A GLIMPSE AT AN EVOLVING PRACTICE ENVIRONMENT
The Institute of Medicine (IOM) Roundtable on Evidence-Based Medicine recently conducted a workshop, "Leadership Commitments to Improve Value in Health Care: Finding Common Ground." The IOM established the Roundtable in 2006 "as a unique and neutral venue where the key stakeholders could work cooperatively to help transform the way in which evidence on clinical effectiveness is generated and used to improve health and health care and to drive improvements in the effectiveness and efficacy of medical care in the United States." Central to the IOM vision is the notion that collectively, the healthcare sectors possess the knowledge, expertise, and leadership necessary to transform the healthcare system and that what is most acutely needed is a shared commitment to improving the development and use of information about the efficacy, safety, effectiveness, value, and appropriateness of the health care delivered. The underlying objective is to develop a "learning healthcare system" in which, by the year 2020, 90% of clinical decisions will be supported by accurate, timely, and up-to-date clinical information and will reflect the best available evidence. The three stated goals were: (1) To consider stakeholder capacity for stronger progress toward a "learning healthcare system;" (2) To explore transformational opportunities; and, (3) To identify possibilities for collective initiatives that might be considered by Roundtable sectors. The participants included high level officers from the Mayo Clinic, Blue Shield of California, National Business Group on Health, Consumers Union, AMA, SEIU, CMS, VA, and a number of other impressive organizations.
Common Concerns and Themes: * Rising costs and limited resources. System inefficiencies. Increasing complexity. Expanding evidence gap. Limited system capacity and flexibility. And, Entrenched cultures. * Build trust and collaboration. Foster agreement on "value" in health care. Improve public understanding of evidence. Characterize the impact of shortfalls in the evidence. Identify the priorities for evidence development. Improve the level, quality, and efficiency of the research. Clarify and promote transparency. Establish principles for the interpretation and use of evidence. Improve engagement in the full life cycle of interventions. Focus on frontline providers. Foster a trusted intermediary for evidence. Build the capacity to meet the demand. Create incentives for change. And, Accelerate advances in health information technology (HIT). The envisioned "learning healthcare system" is one that maintains a constant focus on the health and economic value returned by care delivered and continuously improves in its performance.
The workshop participants felt that broad culture change is especially needed to enable the evolution of the learning environment as a common partnership of patients, providers, and researchers alike. Currently, health care has various customs and practices which often are not conducive to reform. Caregiving and caregivers are often "siloed," with inadequate communications among the various functional areas of the healthcare system. Information is not shared as widely as it should be within specific healthcare systems, let alone between systems, contributing to inefficiency and distrust in the system. In general, providers, patients, and other sectors do not yet believe that the development of evidence is an activity relevant to their experience in the routine delivery of care. Accordingly, the point of care must be the central focus for this continuous learning process – a major point, which Steve Ragusea has been making to psychology's leadership for over a decade.
Intriguing Notions: Accelerating the potential for better development and application of evidence requires improved communication between patients and clinicians about the nature of the evidence base and the need for partnership in its development and use. Leadership is required from every quarter – strong, visible, and multifaceted leadership from all involved sectors to marshal the vision, nurture the strategy, and motivate the actions necessary to create the "learning healthcare system" desired. "Workshop discussions were largely predicated on a central belief that evidence-based care should be delivered by interdisciplinary teams, an approach that requires a significant shift in the culture of health care, including embracing the patient as part of the team. To make team-driven care the norm, attention is needed on retooling practices in the areas of clinical education, ongoing training, testing, and credentialing for front-line healthcare providers. The development of decision tools and prompts for use in the practice setting and the establishment of infrastructures to improve the focus, accessibility, use, and generation of the best evidence by providers would also help make evidence-based, team-driven care the norm. Similarly, practices could be designed and implemented to ensure that existing data from patient care loops back to inform the generation of new evidence. Other levers noted to promote broader uptake of the use of evidence in clinical practice include education, payments, measurement and assessment, enhanced patient engagement, and reporting requirements."
This overarching vision is proposed within the context that 89% of physicians work in solo practices or small-group practices (less than 10 physicians, with 50% working with four colleagues or fewer); a similar situation probably exists for psychologists. Because information in the healthcare system is presently partitioned into "silos" without connectivity, a clinical data and analytic infrastructure must be created to enable evidence-based medicine, especially since physicians spend 60% of their time seeking data. The importance of developing trust among the various stakeholders, as well as encouraging interdisciplinary collaboration, are major reoccurring themes.
Yet, during the recent Congressional deliberations on President Obama's healthcare reform legislation, in their December 1, 2009 letter to the Senate Majority Leader, the AMA shared its view: "In lieu of the proposed nurse-managed health clinics, the AMA supports fully integrated multidisciplinary health care teams that are comprised of nurses and other health care professionals, which are led by physicians to ensure that patients get the best possible care" [highlighted in the actual letter]. The nurse-managed clinic provision was retained in the final version of the Patient Protection and Affordable Care Act (PPACA) (P.L. 111-148), notwithstanding the AMA's expressed concern. Today, pharmacists make up the third largest group of healthcare professionals. Having matured to requiring the doctor of pharmacy or clinical pharmacy degree as their educational standard, their members are providing an increasingly wide range of health services (including behavioral health) to their patients.
Change Is Coming: It has consistently been reported that not only does care vary significantly for reasons unrelated to appropriateness, but that even when the available evidence strongly supports a regimen of care – i.e., identified best practices exist – such care is received, on average, only half of the time. It should not be surprising, therefore, that in general, the public is not aware of the concept of evidence-based medicine, nor does the current terminology used to describe the concept resonate with consumers when presented to them. We have a long way to go in developing the necessary level of "health literacy" among the general population. The IOM estimates, for example, that more than 47% of adults have difficulty locating, matching, and integrating information in texts. In fact, studies indicate that a majority of Americans get their health information from the media. Today's consumers are largely unaware of the variability in healthcare quality and do not have adequate information with which to make informed healthcare decisions that are based on evidence and that reflect their values and preferences. Currently, the results of 10,000 randomized control trials (RCTs) are published each year. "The complexity of modern medicine exceeds the inherent limitations of the unaided human mind." "(T)he critical importance of evidence-based decision making does not yet seem to be on the radar screen of the majority of physician and hospital leaders, although the tipping point may be near." A major challenge -- "(T)he United States devotes less than one-tenth of a percent of its total healthcare expenditures to understanding how well health care works and how to improve it, an amount that is small compared with the amounts invested to understand other major segments of the economy."
Russell Lemle points out that "The VA has been in the forefront of promoting the use of evidence based psychotherapies (EBPs) for mental health problems. However, they have instituted a narrow subset of EBPs (without transparent selection criteria) in a manner that limits VA clinicians' use of the broader array of best available evidence-based interventions." Reflecting the concerns of many clinicians, Morgan Sammons cautions that: "What is eminently clear is that the effect size of EBTs often does not differ substantially from the effect size of treatment as usual. There is often an .05 or better statistical difference between EBTs and a wait list or sham condition, but the difference becomes much smaller when you compare two active treatments. It's quite disconcerting to the developers of evidence based treatments but there it is. This is likely an expression of the 'Wampold factor' – all active credible treatments are about as good as any other active credible treatment. So rather than focusing on a narrow subset of EBTs, we should look at those components of active credible treatments that make them in general somewhat, although not terribly, effective. Perhaps it would be more efficacious and ecologically valid to focus on disease management strategies, rather than overly focusing upon a specific intervention that may not be applicable to many patients outside the confines of randomized trials. We live in a world of nonspecificity of effect – and it doesn't make a lot of sense to devise highly elaborate, specific treatments for a range of conditions that don't respond to highly elaborate, specific treatments any better than they do nonspecific ones. This isn't antiscientific – indeed, it's quite a scientific opportunity – but it defies the probability based analyses that the real 'scientific' psychology has become endeared of."
The Commonwealth Fund: "Using Pharmacists, Social Workers, and Nurses to Improve the Reach and Quality of Primary Care. As the landmark health reform law goes into effect, bringing millions of uninsured Americans onto insurance rolls over the next five years, demand for primary care services will increase. So, too, will demand for more accessible, effective, and efficient models of primary care. Rather than hiring more primary care physicians, many medical practices, health centers, and other primary care settings have been experimenting with innovative models of care that both extend the reach of primary care physicians and increase the quality of ambulatory services... [bringing] pharmacists, social workers, nurses, and nurse practitioners to primary care practices. With them comes a new set of skills that can improve care and lower costs for patients with depression, physical disabilities, and other conditions that have proven difficult to treat in primary care settings….
"The Commonwealth Care Alliance invested heavily in the model – spending approximately $4 million on 25 practices, many of which are located in low-income, safety net clinics. The investment, which covers the cost of hiring the nurse practitioners by the primary care practices and investing in infrastructure such as electronic medical records, is more than offset in reductions in hospitalizations for preventable conditions as well as delays in nursing home placements…."
Dramatic Change Is Coming: Over the next five years, we will witness the systematic implementation of what is perhaps the most significant social legislation enacted by the Congress since the Great Society programs of President Lyndon Johnson. Change is definitely coming. This could well be an extremely exciting era for our profession's prescribing psychologists. Those with vision and perseverance will thrive and flourish. Aloha,
Pat DeLeon, former APA President – Division 55 – September, 2010
