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From Bedside to Bench

April 25, 2015

How evidence-generating medical care could revolutionize research

Since the passage of the HITECH Act of 2009, rates of adoption for electronic health records (EHRs) have doubled for physicians and quadrupled for hospitals. As of 2013, 78 percent of office-based physicians had adopted at least a basic EHR system, and nearly half of all physicians and six in 10 hospitals had adopted an EHR system with advanced functionalities.

Since EHR implementation at Nationwide Children’s Hospital, the third busiest pediatric hospital in the country, the hospital has accumulated a record 800 million patient data collection forms.

With health care effectiveness, quality and efficiency as top priorities for hospitals around the country, one important question is on the minds of researchers and clinicians.

What — if anything — can be done with all this clinical data?

In recent years, substantial federal investments and initiatives have encouraged clinical and translational research. Traditionally, the relationship between research and practice has been unidirectional: research findings influence practice to comprise evidence-based medicine.

This is the classic bench-to-bedside paradigm.

But with millions of data collection forms being created through EHR systems, experts are suggesting a shift in this paradigm to redefine the relationship between research and practice as bidirectional. Information, they argue, should go both ways.

UNDERSTANDING EVIDENCE GENERATION

Peter J. Embi, MD, MS, chief research information officer at The Ohio State University Wexner Medical Center, knows a thing or two about data.

Dr. Embi has discussed the concept known as evidence-generating medicine at national meetings, including the American Medical Informatics Association Annual Symposium and the Summit on Translational Science. He also recently co-authored a study on how a sea change involving evidence-generating medicine (EGM) could accelerate research and improve health care.

“Successful medical research depends on the ability to leverage activities at the point of care and on systems that generate knowledge through routine practice,” says Dr. Embi, who is also vice chair of the Department of Biomedical Informatics and an associate professor of biomedical informatics and of internal medicine at The Ohio State University. “Health care professionals can systematically collect relevant data during clinical practice, generate research questions informed by practice and recruit patients for clinical studies.”

But this ideal bidirectional relationship may be difficult to implement.

According to Simon M. Lin, MD, MBA, chief research information officer at Nationwide Children’s Hospital, the bottleneck involves hospitals realistically utilizing the large volume of data collected by EHRs to gain insight and better inform clinical practice.

“Other industries, such as retail and hospitality, are already collecting and using data to improve customer service,” says Dr. Lin, who is a national expert on data-driven health care innovations. “Institutions like ours are investing in health information technology infrastructure and accumulating data at a rapid rate. The next steps are to derive value from this data by analyzing it and using it to change practice.”

The EGM movement is a foundation for what the Institute of Medicine calls the “learning health system” — ongoing adoption and meaningful use of health information technology, such as electronic health records, to continuously improve health care and accelerate research.

LEARNING FROM PATIENTS,  FOR PATIENTS

Learning health care systems are a major research focus for Kelly J. Kelleher, MD, director of the Center for Innovation in Pediatric Practice and vice president of Health Services Research at The Research Institute at Nationwide Children’s.

“In pediatrics, most database studies are conducted with national surveys by federal or large insurance claims databases,” explains Dr. Kelleher, who is also a pediatrician and professor in the Department of Pediatrics at The Ohio State University College of Medicine. “One largely untapped source of data is the burgeoning EHR repositories, which can be used to study all the patients and data routinely collected by labs and clinics to learn what works best for whom and under what circumstances.”

But according to Dr. Embi, current regulatory frameworks are often developed, implemented and interpreted with research as an afterthought. This leads to the unintended consequence of erecting barriers between research and practice, ultimately restricting access to and use of clinical information for both scientific and health services improvement endeavors.

“Reversing the research-to-practice paradigm requires a variety of system-level changes,” agrees Dr. Lin. “And it starts with an investment in health IT infrastructure to support rapid and efficient data collection and analysis.”

Use of EGM — where every patient encounter becomes an opportunity to learn — should lead to accelerated and generalizable findings, says Dr. Lin, making it more likely that evidence will exist to improve the care of future patients.

And according to Dr. Embi and colleagues, health care organizations that prioritize investments in health IT infrastructure and integration of medical research are poised to lead the way in the development and operationalization of EGM’s future — which, it seems increasingly likely, is the future of medicine as a whole.

 

References:

  1. Embi PJ, Payne RR. Evidence generating medicine: Redefining the research-practice relationship to complete the evidence cycleMedical Care. 2013 Aug, 51(8 Suppl 3):S87-91.
  2. Furukawa MF, King J, Patel V, Hsiao C-J, Adler-Milstein J, Jha AK. Despite substantial progress in EHR adoption, health information exchange and patient engagement remain low in office settings. Health Affairs. 2014 Sep, 33(9):1672-9.
  3. Gardner W, Kelleher K. A learning health care system for pediatrics. JAMA Pediatrics. 2014 Apr, 168(4):303-4.