Recently, I read about another company marketing another product through medical offices which purports to improve the quality and length of life. Unfortunately, while science assures us that eating fruits and vegetables improves our health; there is no scientific literature which supports that taking pills of processed chemicals from fruits and vegetables, improves health.  In 2009, the Associated Pressed reported:

“Americans spend about $34 billion annually on alternative medicine... Chiropractors, acupuncturists and herbal remedies are commanding more consumer dollars as people seek high-touch care in a high-tech society...‘We are talking about a very wide range of health practices that range from promising and sensible to potentially harmful,’ said Dr. Josephine Briggs, director of the National Center for Complementary and Alternative Medicine, the federal agency that leads research in this field.”

Concern about neutraceuticals, herbs and non-regulated “medicines” has resulted in the introduction of U.S. Senate Bill 959 to allow the Food and Drug Administration to regulate these substances.  Rather than welcome this scrutiny, the alternative drug and practice industry is lobbying for the defeat of the bill.

It is always surprising when we are reminded that everyone does not ascribed to a national standard of care.  Southeast Texas Medical Associates, LLP (SETMA) has always ascribed to what is called evidence-based medicine (EBM), which is medical treatment supported by rigorously conducted, scientific studies.   The concept of EBM is very old,  but it was in the early 1990s that a group of clinicians and epidemiologists at McMaster University in Ontario, Canada, officially coined the term, "evidence-based medicine."  The concept faced mixed reviews from those in the academic and research worlds because of the suspicion that those in the "real world," would find EBM impractical in a busy medical office.  With the advent of electronic medical records (EMR) and its successor electronic patient management (EPM), and their ability to provide  clinic decision support tools (CDS), EBM is more “doable.”

With EMR, it is possible to bring CDS to the examination room without complex and time-consuming literature searches at the point of care.  The original model of EBM presented in 1992 in the Journal of the American Medical Association went something like this: A clinical question would arise at the point of care, and the physician would conduct a literature search yielding multiple (sometimes hundreds of) articles. The physician would then select the best articles from the results, evaluate the research, determine its validity and decide what to do - all while the patient waited in the exam room. In reality, "that almost never happens," said John Ely, MD, associate professor in the Department of Family Medicine at the University of Iowa College of Medicine. "It's just not practical. Even the original authors of EBM were saying it isn't practical.”

EMRs were first designed simply to allow a patient encounter to be documented electronically, but very quickly innovative providers and practices began to design CDS and disease management tools which made it possible to improve care.  EMR, EPM and CDS allowed healthcare providers to rethink healthcare delivery and the following concepts became apparent:

1. Healthcare delivery is not improved simply by the providing of more information to the healthcare provider at the point of care. 
2. Healthcare delivery is improved when the organization of that information is such that there is a dynamic interaction between the provider, the patient, the consultant and all other members of the healthcare equation, as well as the simultaneous integration of that data across disease processes and across provider perspectives, i.e., specialties. 
3. Healthcare delivery is not necessarily improved when an algorithm for every disease process is produced and made available on a handheld, pocket-computer device but it is improved when the data and decision-making tools are structured and displayed in a fashion which dynamically change as the patient’s situation and need change. 
4. Healthcare delivery also improves when data and information processed in one clinical setting is simultaneously available in all settings.  This improvement does not only result from efficiency but from the impact the elements contained in that data set exert upon multiple aspects of a patient’s health.  In this way, the data reflects the dynamic within the system under analysis, which in the case of healthcare is a living organism which is constantly changing.
5. Healthcare is improved when there is simultaneous evaluation of the quality of care as measured by evidenced based criteria is automatically determined at the point of and at the time of care.  Healthcare is improved when the data display makes it simple for the provider to comply with the standards of care, if the evaluation demonstrates a failure to do so.
6. Healthcare is also improved when data can be displayed longitudinally, demonstrating to the patient over time how their efforts have affected their global well-being.  This is circular rather than linear thinking.  A person begins at health.  Aging and habits result in the relative lack of health.  Preventive care and positive steps preserve, or restore health. 
7. Healthcare improvement via systems will require dynamic auditing tools which give the provider and the patient immediate feedback on the effectiveness of the care being provided and received.

Based on EBM and these concepts, SETMA developed ten principles which guided our development of the EMR:

1. Pursue Electronic Patient Management rather than Electronic Patient Records
2. Bring to bear upon every patient encounter what is known rather than what a particular provider knows.
3. Make it easier to do it right than not to do it at all.
4. Continually challenge providers to improve their performance.
5. Infuse new knowledge and decision-making tools throughout an organization instantly.
6. Establish and promote continuity of care with patient education, information and plans of care.
7. Enlist patients as partners and collaborators in their own health improvement.
8. Evaluate the care of patients and populations of patients longitudinally.
9. Audit provider performance based on the Consortium for Physician Performance Improvement Data Sets.
10. Create multiple disease-management tools which are integrated in an intuitive and interchangeable fashion giving patients the benefit of expert knowledge about specific conditions while they get the benefit of a global approach to their total health.

These principles and the EMR developed around them allowed dynamic CDS to bring the best of EBM to the examination room and to every patient encounter.

How can consumers evaluate their care?

Consumers can evaluate the tension between evidence-based and alternative medicine with several questions:

1. Does the new treatment result in the healthcare provider selling a product to the patient which product is not covered by Medicare, Medicaid or other insurance providers?
2. Does the new treatment promise to reverse the ageing process, or suggest that it can cure a chronic condition?
3. Does the scientific evidence given in support of this new and novel treatment appear in peer-reviewed, mainstream medical literature?  Remember, many alternative treatments are supported by “literature,” but when examined that literature is often in proprietary journals and publications which were created by the alternative medicine industry to give it an appearance of legitimacy. 

There is another way to view this distinction and tension which is the struggle in medical practice between entrepreneurism and professionalism.  An explanation of that distinction can be reviewed under Your Life Your Health at www.jameslhollymd.com.