'Best Practices' Provoke Controversy, Opposition
The notion of “best practices” is an emerging concept in health care policy and practice. Exactly what it means and how it will affect patient care are open to debate.
Minnesota Considers “Best Practices” Language
Minnesota House Republicans introduced “best practices” language into a health care cost containment bill (HF 1681) as a shield against medical malpractice lawsuits. The bill states, “In an action against a provider for malpractice, error, mistake, or failure to cure, whether based in contract or tort, adherence to a best practice guideline approved by the Board of Medical Practices is an absolute defense against an allegation that the provider did not comply with accepted standards of practice in the community.”
If enacted, the legislation will change medical practice in Minnesota in three significant ways.
- First, it could be inferred that any practice not approved by the Board is malpractice, and therefore ripe for litigation.
- Second, health care decision-making would be centralized in a bureaucratic quasi-government institution with committee processes essentially dictating availability of care.
- Third, medical practice would be infused with politics as Board members became the target of lobbying by insurers, employers, patient advocates, professional associations, pharmaceutical companies, and medical device manufactures.
The Minnesota Board of Medical Practice currently has a limited purpose. According to the Board’s 2002 Biennial Report, its mission is “to protect the public by extending the privilege to practice to qualified applicants, and investigating complaints relating to the competency or behavior of individual licensees or registrants.” Republicans propose to substantially expand that mission.
Although proposed as a remedy for unnecessary medical malpractice litigation, there is little evidence to assure patients that following “best practices” will improve their medical care. The possibility of severe penalties for doctors straying outside the “best practices” box will more likely lead to rationing of care.
“Best practices” has gained a national audience as well, most recently through an Institute of Medicine (IOM) publication, “Patient Safety: Achieving a New Standard for Care.” The report supports the establishment of a National Health Information Infrastructure (NHII) to facilitate sharing of patient data and dissemination of best practice guidelines to direct physician treatment decisions.
As envisioned, the NHII would facilitate information exchange on three levels: (1) personal health, to provide information to individuals about wellness and health care decision-making; (2) health care providers, to provide 24/7 access to detailed patient data and clinical decision support systems; and (3) public health, to facilitate state and federal public health surveillance activities.
In IOM’s vision of a new health care system, best practices and clinical decision support systems would be used together to direct physician practice. Computerized decision support systems take many forms, according to the report’s authors: reminders, alerts, embedded controls, decision assistance, and risk prediction using the “most up-to-date evidence from the research literature and practice-based resources.”
Research and evidence-gathering are funded by the Agency for Healthcare Research and Quality (AHRQ). Thirteen evidence-based practice centers (EPCs) around the country are working to churn out practice guidelines derived from analysis of studies on “clinical, social science, behavioral, economic, and other health care and delivery issues.”
These computerized “evidence-based” guidelines could be sent directly into the exam room, where physicians can be prodded by computers to perform in sync with the guidelines. As the report notes, “Putting evidence-based guidelines into a computer-readable format that can be used with decision support systems during clinical encounters is the objective of the informatics community.”
Once set in motion, the computerized systems would not only encourage practitioner cooperation, but also monitor practitioner compliance. Throughout the report, the authors note several possible ways the national health information infrastructure could be used to influence medical decision-making:
- linking patient outcomes with those responsible for those outcomes;
- measuring physician performance;
- monitoring compliance with best practices;
- ranking doctors and hospitals;
- providing financial rewards to practitioners based on performance ranking;
- submitting data to a national patient safety database; and
- permitting state and federal government health surveillance.
A Difficult Task
Determining what constitutes a “best practice” is a difficult task.
The IOM authors acknowledge “there are gaps and inconsistencies in the medical literature supporting one practice versus another, as well as biases based on the perspective of the authors, who may be specialists, general practitioners, payers, marketers, or public health officials.” Consequently, it is likely biases will be found among those who analyze studies and determine what “evidence” will be used to create the guidelines that appear on a doctor’s computer screen.
Moreover, insufficient clinical research exists to support evidence-based medical policy and coverage decisions, according to a recent article in the Journal of the American Medical Association. In an interview published by Medscape Medical News, Nancy S. Sung, lead author of the JAMA article, makes four important points that in themselves show the difficulty of defining “evidence” and avoiding bias:
1) Comparative data on the effectiveness of old versus new technologies are not available.
2) Significant holes exist in the body of evidence on which clinicians and patients base treatment decisions.
3) Employers and health insurers find clinical research has not met their needs to support evidence-based decisions.
4) Purchasers and payers of health care have worked with the Clinical Research Roundtable to develop a prioritized list of research questions they need answered.
There is also reason to worry that “micromanagement” through a computer terminal may reduce health care access. Managed care has already led to early retirement of physicians and fewer nurses. Applications to medical school continue to slide. Further interference by health system “executives” or aggressive penalties for non-compliance will only exacerbate this workforce problem.
The IOM also acknowledges in its report what it calls “the cycle of fear.” Authors note that use of performance data to rank, rate, or penalize a practitioner or institution may lead to defensiveness, gaming of the data system, or systematic manipulation of the data.
“Things we were forced to do back when I was in training would be considered malpractice today,” noted Dr. Jane Orient, executive director of the Association of American Physicians and Surgeons. “Establishing a rigid definition of ‘best practices’ would have a chilling effect on doctors thinking for themselves, making improvements, and correcting errors in the accepted ‘best practice’ standard. There is no better way to stifle innovation than to increase the legal risk for not following the cookbook.”
And finally, implementation of best practices may lead to a myopic focus on certain conditions with little attention to the other pressing needs of patients. In 2002 the IOM recommended 20 priority areas for evidence collection, practice guideline creation, and performance measurement development. Myriad conditions, and myriad iterations of conditions experienced by patients, are not on the list.
In theory, “best practices” sounds like a great idea. However, the standardization of health care and centralization of decision-making proposed in publications and legislation may not be as well-received by patients or practitioners. If a physician “fear factor” emerges alongside implementation of best practices, as the IOM cautioned, patients with complex requirements and unusual medical situations may find their doctors treating to a performance score rather than the needs of their patients.
Twila Brase, R.N. is president of Citizen’s Council on Health Care, St. Paul, Minnesota, and a frequent contributor to Health Care News. Her email address is firstname.lastname@example.org.