How innovations such as
on-line 'just-in-time' CME may help bring about a genuinely evidence-based
clinical practice
Enrico Coiera
Centre for Health
Informatics, University of New South Wales
S. Bruce Dowton
Faculty of Medicine, University
of New South Wales
(Appeared
in Medical Journal of Australia 2000;173:343-344)
Keeping your clinical knowledge up-to-date is
an outmoded 20th century concept. In this new century, clinical science
produces information at a rate that far exceeds your individual capacity to
seek it out, read or absorb it. The ever-growing clinical information soup that
surrounds you means that it will never again be possible to claim total mastery
of a field of knowledge.
Consider this. The Cochrane Collaboration is arguably the largest and best-equipped international organisation solely focussed on determining what is best clinical practice based upon the objective evidence. It has produced 795 complete systematic reviews of the literature, covering 12,000 trials in the last seven years 1. There are now over 200,000 new trials in the library, so at this rate it will take the Cochrane Collaboration roughly 116 years for only the existing trials to be analysed. When we now add into the equation the new trials that will appear over this period, the problem is compounded substantially. So, if an organisation like the Cochrane Collaboration can't keep up to date with the clinical literature, individual clinicians have no chance.
Yet somehow the best clinical evidence must
find its way into clinical practice. Consumers expect it, and increasingly use
tools like the Internet to find it for themselves 2. It is also
abundantly clear that clinical practice generates unacceptably high level of
avoidable errors. The growing body of work on clinical safety emphasises that
improving the performance of our health system requires not just a change in
our technologies or our processes, but also in our culture 3.
The lesson is the same for evidence-based
medicine. We are in an age in which on-line technologies for information
storage and retrieval offer unparalleled access to information. As Weekley et
al. point out in this issue, there is now good evidence that computer-based
decision support systems have an important role in improving the quality of
clinical decisions and the effectiveness of healthcare delivery 4.
Yet, no matter how powerful the information technology might be, if we do not
change our beliefs about what constitutes acceptable clinical work practice, if
our culture does not alter to embrace change, then the technological
achievements are wasted 5.
We thus need to develop a new set of clinical
behaviours. Every time we make a clinical decision, we should stop to consider
whether we need to access the clinical evidence-base. Sometimes that will be in
the form of on-line guidelines, systematic reviews or the primary clinical
literature. Sometimes the interaction will be through a computer-based decision
support system, for example checking the appropriateness of a prescribing
decision. Often the 'knowledge base' will not exist in documents or on a
computer but in the heads of other clinicians, and on-line systems can also
function as communication tools, connecting clinicians with questions to those
who have answers 6.
Clinicians in the past were trained to master
clinical knowledge and become experts in knowing why and how. Today's
clinicians have no hope of mastering any substantial portion of the medical
knowledge base. However, with access to the right information and communication
tools, we can become masters at knowing how to find out, assess, explain and
apply clinical knowledge 7,8.
This still begs the question of what the
drivers for such a fundamental change might be. Financial incentives clearly
work. As Kidd and Mazza report in this issue, the Federal Government's Practice
Incentives Program has enticed GPs to computerise at a remarkable rate, with
65% claiming that they now use their computers to prescribe electronically,
compared with 15% in 1997 9.
However, it might be that Continuing Medical
Education (CME) becomes one of the most potent drivers for changes in clinical
practice. Assessing the research about different educational activities, it is
clear that traditional didactic measures such as lectures do not change
clinical performance or improve clinical care 10. In contrast,
interactive educational activities, structured around actual problems in the
clinical work place are much more successful.
So, if keeping up-to-date as a separate
activity is no longer feasible, and if learning works best when focussed on
issues in the clinical work place, then in the future most CME will consist of
using on-line information technology to answer immediate clinical questions 11. Thus, the whole notion of CME changes from
one of periodic updates to a clinician's knowledge to a 'just in time' model
where a clinician checks the medical knowledge base, potentially at every
clinical encounter.
We already have CME systems in Australia which
award credits for CME activities 12. With an on-line CME system, it
is possible to reward clinicians for good evidence-based behaviours like
consulting a clinical guideline, looking up a critical review, or conducting a
quick literature search. We could also reward contributions to the shared
knowledge base, awarding credits for authoring guidelines, reviews and the
like. As a by-product, the collection of CME credits will be automated.
Clinicians will no longer have to laboriously document their behaviours for
accreditation. Indeed, it may make more sense in this world to remove arbitrary
CME targets all together. Rather, clinicians can use their accumulated credits
to compare their activity with that of their colleagues. The Colleges could
counsel individuals whose behaviours were substantially out of step with the
normal practice of their peers. So, in the near future, as you use your
computer during the clinical encounter, you wont just be writing prescriptions
or working with an electronic record, you may be earning CME points as you check
the latest evidence 9.
If we are to contemplate such changes, then
building and disseminating the technologies will not be enough. At its heart,
this is about cultural change and the reinvention of many aspects of clinical
practice. We thus need to pay explicit attention to educating both working
clinicians and the students in our medical schools in good evidence-based
practice, as well as the use of the new information tools 8. Changes
also need to be made to the way in which clinicians are encouraged to be
evidence-based. CME points will help, but ultimately consumers and health
funders need to recognise that the good practices they expect require a change
in the clinical encounter. Evidence-based practice requires clinicians to spend
more time with their patients, to learn new skills, and to invest in new
information technology. So, all the players in our complex health system need
to own and embrace the costs and benefits of moving to a truly evidence-based
practice. This is one culture change clinicians can't make alone.
1.
Silagy C. Personal communication.
2.
Eysenbach G. Consumer health informatics BMJ
2000; 320: 1713-1716.
3.
Leape LL Berwick DM. Safe
health care: are we up to it? BMJ 2000;320:725-6.
4.
Weekly
JS, Smith BJ, Pradhan M. The intersection of health informatics and
evidence-based medicine: Computer-based systems to assist clinicians MJA
2000:173;376-378.
5.
Coiera E. Editorial: The Impact of
Culture on Technology, MJA 1999;171:508-509.
6.
E. Coiera. When Communication is better than
Computation. Journal American Medical
Informatics Association. 7,277-286, 2000.
7.
Slawson DC, Shaughnessy AF, Bennett JH Becoming a
medical information master: feeling good about not knowing everything. J
Fam Pract 1994 May;38(5):505-13.
8.
Coiera E. Editorial: Medical
informatics meets medical education - There's more to understanding information
than technology, MJA 1998;168: 319-320.
9.
Kidd
M, Mazza D. Viewpoint: Clinical Practice Guidelines and the computer on your
desk MJA 2000:173;373-375.
10.
Davis
D, Thomson O'Brien MA, Freemantle N et al. Impact of formal continuing medical
education - do conferences, workshops, rounds, and other traditional continuing
education activities change physician behaviours or health outcomes? JAMA
1999:282;867-874.
11.
Weed LL Knowledge
coupling, medical education and patient care. Critical Reviews in Medical
Informatics. 1(1):55-79, 1986.
12.
Newble D, Paget N, McLaren B.
Revalidation in Australia and New Zealand: approach of the Royal Australiasian
College of Physicians. BMJ 1999;319:1185-1188.