On average, it takes 17 years for new treatments to reach general clinical practice. This means that when patients visit a doctor in 2020, they will often receive guidance from 2003. For comparison: current practices date from a time before the iPhone! But during the pandemic, the pace of change in medical decision-making accelerated rapidly. COVID-19 was a new, highly communicable disease, and just as the data on the virus changed daily or weekly, so did the frontline nurses. The question now is how we can continue to respond to the latest medical science.
Case Study: The Speed of New Tests
COVID-19 tests are a vivid example of how quickly medical practice has changed during the pandemic. Initially, only nasal PCR tests were available that could only be performed by healthcare professionals. Within a few weeks, the instructions were updated so that patients can test themselves in the presence of a doctor, e. B. at drive-through test sites, and later alone in your own four walls. New tests soon became available, including saliva PCR tests, as well as antibody and antigen tests. We also kept receiving new information about certain manufacturers and tests. A 15-minute PCR test from Abbott Laboratories initially received much praise, but weeks later it was found to have a high false-negative rate. In short, the medical science of COVID-19 testing was changing rapidly, but in the face of the stress of the global crisis, medical practice has largely kept pace.
Can we keep this pace of innovation?
While COVID-19 offers an extreme case study for rapid medical advancement, it is just a matter of gradation. Approximately 2 million scientific articles are published each year, and new clinical guidelines are published every 1 to 3 years for each serious disease. In addition, there are new FDA notices and it leads to an information overload. A few years ago a common high blood pressure drug was found to contain a harmful pollutant, which resulted in a recall. However, months after this warning, I still saw new patients in my practice taking it.
The pandemic has shown that healthcare needs to be more responsive to changes in medicine, and it has shown that it can. But the way we did this isn’t scalable. We have kept pace with COVID-19 mainly because it has dominated the headlines and discourse in medicine and in our everyday lives. But that won’t work with the hundreds of conditions I handle in my practice every year.
Instead, here are some proven solutions to help doctors keep pace with the pace of change and better serve their patients:
Intelligent clinical decision support
The electronic health record system (EHR) I use in my clinical practice is little more than an expensive collection of scanned paper cards. I document decisions in it after I’ve made them – the EHR doesn’t help me make better decisions. Clinical decision support comes in a few forms, but it’s often not useful – take pop-up alerts for potential drug interactions, for example, which are generally just an unhelpful distraction.
If we want faster adoption of new clinical guidelines, we need intelligent decision support embedded in the EHR. When entering a patient’s medical history, Smart Support should ask additional questions to ensure that I am taking a complete medical history. When diagnosing, alternative possible diagnoses should be suggested in order to reduce misdiagnosis or to limit the search for drugs to those that have been shown to be effective.
It is not enough to have access to information on the latest medical science. In training we learn through “seeing one, making one, teaching one”. It is not enough just to see a pop-up in our EHR, although it helps. In medicine, learning is a social process.
A proven model for leveraging social learning once clinicians enter clinical practice is telementoring, developed by Sanjeev Arora, MD. As a liver specialist at an academic medical center in New Mexico, Arora looked at patients for patients with hepatitis C complications that might have been preventable with previous treatment. Knowing that he couldn’t treat every patient with hepatitis C in the state, he set up a hub-and-spoke system where family doctors in the community would video-confer cases weekly to specialists at his academic medical center. This gave them the opportunity to learn how best to treat hepatitis C from real patient cases.
In an article in the New England Journal of Medicine, Arora and colleagues demonstrated that with this experiential learning, these community physicians were able to treat hepatitis C as well as specialists.
Doctors are naturally driven to improve themselves, but we often don’t because we lack reliable, objective data to show where improvement is actually needed. Surgeon and researcher Marty Makary, MD, MPH, editor-in-chief of MedPage Today, has developed a method that doctors can use to obtain such information. Using a national record, Makary sent hundreds of Mohs microsurgeons a letter stating their performance in Mohs operations compared to their peers. Without sticks or carrots, the data alone changed the behavior of doctors. Doctors rated as outliers compared to their peers saw a remarkable 83% improvement in their practice. The key to the success of these doctor scorecards was that they came from a colleague, were objective, and were not intended for payment or punishment, but for learning.
Taken together, these three innovations have the potential to dramatically accelerate the pace of innovation at the cutting edge of care. We needed a global pandemic to update our clinical practice faster. It is now up to us whether we maintain and scale these improvements.
Shantanu Nundy, MD, MBA, is a practicing family doctor, Chief Medical Officer at Accolade, and author of Care After Covid: What the Pandemic Revealed is Broken in Healthcare and How to Revent It.