Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:The Culture of Health Care
Unit:Evidence-Based Practice
Lecture:Putting evidence into practice
Slide content:Limitations of Guidelines May not apply in complex patientsfor 15 common diseases, following best-known guidelines in elderly patients with comorbid diseases may have undesirable effects and implications for pay-for-performance schemes (Boyd et al., 2005) Difficult to implement in EHRsissues include precise coding of logic and integration into workflow ( Maviglia et al., 2003) May be influenced by pharmaceutical industry87% of authors have ties to industry, 58% receive financial support for research, and 38% serve as employees or consultants (Choudhry, Stelfox , & Detsky , 2002; Norris, 2011) 10
Slide notes:10 Practice guidelines certainly have limitations. One challenge for guidelines is that they are difficult to apply in complex patients. For example, a study by Boyd and colleagues looked at fifteen common diseases. They took the best known guidelines for those diseases and assessed them for use in elderly patients who had many comorbid or coexisting conditions. They reached the conclusion that following the guidelines to the letter would have undesirable effects because of the presence of these other conditions. In fact, if these guidelines were tied into pay-for-performance schemes, there may be some negative implications in that physicians who adhere to the letter of the guidelines may actually not be providing the highest quality of care. Guidelines can be difficult to implement in electronic health records. In particular, its challenging to take the logic that is in guidelines and integrate it into the workflow. Some of the logic in guidelines is somewhat vague and may not fit into easy rules that can be implemented in a decision support system. A paper by Maviglia [ mahv-ee-lya ] and coauthors gives a number of examples of that challenge. Another problem with guidelines is the influence of the pharmaceutical industry: many individuals who work on developing clinical guidelines are also funded in part by the pharmaceutical industry. About eighty-seven percent of authors, at least in the survey that was done for this paper, have ties to industry. About fifty-eight percent of them received financial support for their research, and some of those individuals also serve as employees or consultants to pharmaceutical companies, raising questions of objectivity. Also, some services and care activities recommended in a guideline may not be covered by insurance companies or may not be approved by the insurance company for payment.