Health system takes EBM beyond its four walls

Follow-up at home key to intervention success

A growing number of quality professionals have adopted an evidence-based approach to ensuring quality in health care interventions, but for the most part, their emphasis has been on the inpatient stay. Now a Massachusetts health system has decided to send evidence-based medicine home with its patients after discharge.

"It’s one thing to get it all right in the hospital, but the real impact of these interventions is if the patient and the primary physician continue these interventions," notes Gray Ellrodt, MD, chief of medicine at Berkshire Health System in Pittsfield. Berkshire Health System, an integrated-delivery network, provides about 90% of the acute health care to the region through two hospitals, 900 nursing home beds, and multiple community outreach programs. "Berkshire is a teaching hospital," he explains.

Why evidence-based medicine?

To many quality managers, speaking of evidenced-based medicine is "preaching to the choir." But Ellrodt says it is instructive to review its benefits. "Basing interventions you want to improve on those that are solidly supported in the literature makes sense because you know from the literature what the impact will be. Therefore, it’s most likely that if you implement these interventions, you will see a decrease in morbidity and/or mortality," he explains.

"Indeed, those hospitals listed by U.S. News & World Report as among the finest hospitals had lower mortality rates than those that were not listed. But when you looked carefully, they simply gave aspirin and beta-blockers, both of which cost pennies, far more frequently than the hospitals that did not make the list. In other words, you could be a tiny rural hospital and do just as well; you just have to make sure to block and tackle [or stick to the basics]," he notes.

He cites these additional benefits of evidence-based medicine:

— Working from the evidence means you don’t have to measure outcomes — only the process. "I know cardiac patients will do better if I give them aspirin," he explains. "What you have to monitor is what percentage of your patients get the aspirin."

— If you are trying to change physician behavior, it’s far easier to do it when the evidence is compelling. "It’s hard for them to disagree with the literature," Ellrodt says.

— An evidence-based approach allows you not only to drive for some improvement, but to strive for perfection. "We have fallen down as a system because many institutions are satisfied if they go from 60% of patients getting aspirin to 80%," he asserts. "Yes, that’s significant, but for patients without serious contraindications, it should be perfect. At our institution over the past four months, 100% of our eligible patients got aspirin, beta-blockers, and ACE inhibitors — and 88% have taken smoking cessation programs."

— You can shift your whole program’s emphasis from a quality-improvement effort to an error-prevention effort. "You can do that when you have compelling evidence," Ellrodt adds.

Taking the next step

Berkshire Health System will continue its interventions with discharged patients using EBMpact, a system developed by EBM Solutions Inc. (www.EBMSolutions.com) of Nashville, TN. Ellrodt, who also serves as EBM’s chief medical officer, already has employed the information contained in EBMpact for his in-house programs. "Now what we are beginning to do is, as the patient comes out of the hospital, we are going to offer to physicians and their patients a password to EBMpact," says Ellrodt. Since the health system already has purchased the program, he explains, there will be no charge to patients or to physicians. Ellrodt plans to begin by focusing on cardiac patients.

The same information is expressed on multiple language levels — clearly and concisely for physicians, and at about the fifth- or sixth-grade level for patients. (See "Patients' low health literacy is a 'significant threat' to quality care," in this issue.)

That’s just the beginning, says Ellrodt. "We think that it’s wonderful to get patients information that’s reinforcing, but we want to make sure to give them the tools to help them adhere as well." EBMpact contains multiple patient adherence tools: a medical adherence tool, a weight tool, a blood pressure monitoring tool, and so on. These tools make it easy for patients and physicians to track and graph medication administration, diet, exercise, and other important trends.

The EBMpact program is customized to the individual patient. When heart attack patients are discharged, for example, they also will be given an Internet prescription number, which will enable them to access the heart attack guide. They will choose the language level in which they feel most comfortable and learn about key interventions based on evidence, as well as information about diagnosis, therapy, and prognosis.

Throughout the process, as patients become more knowledgeable, they can advance to other levels. "Patients who now have a chronic, serious condition need a bottom line to get started, but over time, they become increasingly sophisticated about their condition," Ellrodt explains. "We want them to advance to the point where they can read 10-, 20-, or 30-page documents. Some patients get to the point where they can read the physician side, which also is available to them."

The patient and physician versions also can be viewed side by side and translated through a dictionary and pharma resource that are included on the site. Also, through this secure system, patients are sent questions about their satisfaction with the program, as well as clinical questions, such as "Are you taking your aspirin?" 

"If only half the patients are adhering, we’ll be able to contact the physician," Ellrodt explains. In addition, the system offers references to other applicable areas of the program. "For example, if a patient has high cholesterol, there is a whole guide on preventing coronary artery disease," Ellrodt says.

He notes that this new approach falls under what the Wall Street Journal has called "information therapy." "I think that’s a great term," he offers. "You’re getting recommendations to the patients, and they’re responding in a very informed way while understanding the consequences of not doing so. That’s informed adherence."

If you look at the leading studies cited by proponents of evidence-based medicine, "They always had ways of ensuring that patients were complying," Ellrodt emphasizes. "And we can do this more effectively through a web-based system than through nurses’ phone calls." 

Need More Information?

For more on evidenced-based medicine, contact:

Gray Ellrodt, MD, Berkshire Medical Center, 725 North St., Pittsfield, MA 01201. Telephone: (413) 447-3098. E-mail: Gellrodt@bhs1.org.