Wednesday, December 11, 2013

Guidelines for Guidelines

"Guidelines" (like these) drive health leaders, policymakers, politicians and caregivers crazy. They're supposed to describe "evidence-based" "best practices" for diagnosis, treatment and overall management for hundreds of medical problems. Yet, it's been known for years they often go ignored by many practicing physicians who are unaware of them, would rather rely on their individual independent judgment and experience, doubt their validity or would rather continue with what they've done for years.

What's the problem? Is it the guidelines or is it the docs?

Johns Hopkins' Peter Pronovost, writing in the Dec. 5 JAMA wonders if both can be helped with some common sense guidelines for guidelines:

1. Any guideline should prioritize its recommendations (based on patient benefit) and explicitly link them to "time and space" of a specific point in the course of an episode of care  The author points out that it's not uncommon for guidelines to be more than a hundred pages and simply list all the recommendations.

2. Guidelines should identify the barriers to their adoption and recommend strategies for their successful implementation.  Naturally, the developers of these guidelines would need to climb down from their ivory towers and actually think (and maybe perform research) on getting the guideline into the front lines of real-world health care.

3. Guidelines need to contemplate co-existing conditions and stop focusing on single diseases or risks.  In a hospital, it's not unusual for safety checklists to deal with single issues, resulting in dozens of lists.

4. Automate automate automate and use "systems" of care instead of relying on the memory and best intentions of human beings.  Robotics can do a lot of routine monitoring, patient work flows can incorporate safety and docs and nurses should be freed to be..... docs and nurses!

5. Develop "practice strategies" that integrate multi-disciplinary teaming and pools expertise in the related sciences of epidemiology, implementation and engineering.

The DMCB agrees with the ideas and wonders if these recommendations can't also be used by Accountable Care Organizations, health care systems and population-based service providers as they seek to disseminate best practices for the care. It's one thing to "post" or "link" a standard guideline in an intranet or an electronic health record "prompt," it's another to make it useful at the point of care.

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