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?
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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.
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.
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.
Challenge Team Perspectives
We selected 10 questions out of the many submitted by our Great Challenges Community, to be addressed by each of our Team members.
See their responses and perspectives, below.
Question 1What 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.
Select a Question to View The Challenge Team's Responses
The following questions were submitted by the TEDMED Community and selected for further discussion. The Team Members have weighed in on each, select below to see their responses: