Rakesh -
Could you say more about how you conceptualize EHRs as being helpful in
improving clinical decision making? We are in the process of designing an
electronic medical record in our community mental health center and one
advantage that we hope to derive from this is better support for clinical
decision making at the point of care - so would be intersted in hearing if you
have any personal experience or references about EHRs can help with this.
-Vinod
>
>
>
> Rakesh Biswas wrote:
>
> Thanks Vinod,
>
> You have raised a very important point here...where the
> evidence itself is preliminary but its inappropriate(over)application
> generates a pseudo-EBP...
>
> We see enthusiastic overapplications in most fields of medicine
> (again citing the cliched HRT, etc...). Our EBM literature is dynamic
> and rapidly evolving and as physicians most humans have a tendency to
> apply whatever tiniest thread is available in a given area of dire need
> ( need depends on the user/individual). Again here shines the dichotomy
> between population based and individual based practice.
>
> Interestingly there are underapplications of EBM also reported
> in the literature (underapplication of thrombolysis,antiplatelets for
> MI etc).
>
> Where/how do we draw the line is again left to the individual
> decision maker and most of our day to day individual decision making
> goes unrecorded/undocumented and these are valuable data that could
> perhaps influence better evolution of the EBM knowledge base.
>
> Herein perhaps lies the importance of EHRs (electronic health
> records) and process-information based practice that is an emerging
> competitor to experimental-outcome research based practice as
> epitomized by EBM.
>
>
> rakesh biswas
>
>
> Rakesh Biswas MD
>
> Associate professor,
>
> Department of Medicine,
>
> Melaka-Manipal Medical College
>
> 75150 Melaka, Malaysia
>
> Phone: 60-6-2925851-extn 1151 (office) and 2001 (residence)
>
> Fax: 60-6-2817977/60-6-2925852
>
>
> Mobile: 60-16-6434253
>
> Email: [log in to unmask]
>
> http://www.manipal.edu/melaka/departments/departments.htm
>
>
>
> On 2/15/07, Vinod H. Srihari <[log in to unmask]
> > wrote:
> Roy
> and Paul -
>
>
>
> I welcome the term PBM. I remember reading something by Dave Sackett
> some years
>
> ago remarking on what he called 'Sackettization' or the practice of
> adding the
>
> apellation 'evidence-based' to elevate a whole variety of claims with
> little
>
> attention to the level of evidence supporting each.
>
>
>
> In addition to the corrupting influences you point out (money,
> publication bias)
>
> I can think of one more pedestrian and perhaps more common source of
> corruption
>
> - the therapeutic evangelism of those who develop or have an interest in
>
> promoting a particular practice and sytematizing its implementation by
> calling
>
> it evidence-based.
>
>
>
> I am probably going to get in trouble with someone on this list for
> this (please
>
> correct me if I am wrong!) but the Substance Abuse and Mental Health
> Services
>
> Adminstration (U.S.) website
>
> http://mentalhealth.samhsa.gov/cmhs/communitysupport/toolkits/
>
> has a list of 'tool kits' to implement a list of Evidence-Based
> Practices. The
>
> current list includes everything from Assertive Community Treatment
> teams and
>
> Family Psychoeducation (very good evidence) to Integrated Dual Diagnosis
>
> Treatment (very underwhelming evidence) and Illness Management and
> Recovery
>
> (?evidence).
>
>
>
> Integrated Dual Diagnosis Treatment is fast becoming an expected
> standard of
>
> care in community psychiatry although the evidence for this (as shown
> in a
>
> recent Cochrane review) hardly supports such widespread application. I
> believe
>
> this is a case where the evidence itself is preliminary but its
> inappropriate
>
> (over)application generates a pseudo-EBP. So there is PEBP in addition
> to
>
> PEBM..!
>
>
>
> Vinod Srihari, M.D.
>
> Assistant Professor
>
> Department of Psychiatry
>
> Yale University School of Medicine
>
>
>
>
>
>
>
>
>
> Quoting Paul Glasziou <
> [log in to unmask]>:
>
>
>
> >
>
> >
>
> >
>
> >
>
> >
>
> >
>
> > Dear Roy
>
> >
>
> > Thanks - I think its very helpful that we stay vigilant to
> problems in
>
> > the evidence chain, and the term PBM is a good alert for that.
> However,
>
>
> > I am quite optimistic, as there have been important changes over
> the
>
> > years. 20 years ago publication bias existed but very few people
> were
>
> > aware of it, and fewer talking about it. John Simes elegantly
>
>
> > demonstrated the problem existed and proposed the key solution -
> trials
>
> > registries[1]. That was 1986, and action has been slow but we are
> now
>
> > moving close to universal registration of trials. Similarly Cindy
>
>
> > Mulrow in 1987 pointed out the unscientific process of most review
>
>
> > articles[2], concluding that "These results indicate that current
>
> > medical reviews do not routinely
>
> > use scientific methods to identify, assess, and synthesize
>
>
> > information". But the decades since then have seen an enormous
> leap in
>
> > usage and quality of systematic reviews. Of course, there is much
> more
>
> > to do. The recent analysis by Chan and colleagues[3] showed a
> mismatch
>
>
> > between the outcomes presented in protocols and published reports,
> but
>
> > again access to protocols is improving. So one of the results of
> EBM
>
> > has been to raise awareness of such problems - but problems that
> had
>
>
> > always existed. So we do need to be critical and vigilant but
> rather
>
> > than despair and give up EBM we should all work towards fixing
> them.
>
> >
>
> > Best wishes,
>
> >
>
> > Paul Glasziou
>
> >
>
>
> > 1. Simes RJ. Publication bias: the case for an international
> registry
>
> > of clinical trials. J Clin Oncol. 1986 Oct;4(10):1529-41.
>
> >
>
> > 2. Mulrow CD. The medical review article: state of the science.
> Ann
>
>
> > Intern Med. 1987 Mar;106(3):485-8.
>
> >
>
> > 3. Chan AW, Hrobjartsson A, Haahr MT, Gotzsche PC, Altman DG.
> Empirical
>
> > evidence for selective reporting of outcomes in randomized trials:
>
> > comparison of protocols to published articles. JAMA. 2004 May
>
>
> > 26;291(20):2457-65.
>
> >
>
> >
>
> >
>
> > I posted this on the Health Care Renewal blog
>
> > (
> http://hcrenewal.blogspot.com/)
>
> > and I think it bears re-posting on this email list.
>
> >
>
> > I understand that Clinical Governance is probably more widely
> available
>
> > across the pond from here....
>
>
> >
>
> >
>
> >
>
> > Clinical Governance, a
>
> > respected
>
> > but not widely-circulated journal from the UK, just published
>
> > an
>
> > article (subscription required) entitled
>
> > "pseudoevidence-based medicine: what it is, and what
>
>
> > to do about it," written by Health Care Renewal occasional blogger
>
> > Dr Wally R Smith. [Smith WR. Pseudoevidence-based meidicne: what
> it is,
>
> > and what to do about it. Clinical Governance 2007; 12: 42-52.] The
>
>
> > article was featured on the publisher's
>
> > latest
>
> > monthly highlights page.
>
> >
>
> >
>
> >
>
> > I read (and commented on) an earlier draft of this article, and
> was
>
> > struck by its use of the term pseudoevidence-based medicine to
> describe
>
>
> > some of the less healthy trends we have discussed on Health Care
>
> > Renewal.
>
> > Some key quotes:
>
> >
>
> >
>
> >
>
> >
>
> > Another, perhaps not new threat to the practice of EBM
>
> > [evidence-based medicine] has been discovered --
> pseudoevidence-based
>
>
> > medicine (PBM). PBM can be defined as the practice of medicine
> based
>
> > on falsehoods that are disseminated as truth. Falsehoods may
>
> > result from corrupted evidence--evidence that has been suppressed,
>
>
> > contrived from purposely biased science, or that has been
> manipulated
>
> > and/or falsified, then published. Or falsehoods may result from
>
> > corrupted
>
> > dissemination of otherwise valid evidence. These falsehoods, when
>
>
> > consumed as truth by unwitting and well-intentioned practitioners
> of
>
> > EBM,
>
> > then disseminated and adopted as routine practice, may well result
> not
>
> > only in inappropriate quality standards and processes of care, but
> also
>
>
> > in harms to patients.
>
> >
>
> >
>
> >
>
> >
>
> > EBM rests on the premises of professionalism in science and
>
> > medicine.
>
> > EBM presumes that evidence is produced by scientists who strive to
> be
>
>
> > objective. EBM presumes that those producing evidence have no
>
> > pre-conceived hopes or goals for what the evidence will show. EBM
>
> > presumes that producers of evidence have no stakes in what the
> evidence
>
>
> > will show. EBM presumes, or at least strives to assure, that the
>
> > scientific evidence-production process is free manipulation by
> people
>
> > with vested interests with goals other than improvement in
>
> > patients’
>
> > mortality, morbidity, or quality of life.
>
> >
>
> >
>
> >
>
> >
>
> > There are reasons to believe EBM’s
> presumptions are in
>
> > question,
>
>
> > and that PBM is a “new”
> threat to EBM. Only two
>
> > conditions are
>
> > necessary for PBM to flourish. First, one link in the chain of
> evidence
>
> > production, assembly, or dissemination must be purposely
> corrupted,
>
>
> > resulting from a compromise of professionalism in science and
> medicine.
>
> > Second, the belief must be promulgated that a given piece of
> evidence
>
> > is
>
> > true and of the highest quality possible, when in fact it is
>
>
> > tainted.
>
> >
>
> >
>
> >
>
> >
>
> >
>
> >
>
> >
>
> >
>
> >
>
> > Smith attributed the rise of pseudoevidence-based medicine to the
>
> > conflict between the profit motive and physicians' traditional
>
>
> > values.
>
> >
>
> >
>
> >
>
> >
>
> > By definition, pharmaceutical companies, device
>
> > manufacturers, some
>
> > health care providers, many insurance providers, and various
> middlemen
>
> > and brokers in health care are in business for a profit. And while
> the
>
> > profit motive is not itself wrong or dangerous, the profit motive
> is
>
> > dangerous when placed in direct competition with protecting and
>
>
> > prolonging human life, the precise business in which health care
>
> > stakeholders should be engaged.
>
> >
>
> >
>
> >
>
> >
>
> >
>
> >
>
> >
>
> > As they say, "read the whole thing."
>
>
> >
>
> >
>
> >
>
> > And I think that we will find the term pseudoevidence-based
> medicine
>
> > very
>
> > useful on Health Care Renewal.
>
> >
>
> >
>
> >
>
> > --
>
> >
>
> > Posted By Roy M. Poses MD to
>
>
> > Health
>
> > Care Renewal at 2/12/2007 10:31:00 AM
>
> >
>
> > Roy M. Poses MD
>
> >
>
> > Clinical Associate Professor
>
> >
>
> > Brown University School of Medicine
>
> >
>
> > <
> [log in to unmask]>
>
> >
>
> >
>
> >
>
> >
>
> >
>
> > --
>
> > Paul Glasziou
>
> > Director, Centre for Evidence-Based Medicine,
>
> > Department of Primary Health Care,
>
> > University of Oxford www.cebm.net
>
> > ph +44-1865-227055 fax +44-1865-227036
>
> >
>
> >
>
> >
>
> >
>
>
>
>
>
> --
>
> Vinod Srihari, M.D.
>
> Assistant Professor
>
> Department of Psychiatry
>
> Yale University School of Medicine
>
>
>
> Staff Psychiatrist
>
> Connecticut Mental Health Center
>
> 34 Park Street
>
> New Haven, CT 06519
>
>
>
> Office: (203) 974-7816
>
>
> Fax: (203) 974-7502
>
>
>
>
>
>
>
>
>
>
> --
> Paul Glasziou
> Director, Centre for Evidence-Based Medicine,
> Department of Primary Health Care,
> University of Oxford www.cebm.net
> ph +44-1865-227055 fax +44-1865-227036
>
>
>
>
--
Vinod Srihari, M.D.
Assistant Professor
Department of Psychiatry
Yale University School of Medicine
Staff Psychiatrist
Connecticut Mental Health Center
34 Park Street
New Haven, CT 06519
Office: (203) 974-7816
Fax: (203) 974-7502
|