This blog post is in response to Shimona's query below:
" What is the relevance of EMR to the current practice of evidence based medicine? "
Well I have modified the question slightly as I wasn't able to directly copy paste it from the whatsapp group and I know she is also particular about EBM and so in the conversations in the evidence based list serve below I try to provide her more food for thought on this topic based on an older discussion where I had participated and am fishing out from my email box:
"El 03/11/2011 15:40, Dr. Carlos Cuello escribió:
On Thu, Nov 3, 2011 at 10:54, Rakesh Biswas <rakesh7biswas@gmail.com> wrote:
"SCMAIL.AC.UK] On Behalf Of Brian Alper MD
Date: Fri, Nov 4, 2011 at 9:10 AM
Subject: Re: Evidence-Based Medicine in the EMR Era
To: EVIDENCE-BASED-HEALTH@
" What is the relevance of EMR to the current practice of evidence based medicine? "
Well I have modified the question slightly as I wasn't able to directly copy paste it from the whatsapp group and I know she is also particular about EBM and so in the conversations in the evidence based list serve below I try to provide her more food for thought on this topic based on an older discussion where I had participated and am fishing out from my email box:
"El 03/11/2011 15:40, Dr. Carlos Cuello escribió:
Quite interesting on how electronic medical records can become a part of observational evidence and apply when there is no other evidence at hand.Good readhttp://www.nejm.org/doi/full/10.1056/NEJMp1108726 --
Carlos A. Cuello-García, MD
Centre for Evidence-Based Practice & Knowledge TranslationTec de Monterrey School of MedicineCochrane Collaboration Iberoamerican branchCITES piso 3. Morones Prieto 3000 pte. Col. Doctores 64710Monterrey, NL. Mexico."
On Thu, Nov 3, 2011 at 10:04 PM, Healingjia@msn.com <Healingjia@msn.com> wrote:
Dear Carlos and Ernesto,I am also intrigued with this field not only for traditional medical care but also for use in the realm of mental health. this over time could provide patterns that could lead to defining research instead of researchers beating the same dead horse without resurrection tactics from multiple angles it would also cross reference objectively behaviours and medication effects other than psychotropic agents although of course could include these
On Thu, Nov 3, 2011 at 10:54, Rakesh Biswas <rakesh7biswas@gmail.com> wrote:
The authors have summed it up interestingly...
"Did we make the correct decision for our patient? ...we may never really know.
“...in the light of experience as guided by intelligence...”
In the practice of medicine, one can't do better than that."
:-)
"SCMAIL.AC.UK] On Behalf Of Brian Alper MD
Sent: 03 November 2011 02:06 PM
We want the best available evidence at the time we are making a clinical decision. Ideally we have the best available evidence in a clearly understandable form, including understanding the quality/certainty/limitations of that evidence.
When the best available evidence is observational data from EMR records it would be ideal to have that readily available (with an understanding of its limitations).
In our traditional approaches some clinicians and researchers will seek observational data like this and publish it in the form of cohort studies, case-control studies or case series. This observational data may then be found by clinicians and may represent the best available evidence for a given concept. It can also be found by researchers and may stimulate further research and understanding.
In the new model described (this “case report” of using observational data from an EMR for a local decision) the data is unpublished (except for what was shared in this special report) and is otherwise not available for others. Likewise the clinicians in this example could not find the data that may be available in other EMR records at other institutions, and that data may be similar (corroborating) or different. It also took the clinicians 4 hours to obtain and analyze the data which is not be feasible for many clinical questions during practice.
Perhaps we will see a future when observational data from EMRs can be obtained without compromising privacy or ownership concerns, compiled from multiple settings, represented in real time to fit specific information needs, and be interpretable with the understanding of its limitations as observational data, ideally presented in context with sharing of more reliable evidence when more reliable evidence is available.
Brian S. Alper, MD, MSPH
Editor-in-Chief, DynaMed (www.ebscohost.com/dynamed)"
Subject: Re: Evidence-Based Medicine in the EMR Era
To: EVIDENCE-BASED-HEALTH@
Carlos,
I think Brian answered well. In the first instance the concept annoyed me due to an experience where I experienced physicians blindly accepting the printout on an ECG...as a minor finding of variations. Well the patients fingernails were bluish, he could barely stand, was dizzy etc so I sent him to the hospital, later at a surgeon friends home I went to his library and took out the cardiology book and matched the rhythms to the print out. When he asked what I was doing I told him and he said “Oh Amy, only the cardiologists bother with that, I am surprised you can read that”. They were patterns with labels..a six year old could have gotten it. I apparently made a good call as the hospital took him and he had open heart surgery. This really kind of biased me against EMR as I figure if none of the chart helps existed they would have actually looked at the patient and all the evidence....you know a patient is more than a traffic light and may need help even if the diagnostic doesn’t show in bold or red...I think when there is too much automation perhaps people forget what they once knew...
Really, I only looked at the link because you sent it through and then I started thinking about data mining possibilities, I think the possibilities are impressive and I really appreciate your assistance today in opening a rather firmly closed mind!
Amy "
Date: Fri, 4 Nov 2011 16:05:53 +0530
EMRs/Case Reports contain contextual information about an 'individual' that can have a psychological appeal for most clinicians as we often tend to think in terms of clinical pattern matching/recognition ( as in Amy's ...fingernails were bluish, he could barely stand, was dizzy etc or even ECG patterns for that matter?).
On the other hand current evidence based reviews contain information about a 'population' that is difficult to match with the patient at hand (due to the uniqueness of each individual case) and consequently at times may appear psychologically less appealing to clinicians?
Either way if there were a randomized controlled trial between a combined 'individual and population based information' (as in the evolving EMR model) and just 'population' based information ( as in the current model) to study their effect on clinical decision making in terms of patient related health care outcomes it is more likely that the combined approach would fare better?
:-)
regards,
rakesh
On the other hand current evidence based reviews contain information about a 'population' that is difficult to match with the patient at hand (due to the uniqueness of each individual case) and consequently at times may appear psychologically less appealing to clinicians?
Either way if there were a randomized controlled trial between a combined 'individual and population based information' (as in the evolving EMR model) and just 'population' based information ( as in the current model) to study their effect on clinical decision making in terms of patient related health care outcomes it is more likely that the combined approach would fare better?
:-)
regards,
rakesh
