Answer: 60-30-10
Question: How much of clinical care is guideline-based, waste, or harm, respectively?
These numbers come from a well-known paper by Jeffrey Braithwaite, whom I’ll meet in person for the first time today in Sydney (see photo). A major cause of the waste and harm is clinical variation.
Individual clinician decision making is commonly associated with mindless or unwarranted variation (deviations from best practice, not based on evidence or patient preference) and associated with waste, morbidity, and mortality. Even specialists claiming to follow best evidence do not consistently do what they say.
This comes from Alan Morris, who spent a career demonstrating that you can represent the minute details of clinical decision making to create automated systems that outperform humans in some clinical tasks. Whereas other hospitals showed a survival rate for Acute Respiratory Distress Syndrome (ARDS) patients of about 10 percent, Alan showed that Intermountain’s rate was 40 percent. They achieved that through a closed-loop decision support system (i.e., the clinician didn’t make decisions--the algorithm did it all on its own) that adjusted the mechanical ventilation.
The ARDS guidelines say “... use the least PEEP [positive end-expiratory pressure] and tidal volume necessary to achieve acceptable gas exchange while avoiding tidal collapse and reopening of unstable lung units.” This replicable statement can lead to many different specific interventions by different clinicians, or even by the same clinician at different times, because it lacks the detail required for replicable clinician actions.
They also eliminated all variation in blood glucose management and blood glucose value distributions between 4 ICUs in 3 US states and Singapore with detailed bedside decision support (see this study).
A JAMIA paper by Alan makes a clarion call for Enabling a learning healthcare system with automated computer protocols that produce replicable and personalized clinician actions.
Computer protocols leading to replicable clinician actions (eActions) reduce mindless, unwarranted variation in clinical care and research. eActions could improve both clinical care quality and research by unburdening overtasked clinicians and by reducing noise in clinical databases. Common current clinical decision-support tools or aids, including guidelines and protocols, neither enable replicable evidence-based actions, nor provide individual patient-specific care. eActions should be formally discussed and pursued, nationally and internationally, in our efforts to reduce clinician variation, improve care, and establish a learning healthcare system.
Next week I will write more about the computable knowledge that is the keystone of an LHS with highlights from the upcoming MCBK Conference.
I wish I had a way to get replicable actions from my arm when I throw a baseball--we bought baseball mitts, and I played catch this weekend with my son. It’s scary to catch with me, because my throws are all over the place--the optimist in me thinks I’ll get better with practice. I’ll also keep you updated on that.
Regional Linguistic Quirks (RLQ): I started watching the new mini-series True Colors and was reminded of the unique use of the word “deadly” for awesome or great. That took me by surprise the first time I heard it.
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