To the Editor:
To continue to improve quality of care while minimizing cost, it is essential that physicians begin to embrace the principles of evidence-based medicine (EBM) and implement them in their clinical practices. The series in The Journal of Family Practice on Patient-Oriented Evidence that Matters (POEMs) is a major step in incorporating EBM into primary care. POEMs are an easily digestible form of the best recent evidence that is relevant to primary care physicians. I think POEMs have contributed a great deal in getting the readers of the Journal to think about EBM and how to practice higher quality care.
However, I think that POEMs will have very little impact on clinical practice by themselves. That is because getting physicians to change their practice behavior requires not only providing information that is valid, useful, and easy to read but also that this information is available at the time the physician is making a clinical decision, at the point of care. Therefore, although the POEMs are a good first step toward higher quality care, the greatest hurdle still remains, incorporating POEMs into everyday clinical practice.
To determine how to clear this hurdle, we must first think about how primary care physicians currently obtain information for the purpose of clinical decision making. Research has shown that physicians are most likely to go to quick reference guides, such as the Physicians’ Desk Reference, The Washington Manual of Medical Therapeutics, The Harriet Lane Handbook: A Manual for Pediatric House Officers, or the Sanford Guide to Antimicrobial Therapy. None of these guides is particularly evidence-based. The reason physicians use them is that they give practical information quickly. Although POEMs and other evidence-based sources of information are available (United States Preventive Services Task Force guidelines, for example), this information is not widely used because it is not organized in a way that makes it usable in the course of a 10- or 15-minute patient visit.
So how do we organize POEMs or other evidence-based information in a manner that makes it usable at the point of care? I think the only way to do it is electronically. It is conceivable that these sources could be linked into a database that is searchable by medical problem, medication, and so forth. This could be organized into a hypertext format where the first screen shows the basic recommendation for the medical problem, and the physician could dig deeper, if desired, to explore the evidence on which the recommendation is based.
An even better scenario would be to automate this process by linking such an EBM database with an electronic medical record (EMR). One could envision a scenario where a physician enters a diagnosis and a test or medication into the EMR, and a link appears that tells the physician that there is an evidence-based recommendation that could help support his or her decision. It could also provide alerts or warnings when tests or medications are ordered that are inappropriate for the diagnosis given. For this to work, it would need to be informative but unobtrusive and would have to allow multiple layers of complexity, depending on the physician’s need and time.
Such a scenario is not futuristic. It is technically feasible, and in fact, similar ideas are being discussed among medical informaticians. For this to become a reality, there needs to be an ongoing dialogue between the experts in primary care informatics (eg, the Primary Care Working Group of the American Medical Informatics Association) and the experts in evidence-based medicine. I am confident that by putting the best ideas of these 2 groups together we will be able to explore ways to make POEMs truly useful to the practicing physician. Once this happens, I believe that POEMs will begin to have a significant positive impact on quality and outcomes of care.
James M. Gill, MD, MPH
Christiana Care Health Services
Wilmington, Delaware