Why aren’t all physicians using clinical practice guidelines?

Guidelines are essential to evidence-based medicine; here’s how to close the gaps between theory and implementation

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Nowhere has the use of practice guidelines (from simple checklists to complex process recommendations) so clearly improved safety by reducing variability as in the airline industry. Today, required pre-flight checklists and lengthy, sophisticated processes have made aviation the safest form of transportation.

Indeed, many in healthcare point to the airline industry as a model to guide our attempts to improve the safety, quality and cost efficiency of health and healthcare delivery. In healthcare, such tools are known as clinical practice guidelines (CPGs). To best impact health and healthcare quality and cost efficiency, CPGs must remain current (as medications, diagnostic tests and therapeutic options change constantly), credible (from reliable sources), and evidence-based (supported by objective, scientific study whenever possible).

And there is no shortage of commercially available CPGs to empower doctors, nurses, pharmacists and even patients to improve individual and population health and the value of healthcare. In some countries, such as the United States, reform efforts have legislated or financially encouraged the use of Clinical Decision Support Systems (CDSS), including CPGs, in an effort to benefit both payers and patients. In fact, the drive towards consistent, sustainable, higher quality, lower cost healthcare is evident across the globe.

Yet throughout the world, a significant number of physicians who are aware of CPGs have failed to routinely use these powerful solutions. Why?

In my worldwide travels, I have found several common reasons physicians rarely or never use CPGs when caring for their patients. To best understand, think of CPGs in two, broad categories based on how physicians interact with the information: pull solutions and push solutions.

The problem with “pull solutions”

“Pull solutions” are analogous to the seat belts in your car. Seat belts clearly save lives — but only if you buckle them. Many CPGs are available in the form of CDSS “reference solutions.”  Like seat belts, such reference solutions can greatly improve patient safety, clinical outcomes, and the cost of care — but only if the physicians access them. That is, CPGs embedded within pull solutions require physician to pull (actively search for) guidance.

There are several reasons physicians often fail or choose not to access CPGs available in reference or other pull solutions form. Most problematic is the axiom “You Don’t Know What You Don’t Know.” Let me give an example.

A general surgeon plans to perform a standard cancer operation on his 46-year-old patient to remove a cancer of the right colon. The surgeon is entirely unaware that his plan endangers not only his patient but also his patient’s family – and is also financially wasteful. But the surgeon is unaware that his patient’s young age and cancer location strongly suggest an inherited condition associated with high risk of subsequent malignancies as well as a high risk of varying cancers in the patient’s sons, daughters, sisters, brothers and parents. But if the surgeon doesn’t know this, how can we expect the surgeon to go search (pull) CPGs from. The surgeon doesn’t know what he doesn’t know and therefore cannot offer the patient and patient’s family (and payers) the best, most appropriate care.

A second reason physicians don’t access pull solution CPGs is simply that most physicians have too little time to do too much. When racing through an extremely busy day, physicians are unlikely to stop to search for CPG guidance unless they truly doubt they know the answer to a critical clinical question. Add to that the over-confidence or even arrogance of many physicians, and the likelihood of interrupting a rushed schedule to search for an answer is even lower.

Thus, CPGs presented as pull solutions often fail to deliver on their promise.

The benefits of “push solutions”

Fortunately, the second category of CDSS tools removes obstacles to improving health and healthcare through CPG adoption. If pull solutions are like seat belts, “push solutions” are like your car’s airbags. Your airbags are always passively functional, requiring no action on your part. Similarly, CPGs presented as push solutions automatically force physicians to always at least consider current, credible evidence-based care information whenever they care for a patient. The best example of the power of CPGs when presented as push solutions is order sets. Let’s use our previous clinical example of the power of CPGs when pushed to the surgeon.

As soon as the surgeon inputs the young patient’s demographics (including age) and diagnosis (right-sided colon cancer) into the EMR, a set of recommended orders based on CPGs (themselves based on current, credible, evidence-based knowledge) is automatically presented to the surgeon for consideration. In this case, the CPG-based orders recommend that the patient be tested for the inherited colon cancer condition prior to surgery. The CPGs are hyperlinked so that the surgeon can immediately choose to review the guidelines and supporting evidence-based content. The pushed CPG is not affected by the surgeon’s lack of knowledge of the condition (the obstacle to successful use of pull CPGs).

The order set changes physician’s behavior to the benefit the patient and the payer (the proper operation is performed, removing the risk and cost of a second, future cancer). In addition, the pushed CPGs lead the surgeon to order genetic testing for the patient’s first-degree relatives, potentially saving some of these individuals from cancers (preventing treatment and even death) as well as avoiding the direct and indirect associated costs.

Clearly, CPGs pushed to physicians in the form of order sets and other CDSS solutions are even more impactful than guidelines requiring physicians to pull (search for) information. But like the combination of seat belts and air bags in your car, having both push and pull solutions offer the greatest opportunity to improve patient safety, clinical quality and cost of care.

To maximize the impact of CPGs, pushing and pulling our physicians represents the most powerful strategy.

Download Whitepaper - Clinical Practice Guidelines: Closing the Gap Between Theory and PracticeRelated resource

Download the whitepaper by Joint Commission International (JCI) and Elsevier that examines the critical role of clinical practice guidelines in achieving safe, high-quality care for patients: Clinical Practice Guidelines: Closing the Gap Between Theory and Practice.



Written by

Peter Edelstein, MD

Written by

Peter Edelstein, MD

Dr. Peter Edelstein is Chief Medical Officer for Elsevier Clinical Solutions. He is board certified by the American College of Surgeons and the American Society of Colon and Rectal Surgery. He has more than 35 years of experience practicing medicine and in healthcare administration.

Dr. Edelstein was in private practice for several years before serving on the surgical faculty at Stanford University, where he focused on gastrointestinal, oncologic and trauma surgery. He then spent more than a decade as an executive in the Silicon Valley medical device industry.


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