Reducing clinical variation remains a hot topic in healthcare. However, many physicians are concerned that reducing variation means limiting their ability to make crucial decisions for care. These physicians know from experience that certain variations are important to meet patient-specific needs. This is similar to the dilemma physicians are encountering at the intersection of population health and personalized medicine—what is good for most patients in a given population will not always hold true for each individual patient within that group. Consequently, there may be a misperception that a campaign to reduce clinical variation will automatically discount clinical expertise and physician autonomy to treat patients as individuals.

The reality is that many hospitals, facilities, and physicians that embrace evidence-based medicine deliver better outcomes—and at a lower cost—than their counterparts. While there is no cookbook for medicine, there are, in fact, key interventions that for a given condition usually lead to better outcomes. The challenge is in identifying these key interventions, which may be buried within a proliferation of research studies, clinical trials, and other data. In 1950, researchers estimated that the volume of medical knowledge would double every fifty years. By 1980, medical knowledge was doubling every seven years; by 2010, it was taking just 3.5 years. By 2020, the volume of medical knowledge is expected to double every seventy-three days. Sifting through all the literature to identify the most impactful interventions has become more difficult in an environment where demands on clinician time are at an all-time high.

 

Modern Healthcare Needs Modern Decision Support

Organizations are held accountable for the standards they set for their clinicians. Clinical decision support must be relevant and based on high-quality literature. The goal in reducing clinical variation is not to constrain physician practice but, rather, to provide actionable, well-supported interventions consistently throughout the organization. The focus for both clinicians and organizations alike is to avoid the “irrational variation” in patient care—the omissions and commissions that occur outside of patient-specific needs. Irrational variations may be a consequence of diverse training, experiences, or information, but collectively they create an inequality of care that is unacceptable in today’s healthcare environment.

Solving this inequality must necessarily be a collaborative effort. Decision support fails where there is incomplete understanding. This is true for both the decision support building team and the clinical audience for whom it is intended. If the builders do not clearly understand the intent, the electronic output will not make sense. If the target audience of the decision support does not have sufficient evidence to see the value of an intervention, that intervention will not be performed. Clinical inertia stemming from insufficient knowledge of guidelines, disagreement with clinical decision support, or mixed messages from leadership have been well studied in healthcare. Solutions must cut to the heart of the matter and provide vetted, relevant data at the point of care so that when exceptions are made from the standard, they are rational, patient-centric variations. To that end, health systems must think in terms of supporting and sharing knowledge assets consistently throughout the organization.

Focusing specifically on the most vital interventions offers the greatest opportunity to follow the evidence and reduce the noise of “nice to know” alerts. Goal-oriented interventions empower clinicians to deliver better patient care by identifying organizational priorities and creating consistency across the organization. Carefully chosen evidence-based interventions put health systems in a better position to make sure that if variations occur, they are rational and patient focused. Decision support solutions need to enable physicians, healthcare leaders, and clinical decision support builders to understand and support the interventions that provide the greatest benefit. Transparency into the rationale and goals of the interventions in terms of outcomes (clinical and financial), performance measures, and standards of care should be clearly stated.

 

From Individual Decision Support to Collaborative Best Practices

Outcomes and cost of care are receiving unprecedented scrutiny by healthcare systems, payers, and patients. To make meaningful change, organizations need to identify and target the right interventions and share the rationale for that change so support can be built throughout the organization. Transparency should extend beyond a single department or discipline. Today’s tools need to provide the levers for putting the content that is in line with the organization’s goals up front and extending it across policies and procedures. Today’s decision support solutions provide a new opportunity for clinicians and health leaders to follow the evidence and achieve better outcomes.

References

Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 2011;122:48-58.

Hanley K, Zabar S, Altshuler L, et al. Opioid vs nonopioid prescribers: Variations in care for a standardized acute back pain case. Subst Abus. 2017, June 6. [Epub ahead of print]. Available at http://www.tandfonline.com/doi/abs/10.1080/08897077.2017.1319894?journalCode=wsub20.

Popescu I, Schrag D, Ang A, Wong M. Racial/ethnic and socioeconomic differences in colorectal and breast cancer treatment quality: the role of physician-level variations in care. Med Care. 2016;54:780-788.

Lacy B, Patel H, Guerin A, et al. Variation in care for patients with irritable bowel syndrome in the United States. PLoS One. 2016;11:e0154258.