Faster Adoption of Best Practices
About this Challenge:
Best Practices Medical progress only occasionally depends on double blind, placebo-controlled studies. Most healthcare improvements come through small, incremental steps across tens of thousands of surgeries, procedures and protocols — from a better way to take a temperature to a better stitch or a better way to ask a question in the ER. But most of these improvements are not captured, shared and replicated across the healthcare system.
Even when best practices are identified and publicized, many providers seem slow to adopt them. What can we do to capture millions of improvements per year and make best practices available to benefit many more providers and patients?
Meet the Challenge Team
The Challenge Team Members are leaders in their fields and reflect multi-disciplinary, passionate and thoughtful perspectives for the Challenge they represent.
Challenge Team members participate in the discussion held by the Great Challenges community, and will be creating responses to questions submitted by the community on the discussion tab.
- look for this icon throughout the Great Challenges discussions. It is used to identify comments posted by the Challenge Team members.
Brian S. Alper, M.D., MSPH, FAAFP is the founder and Editor-in-Chief of DynaMed (dynamed.ebscohost.com) and the Medical Director of EBSCO Publishing. As a medical student Dr. Alper realized he could not memorize sufficient medical information to support practice so he began organizing information electronically to support his medical practice needs. During a rural practice experience in Tennessee, he saw his disease summary notes making differences in diagnosis and treatment every day and saw the need for clinician support. As a result, Dr. Alper created DynaMed, a clinical reference tool to provide the most useful information to health care professionals at the point of care, and he created a systematic way to monitor current literature and continuously update DynaMed based on the best available evidence.
Dr. Alper has completed residency and fellowship training in family medicine, and serves as clinical research assistant professor at University of Missouri-Columbia. He has conducted original research and systematic reviews and taught evidence-based medicine to medical students, residents, fellows and faculty. He has presented numerous lectures and workshops at educational programs, hospitals and national and regional professional meetings and has served as the Co-Chair of the Society of Teachers of Family Medicine Group on Evidence-Based Medicine.
As the editor-in-chief for DynaMed (dynamed.ebscohost.com) my expertise lies in the critical appraisal of clinical research and summarizing it for rapid interpretation by busy clinicians. The influence this will bring on my perspective to the conversation includes years of detecting potential for bias in the reporting of BEST PRACTICES where biases may be due to commercial influence, logical fallacies, scientific misinterpretation, or lack of recognition of clinical considerations. I also have unique perspective on FASTER ADOPTION as DynaMed is updated daily based on systematic evaluation of best practices—hard to get faster than updating daily.
Anne C. Beal, M.D., M.P.H., is chief operating officer of the Patient-Centered Outcomes Research Institute. A pediatrician and public health specialist, she has devoted her career to providing access to high-quality health care through the delivery of health care services, teaching, research, public health, and philanthropy. As PCORI’s first COO, Beal will be responsible for ensuring PCORI develops the structure and capacity needed to carry out its mission as the nation’s largest research institute focused on patient-centered outcomes research.
Dr. Beal joins PCORI from the Aetna Foundation, the independent charitable and philanthropic arm of Aetna Inc. As president, she led the foundations work on improving health care in the U.S., particularly for vulnerable patient groups.
Prior to her work at the Aetna Foundation, Dr. Beal was assistant vice president for the Program on Health Care Disparities at the Commonwealth Fund, a private foundation that aims to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.
Dr. Molly Joel Coye is the Chief Innovation Officer of the UCLA Health System at the University of California, Los Angeles, and director of the Institute for Innovation in Health at UCLA. The Institute for Innovation in Health leads the health system in identifying new strategies, technologies, products and services that will support large-scale transformation of healthcare delivery and population health management. The UCLA Health System is a national leader in research and healthcare delivery for both highly specialized tertiary and quaternary clinical care and managed care services for large populations.
Dr. Coye was the founder and CEO of the Health Technology Center (HealthTech), a non-profit education and research organization established in 2000 that became the premier forecasting organization for emerging technologies in health care. Dr. Coye has also served as Commissioner of Health for the State of New Jersey, Director of the California Department of Health Services, and Head of the Division of Public Health Practice at the Johns Hopkins School of Hygiene and Public Health. Dr. Coye is a member of the National Academy of Sciences’ Institute of Medicine, and Chair of the Board of Directors of PATH, a large nonprofit organization in international health. She is also a member of the Board of Directors of Aetna, Inc., Prosetta, Inc., and the American Telemedicine Association, and a past member of the boards of the American Hospital Association, the American Public Health Association, The California Endowment and the China Medical Board, as well as the advisory boards of healthcare information technology and services investment firms. Dr. Coye holds M.D. and M.P.H. degrees from Johns Hopkins University and an MA in Chinese History from Stanford University and is the author of two books on China.
Dr. Molly Joel Coye is Chief Innovation Officer and director of the Institute for Innovation in Health at UCLA, leading the health system in identifying new strategies, products and services for large-scale transformation of healthcare delivery. Dr. Coye previously served as CEO of the Health Technology Center (HealthTech), Commissioner of Health for the State of New Jersey, and Director of the California Department of Health Services. She is a member of the Institute of Medicine, Chair of the Board of Directors of PATH, and a member of the Board of Directors of Aetna, Prosetta, and the American Telemedicine Association.
Kedar Mate, M.D. is an Assistant Professor of Medicine at Weill Cornell Medical College and Faculty for the Institute for Healthcare Improvement. Previously he has worked with Partners In Health and served as a special assistant to the Director of the HIV/AIDS Department at the World Health Organization. In addition to his clinical expertise in hospital-based medicine, Dr. Mate has developed broad expertise in health systems science. He currently advises numerous initiatives in transitional and low-income economies on developing and applying novel approaches to strengthening health systems to improve delivery of HIV, TB and maternal and child health services. In his leadership role at IHI, Dr. Mate has overseen the developments of innovative new systems designs to implement high quality health care both in the US and in resource-limited settings abroad. Dr. Mate currently teaches undergraduate and graduate courses in the US, Haiti, and Tanzania about quality improvement and global health systems. He graduated from Brown University with a degree in American History and from Harvard Medical School with his medical degree. He trained in internal medicine at the Brigham and Women's Hospital in Boston and currently resides in Virginia.
I’ve worked with healthcare organizations and practitioners to help them adopt evidence-based best practices for a number of years in a wide variety of contexts. I started this work trying to ensure that vulnerable populations in Africa and Asia had faster and more reliable access to life saving HIV and TB medicines and have used many similar ideas to improve health system reliability with hospital based care in the US. Ten to seventeen years, the time it takes for the fruits of our current scientific knowledge to become widespread practice, is simply too long to wait.
Mitesh Patel, M.D., M.B.A. is a practicing physician, entrepreneur, and academic researcher who leads Docphin's executive management and strategic vision. Docphin is transforming the practice of medicine by enabling healthcare providers to personalize, access, and connect through medical research. The platform has spread nationally and is now being used by hospitals to better disseminate clinical guidelines and best practices. Mitesh is a Robert Wood Johnson Clinical Scholar at the University of Pennsylvania. He has conducted academic research for over a decade and his work has been published in the New England Journal of Medicine and featured in the New York Times. He studies and designs curriculum for medical schools and residency programs at the national level. He is a Senior Fellow at the Leonard Davis Institute for Health Economics and a researcher at the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania.
Mitesh holds undergraduate degrees in Economics and Biochemistry as well as a Medical Doctorate from the University of Michigan. He obtained an M.B.A. in Health Care Management from the Wharton School of the University of Pennsylvania. Mitesh completed his internal medicine residency training at the Hospital of the University of Pennsylvania.
I bring a unique combination of firsthand experience on the adoption of best practices spanning from providing care for my patients, to building technologies for hospitals and providers, and studying how to accelerate the translation of evidence to inform medical decision making. At Docphin, I led the development and national expansion of a platform that makes it easier for providers to personalize, access and connect with the information they need when they need it most. In my academic research, I studied and designed an innovative framework to guide providers to make decisions based on evidence and best practices.
Barbra Rabson has been the executive director of the Massachusetts Health Quality Partners (MHQP) since 1998. MHQP is a nationally recognized coalition of health care providers, plans, consumers, government agencies, academics and purchasers working together to promote measureable improvement in the quality of health care services in Massachusetts. Under Ms. Rabson’s leadership, MHQP has become one of the most trusted names in performance measurement and public reporting of health care information in Massachusetts and in the nation.
Ms. Rabson is the co-chair of the Greater Boston Aligning Forces for Quality Alliance. She is a founding member and past Board Chair of the Network for Regional Healthcare Improvement (NRHI), a national network of regional health improvement collaborative. She also serves on the Board of the Massachusetts eHealth Collaborative (MAeHC) and on one the Mayor of Boston’s selection committee for the Mayoral Prize for Innovations in Primary Care.
Ms. Rabson has a long track record for innovative collaboration. She received her Masters in Public Health from Yale University and her undergraduate degree from Brandeis University.
As the leader of a nationally-recognized regional health improvement collaborative working to drive measurable improvements in health care quality, patients’ experiences of care, and use of resources in Massachusetts, I’ve had experience with “pushing” the adoption of best practices and have learned that adoption comes about when there is a “pull” from those needing to make the change. Motivating the “pull” is the challenge, and we know there are multiple levers for this including the desire to perform as well as one’s peers (using trusted comparative performance information), financial incentives, and making best practices reasonably easy to implement.
Discussion Policy
Discussion Policy
- The TEDMED Community is offered as a free public service to promote discussion on the future of Health and Medicine.
- Any “Submission” made is of the opinion of the community member who posted it and does not, in any way, reflect the views or opinion of TEDMED.
- In making a Submission, you agree that you will not violate any trademark or copyright laws. You agree and acknowledge that TEDMED does not represent any rights to the Submissions.
- As a member of the TEDMED community, we encourage you to share your knowledge, information and opinion. In making a Submission, you agree that such submission is made in a professional manner with the purpose of furthering or expanding discussion on TEDMED.com.
- As a member and participant of TEDMED.com, you also agree to respect the Submissions of your fellow TEDMED community members and allow for equal opportunity and participation.
- In making a Submission you consent to the right of TEDMED to expand or edit any Submission and we may contact you to discuss further.
- TEDMED has the right to remove, in its sole discretion, any Submission made that does not represent or encourage a professional and communal environment.
- TEDMED has the right to indefinitely suspend, in its sole discretion, any account for members registered at TEDMED.com.
7 Comments
-
MD Moulton: Lack of time and priority - In determining best practices relevant to your practice group/team all must review internal lessons learned and those shared by other practice groups. Providers and clinicians have a hard time finding the time for reading journals for changing medical information or other continuous education exercises. This is caused by the reimbursement schema. For today it's "must see more people" and "more paperwork". Therefor all else is lower priority. Apply Lean principles to remove waste from the daily life. Habits die hard so go through new processes with a buddy until there is a body of evidence to show outcome in the change. If it adds value to the individual's life (e.g. going home "on time"), keep it. If it doesn't add value, don't keep it.
What constitutes "best practice"? - Interaction with a patient and application of knowledge to help the patient is contextual.
Lone Wolf syndrome - Even if practicing in a group advocating "Team Medicine" each provider is individually accountable. This can create the mental attitude displayed by the sole proprietor / small business owner. Both Team and Individually Accountable exists in the same person.
Prototyping and mentoring - Adoption improves with use of instructional design ADDIE model, prototyping and/or simulation and "at the elbow" support (someone you can turn to in the moment to confer and discuss). In other words, "you're not in this alone".
Drinking from the fire hose - Don't do lessons learned exercises that lead to best practice policy update that lead to adoption project in a linear manner. As a team schedule a risk and lessons review at least weekly (for workflow, not the medical review meetings). Use current technology content management to make suggestions available, then go through the policy change process for you practice. Balance this. If you make policy changes too frequent, it's too hard to know what is the current policy (see "Lack of time and priority" above).
Outsiders don't understand us - What works in other industries doesn't apply here. We're special. We save lives. Most innovation comes from seeing patterns (from all around us) and seeing that all or part of a process or action could translate. The check list came from the airplane pilots. A worker making error doing the wire wrap for the electrical harness in a 747 on the manufacturing floor, if QC doesn't catch it, can kill 500 people plus however many are in the on ground debris field. Healthcare isn't the only industry that saves lives or kills through error.
As with the patients, if one see a positive value happening in one's life because of the best practice, the provider or clinician will keep it. ... and help one another. -
Amy Edgar: I would add fear to the list of obstacles. Fear is most likely the partner of inertia when considering change. Additionally, the lack of a unifying framework for members of the whole healthcare team. Currently best practice is often disseminated in siloed, discipline specific venues that do not allow for cross pollination of innovation.
-
Andrew Brandeis: I totally agree. This is a problem my team and I are actively solving. Doctors need a way to share best practices in a fast, clinically relevant way. Share Practice is a social clinical reference that doctors use to collaborate on treatments and diagnostics and rank therapies. Kind of like a social Epocrates. We have over a thousand doctors successfully using our closed beta. It is solving a lot of these problems.
-
TEDMED Moderator: If use of electronic health records is a "best practice," then things are looking up. In 2012, 72% of office-based physicians used electronic medical record or electronic health record (EMR/EHR) systems, up from 48% three years ago.
Read more at http://venturebeat.com/2012/12/30/health-tech/#zvwziUXrogLFw6ZV.99
Posted 12-31-12
-
TEDMED Moderator: Can artificial intelligence...think IBM's Watson...help doctors adopt best practices? The answer is yes, according to Dr. James Stoller, chair of the Cleveland Clinic Education Institute. It seems that Watson is going to medical school at places like the Cleveland Clinic and the Sloan-Kettering Cancer Center. Stoller says that eventually, after the computer "learns" much more about how doctors work and think, it may be able to help with diagnosis and treatment. "Watson will advance the best practice of medicine based on evidence to the extent that it learns the most rigorous information," Stoller told Information Week. http://www.informationweek.com/healthcare/clinical-systems/ibms-watson-hits-medical-school/240012800
-
-
Brian Alper MD, MSPH, FAAFP: Marion is correct in that Best Practice should be based on an individualized approach informed by best evidence (accurate understanding of current science) but also adjusting for unique clinical circumstances, and patient values and preferences. One treatment being better on average than another treatment is not sufficient information alone to make it the first choice for all patients. There are some situations (like infection control) where patient safety and social benefits beyond the individual patient warrant top-down regulatory approaches to health care delivery expectations. But for many situations faster adoption of best practices can be served by faster availability of best information to support faster selection of best practices through evidence-informed individualized decision-making.
What the Community Asked:
Ask the Challenge Team: Our Challenge Team is taking questions on this topic for a limited time, and will answer many on this site. We'll let you know if yours is selected for a response.
The Challenge Team Responds
-
Sort by Community Question Here:
-
Browse the Challenge
Team responses Below -
Share Your Opinion
About Each Question
Question 1
What are the top 10 obstacles to widespread acceptance and implementation of best practices?The top 10 obstacles to widespread acceptance and implementation of best practices are:
- Change is hard. Implementation of best practices requires doing things differently and clinicians are experiencing "change fatigue" particularly given the rapid changes at the national and state level around payment and delivery reform.
- Cultural Resistance. When best practice implementation is decided by administrators and it is a "top down" approach there can be a cultural resistance because docs don't like to be told what to do.
- Lack of time. Clinicians often don't have the time it takes to understand the change and how to implement it in their work flow.
- Lack of "how to" knowledge". Clinicians and organizations often the lack knowledge of how to implement the best practices.
- Lack of sharing networks. Clinicians frequently face many barriers to implementing changes and they practice in silos and often lack networks where people can receive information from people they know and trust, and where they can share not only 'what' works but also the 'how to' tools to facilitate implementation.
- Misalignment of financial incentives. Economic incentives, including fee-for service reimbursement based on volume rather than performance, often work against the implementation of best practices.
- Lack of systems and support tools. Clinical decision support tools that support clinicians in the use of evidence based practice - e.g. preventive screening guidelines reminders on IT system - have not been widely used.
- Lack of peer reviewed published evidence based practices. Best practices are often not published in peer review studies since organizations that identify and implement best practices often lack the time to publish findings.
- Conflicting evidence. The literature has conflicting recommendations based on different perspectives such as the recent controversy about screening women between the ages or 40 and 49 for breast cancer when the US Preventive Services Task Force (USPSTF) issued new recommendations in conflict with the American Cancer Society.
- Lack of peer validation. Clinicians may know of the evidence but may not be convinced that it is the standard of care, or lack the confidence that they have good basis for change until they see their peers validating that it works. Having colleagues confirm that the evidence is conclusive ("social validation") helps in gaining this confidence.
Discussion Policy
Discussion Policy
- The TEDMED Community is offered as a free public service to promote discussion on the future of Health and Medicine.
- Any “Submission” made is of the opinion of the community member who posted it and does not, in any way, reflect the views or opinion of TEDMED.
- In making a Submission, you agree that you will not violate any trademark or copyright laws. You agree and acknowledge that TEDMED does not represent any rights to the Submissions.
- As a member of the TEDMED community, we encourage you to share your knowledge, information and opinion. In making a Submission, you agree that such submission is made in a professional manner with the purpose of furthering or expanding discussion on TEDMED.com.
- As a member and participant of TEDMED.com, you also agree to respect the Submissions of your fellow TEDMED community members and allow for equal opportunity and participation.
- In making a Submission you consent to the right of TEDMED to expand or edit any Submission and we may contact you to discuss further.
- TEDMED has the right to remove, in its sole discretion, any Submission made that does not represent or encourage a professional and communal environment.
- TEDMED has the right to indefinitely suspend, in its sole discretion, any account for members registered at TEDMED.com.
1 Comment
-
MD Moulton: Lack of time and priority - In determining best practices relevant to your practice group/team all must review internal lessons learned and those shared by other practice groups. Providers and clinicians have a hard time finding the time for reading journals for changing medical information or other continuous education exercises. This is caused by the reimbursement schema. For today it's "must see more people" and "more paperwork". Therefor all else is lower priority. Apply Lean principles to remove waste from the daily life. Habits die hard so go through new processes with a buddy until there is a body of evidence to show outcome in the change. If it adds value to the individual's life (e.g. going home "on time"), keep it. If it doesn't add value, don't keep it.
What constitutes "best practice"? - Interaction with a patient and application of knowledge to help the patient is contextual.
Lone Wolf syndrome - Even if practicing in a group advocating "Team Medicine" each provider is individually accountable. This can create the mental attitude displayed by the sole proprietor / small business owner. Both Team and Individually Accountable exists in the same person.
Prototyping and mentoring - Adoption improves with use of instructional design ADDIE model, prototyping and/or simulation and "at the elbow" support (someone you can turn to in the moment to confer and discuss). In other words, "you're not in this alone".
Drinking from the fire hose - Don't do lessons learned exercises that lead to best practice policy update that lead to adoption project in a linear manner. As a team schedule a risk and lessons review at least weekly (for workflow, not the medical review meetings). Use current technology content management to make suggestions available, then go through the policy change process for you practice. Balance this. If you make policy changes too frequent, it's too hard to know what is the current policy (see "Lack of time and priority" above).
Outsiders don't understand us - What works in other industries doesn't apply here. We're special. We save lives. Most innovation comes from seeing patterns (from all around us) and seeing that all or part of a process or action could translate. The check list came from the airplane pilots. A worker making error doing the wire wrap for the electrical harness in a 747 on the manufacturing floor, if QC doesn't catch it, can kill 500 people plus however many are in the on ground debris field. Healthcare isn't the only industry that saves lives or kills through error.
As with the patients, if one see a positive value happening in one's life because of the best practice, the provider or clinician will keep it. ... and help one another.
Live Event
Members of the Great Challenge Team, Faster Adoption of Best Practices gathered on Google + Hangout to discuss the topic in a virtual roundtable event.
View the Live Event recast and then continue the discussion by leaving your thoughts below!
 | MODERATOR: This discussion is being moderated by Marie Smith, PharmD, Assistant Dean of Practice and Public Policy Partnerships and Henry A Palmer Professor in Community Pharmacy Practice from the University of Connecticut School of Pharmacy. Marie is a seasoned clinician-educator, boundary spanner, thought leader, and healthcare strategist who enjoys tackling health care delivery, payment reform, and policy challenges using a system-level approach and multidisciplinary perspectives. Learn more about Marie here. |
Participants:
Brian Alper MD, Anne C. Beal, Molly Coye, Kedar Mate MD, Mitesh Patel MD, MBA, Barbra G. Rabson, MPH
Meet the Team