Evidence-Based Medicine for the Busy Primary Care Physician: Using Computers to Integrate New Knowledge into Practice
Authors: Keith B. Holten, MD, Associate Clinical Professor, Department of Family Medicine, University of Cincinnati, Wilmington, Ohio; and Walter W. Rosser, MD, Professor and Chair, Department of Family Medicine, Queen’s University, Kingston, Ontario.
Editor’s Note—Although busy physicians want to practice "up-to-date" medicine, it is not easy to accomplish. The volume of available new clinical information is overwhelming. A significant time commitment is necessary to review new evidence and incorporate these findings into the day-to-day activities of patient care.
Research studies (primary evidence sources) are published in hundreds of medical journals monthly, with varying levels of quality and pertinence for the practicing physician. These studies have limited practical value to the caregiver, unless they are critically appraised. Secondary evidence sources, which have already been appraised (such as evidence-based guidelines and systematic reviews) are easily accessible by personal computer (PC) and hand-held computer.
In this paper, Holten and Rosser suggest a practical approach to facilitate the integration of new evidence into practice: 1) learn about available evidence-based medicine (EBM) computer resources; 2) during patient care, ask an interesting clinical question, at least once a day; 3) using a PC or hand-held computer, search for secondary information; and 4) integrate that information into the care of a patient. Some of the available evidence-based computer resources will be reviewed and their advantages and disadvantages will be considered.
Case Example
A 45-year-old female patient is seen in the office for a posthospitalization visit. During that hospitalization, she had chest pain with dyspnea, a myocardial infarction was excluded, and a stress thallium test was normal before discharge. Today a more thorough history and mental status exam confirm the diagnosis of panic disorder. You suggest a selective serotonin reuptake inhibitor (SSRI). She doesn’t have insurance and she asks for a less costly medication. You remember that tricyclic antidepressants were commonly prescribed for panic before SSRIs were available. You ask the question "are tricyclics equally effective to SSRIs for the treatment of panic disorder?" Where can you find the answer to this question, using your office computer and the Internet?
Introduction
Primary care physicians who spend a majority of their professional time directly involved in patient care have many challenges. The amount of time available to review the medical literature is minimal because of the competing demands of patient care and "paperwork." The patient populations are diverse, having a wide range of ages, a large variety of medical illnesses, many risk factors affecting health, and the need for timely preventive care advice. There is great need for new information that is easily accessible.
Although busy physicians want to practice "up-to-date" medicine, the flood of information makes this objective difficult to achieve. A significant time commitment is necessary to review new evidence and incorporate it into the day-to-day activities of patient care. Research of common primary care medical problems has increased at an explosive rate in the last decade. This new knowledge is available to physicians in many forms. Research studies (primary information sources) are published in hundreds of medical journals monthly, with varying levels of quality and pertinence for the practicing physician. However, these studies have no practical value to the caregiver unless they have been critically appraised. Secondary sources of information (such as evidence-based guidelines and systematic reviews) are now more available. These have been prepared by others who have the time to critically evaluate the primary literature. The volume of this information is overwhelming to busy physicians and is often found in the tall stacks of journals on the physician’s desk.
The use of computer technology, at the point of care, to integrate new information into daily practice will be addressed.
Background
New information should be driving a continuous change in the way doctors practice medicine, but there are growing gaps between the evidence and practice.1 Medicine is a field where lifelong learning is necessary to stay "up-to-date," but physicians have been shown to be averse to innovations and feel overwhelmed with information.2 Therefore, the need to provide physicians a fast and effective way to access current evidence is crucial. The following are necessary to accomplish the goal of practicing evidence-based medicine: 1) physicians must be motivated to continuously learn and have a questioning behavior; 2) new clinical information must be easily accessible and critically appraised; 3) information must be pertinent to the physician’s practice; and 4) evidence must be available during patient care sessions. (See Table 1.)
| Table 1 | |
| Necessary Behaviors for Practicing Evidence- Based Medicine | |
| • | Motivation to learn |
| • | Questioning behavior |
| • | Easily accessible clinical information |
| • | Information pertinent to the physician’s practice |
| • | Evidence available during patient care sessions (Point of Care) |
|
|
|
Many barriers to practicing EBM have been identified by physicians. (See Table 2.) A study of practicing internists3 reported lack of relevant evidence, newness of EBM, impracticality of clinical use, and a perception of negative effect on the doctor-patient relationship. In a survey of general practitioners,4 literature searching and critical appraisal were felt to be impractical for clinicians and access to summaries of evidence was preferred. Another study5 of Australian physicians cited lack of relevant information as an issue.
| Table 2 | |
| Barriers to Practicing Primary Care Evidence- Based Medicine | |
| • | Time demands |
| • | Newness of evidence-based medicine and lack of relevant evidence in primary care |
| • | Impracticality of clinical use |
| • | Negative effect on the doctor-patient relationship |
| • | Patient requests for unproven treatments |
|
|
|
Physician Motivation to Learn and Attitudes about Evidence-Based Medicine
It is suggested that relevant evidence, which is clinically practical and does not affect the doctor-patient relationship, will motivate physicians to learn and improve their attitude about EBM. However, there is no clear expert consensus about what motivates physicians to learn better patient care methods. It is assumed that internal goal setting motivates professionals. Do physicians lose their motivation to incorporate new information into practice because of "information overload"? The educational literature is more useful than the medical literature when answering this question. McKeachie6 has demonstrated that adults have intrinsic motivation to learn. This is driven by new experiences, enjoyment of new ideas, and the feeling of satisfaction from new competencies.
Individual attitudes of medical professionals toward the use of EBM vary significantly.7 Surprisingly, one recent study of practicing internists reported higher use of traditional sources, such as clinical experience, opinion of colleagues, and textbooks.3 EBM materials, such as primary research studies, practice guidelines, and Cochrane Collaboration Reviews were less commonly used. However, the surveyed physicians cited several reasons for not incorporating EBM into practice—lack of relevant evidence, newness of EBM, impracticality of clinical use, and a perception of negative effect on the doctor-patient relationship.
A study in Australia5 showed mixed attitudes toward EBM by general practitioners, who felt relevance of evidence, not quality, was most important. After surveying general practitioners, McColl4 suggested that improving access to summaries of evidence would be more effective than teaching skills of literature searching and critical appraisal.
Questioning Behavior
New information, which takes little time to access, will promote questioning behavior by physicians. Physicians, by nature, are curious about patients and their care. Barrie and Ward8 found that general practitioners asked 2.4 clinical questions for every 10 patients seen—a small number in his view. He suggested that it is necessary to promote questioning behavior in practice, if EBM is to be successfully introduced. A study by Ely and colleagues in 19929 found family physicians asked 1 clinical question for every 15 patients seen, with most questions about drug-prescribing and orthopedics. Busy practitioners asked fewer questions. They have since shown that doctors do not pursue answers to most of their clinical questions because they believe answers do not exist. As a result, a classification system for these questions is being proposed to guide the development of future practice information resources.10,11 The educational literature6 has shown that exposure to new information, with greater complexity, can foster curiosity.
Guidelines, Systematic Reviews, and Other Secondary Sources
Instruction in critical appraisal has not been effective in changing resident knowledge of EBM.12 Since it takes an average of 43 minutes to answer a question using a primary literature search,13 sources that provide direct and immediate answers are more widely used by practitioners.14 For this reason, guidelines, systematic reviews, and other secondary sources are popular among practitioners. Some of the available electronic sources of primary literature are listed in Table 3.
Do these resources change medical practice? Friedland and associates15 advocate the use of information produced by others as one method to be an evidence-based medicine practitioner. Practice guidelines and systematic reviews are readily available from multiple sources. EBM abstracts and reviews, such as ACP Journal Club and Evidence-Based Medicine, are other options.
Family physicians have a positive attitude about the use of clinical guidelines.7,16,17 Many studies have evaluated the success of implementing written guidelines into practice. There has been mixed success. There is need for better strategies to implement guidelines.18-22 One study1 found only a 5% implementation rate, with the best results from reminder systems and academic detailing. Another study17 demonstrated that 59% of physicians had difficulty finding a guideline when needed, so there was widespread interest in having them available by computer. Many strategies have been suggested to incorporate guidelines into practice.23-24
As with guidelines, distributing systematic reviews to clinicians, without other education, is not sufficient to change clinical practice.25 Systematic reviews are positively viewed by caregivers but are felt to be impractical for day to day use.3 The Cochrane Database of Systematic reviews26 is available on CD-ROM disc and by internet, allowing point-of-care application. Over the last few years, many other sources of secondary information27 have been developed, such as Journal of Family Practice POEMs (Patient Oriented Evidence that Matters28), ACP Journal Club, Evidence-Based Practice Newsletter, and Evidence-Based Medicine Journal. All of these are attractive because the authors have already performed critical appraisal and synopses are provided. Some examples of secondary sources of electronic EBM materials are listed in Table 5 (no fee) and Table 6 (fee-based).
Physician Attitudes about Computer Technology
At the World Summit on Medical Education in 1992, it was reported that the "technological advances of our time astound the public and professional alike."29 Because physicians must be efficient consumers of evidence, the use of computers has great potential. Physicians generally have a positive attitude about computer technology and are beginning to use these tools in practice.17,27,30-36 Family physicians rate computers highly.31 (See Table 4.)
| Table 4 | |
| Physicians and Computers | |
| • | Physicians rate computers highly |
| • | Most physicians have Internet access |
| • | Most physicians have little experience/training with information technology |
| • | Use of hand-held computers is rapidly increasing |
|
|
|
All physicians should have education in information technology that is interactive and sustained.37 The AFMO/AFPRD Strategic Planning Working Group has recommended that graduates of future family practice residency programs "understand how to apply information technology to enhance the clinical practice of family medicine."38 Until recently, physicians did not receive formal training in information technology. CME courses have not addressed this deficiency.
Real-Time Use of Computers
There are excellent evidence-based computer resources currently available for real-time use. Some products under development will additionally link patient characteristics to evidence and automatically search for pertinent new evidence.
Answering clinical questions by having "information at the point of care27" has outstanding potential to change practice patterns of busy practitioners. Computers have potential to become the cornerstone of evidence-based care.39 Clinicians, while seeing patients, can access drug information, evidence-based reviews, guidelines, and systematic reviews. One study has demonstrated the potential benefit of an "evidence cart" with real-time access to secondary sources of evidence, standard textbooks, the Cochrane Library, and MEDLINE on a general medicine inpatient teaching service.40 This evidence cart could not be used at the bedside due to its bulk. Table 3 compares 3 electronic literature search tools. These primary evidence sources are difficult to use at the point-of-care. They can take several minutes to complete, require access to journal articles after the search, and require a critical review of the information in these articles.
There are many excellent secondary sources of information (articles selected and critically appraised by an expert) for hand-held devices and personal computers. Some of the electronic secondary sources of evidence, including their advantages and disadvantages, are summarized in Table 5. The Cochrane Library, ACP Journal Club, Evidence-Based Medicine, and Best-Evidence (a database of ACP Journal Club and Evidence-Based Medicine) can be purchased for the personal computer.41
The Internet offers a wonderful opportunity for new evidence. In a study of rural physicians, 75% of caregivers reported using the Internet daily or 1-4 times a week.42 There are many secondary sources of evidence that are Internet accessible, including the Journal of Family Practice POEMS, TRIP (Turning Research into Practice), the National Guideline Clearinghouse,43 and the Cochrane Library. One easy way to access these materials (at the point-of-care) is to bookmark them or save them as favorites on your computer desktop, depending on the browser you use.
Hand-held computers offer an exciting innovation for access of EBM. The use of hand-held computers has been shown to improve compliance with care guidelines in the treatment of asthma.30 Palm-top computers have been shown to improve access to medical evidence by medical students, with the presence or absence of a reference determined in less than 30 seconds.34 Hand-held computers have been used to access treatment guidelines for stroke.44 Unfortunately, some searches are more time-consuming and do not produce useful references. InfoRetriever® is an excellent software45 package for evidence-based reviews and guidelines. It is available for hand-held computers and desktop computers (with desktop software and Internet access). We suggest that you practice, by searching for the answer to one clinical question per day. After several trials, searches can be completed in 5-10 minutes, affordable even for the busiest practitioner. The pay-off is higher quality patient care.
Hand-held computers offer an exciting future for the busy practitioner. One can envision wireless patient databases that automatically search for pertinent evidence.
Recommendations for the Practicing Physician
1. Familiarize yourself with the EBM computer resources available to you (see Tables 4, 5, and 6).
2. Understand the secondary sources of information; with minimal time investment, information, which has already been appraised by experts, will be at your fingertips.
3. At least once daily, while seeing patients, ask an interesting question about a patient. Using your favorite icons saved on your PC desktop, or a hand-held computer, search for answers to clinical questions. Integrate that information into the care of that patient.
4. Spend some continuing education time and money improving your computer and EBM skills. Practice these skills daily.
5. Share your successes with your colleagues locally.
Response to the Case Example. You do a search on the National Guideline Clearinghouse43 (www.ngc.gov) with search term: "panic disorder." In just a few minutes, you find a guideline from the American Psychiatric Association from 1998 (revised 2000) titled: Practice Guideline for the Treatment of Panic Disorder. It confirms that the 4 classes of medications for panic—SSRIs, tricyclics, benzodiazepines, and MAO inhibitors are roughly comparable in efficacy. The choice of the agent should be based on medication side effects, not cost. After discussing these issues with the patient, you prescribe a tricyclic antidepressant and arrange for follow-up.
Acknowledgments
Drs. Holten and Rosser appreciate Debra Vredenburg, PhD, for her editorial assistance.
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