

What is it?

A Personal Health Record (PHR) is an electronic resource containing clinical information necessary for people to be able to make decisions with regards to their health. A common feature of the PHR platforms that I have consulted is the accessibility that the patient has to a certain amount of relevant information from his/her medical records (hospital admission reports, emergency reports, lab results, etc.) Additionally there are other remarkable characteristics of PHR, not featured or adopted by all the platforms:

• Scheduling doctor, nursing and test appointments.
• Self-monitoring of relevant variables: blood glucose, blood pressure, physical activity, calorific intake, weight, etc. The patient is responsible for maintaining this element of the PHR. It is very useful for ‘at-risk’ and chronic patients.
• Medication control and prescription management.
• Access to radiology images. This is a technically sophisticated function often still under development.
• Secure messaging Mailbox to connect with the healthcare team. See post "E–mail: it starts showing results"
• Managing insurance policy (only American PHR).

Three American PHR

 

The informed medical decision making

In this post, I’ll discuss some initiatives that began in the U.S. long before the emergence of the internet, but now, with the explosion of communication channels and social networks, these have taken on an impressive dimension that I’d like to bring to your knowledge and appreciation because, as we stand today in our environment, we are very far from these advances.

Healthwise is a U.S. company offering all kinds of solutions helping healthy people to better preserve their health and patients to better understand their disease. Many assurances, such as Kaiser Permanente, are offering Healthwise products and solutions to their members, with the aim of supporting policies of empowerment.

E–mail: it starts showing results

Although the health system is advancing very slowly compared to other industries, I'm sure that people are ready to adopt online services and that the health care system is able to open new lines of communication in accordance with the times we live in. Success is guaranteed, provided that the professionals are willing to adapt, and this is the hard part. No wonder the banking offices and travel agencies, to take two examples, have had to redefine, from head to toe, their business models, thanks to or because of online services.

In this review of a scientific evidence program (in the scanned blue cover), the Department of Veterans Affairs in the U.S. asks the following question: What is the association between 'safe' e-mail and clinical outcomes, the patients satisfaction, the treatment adherence and the efficiency or the resource use?

But first, if I may, I’ll clarify the issue of ‘safe’ e-mail because I think it is relevant. For obvious reasons of security and confidentiality, whenever we speak of using electronic messaging to communicate between a patient and their doctor or nurse, one has to do it through a protected access, which for now is the platform of shared clinical record.