OBSERVATIONS - september 19, 2007

IOM Advancing EBM Goal

The Institute of Medicine Roundtable on Evidence-Based Medicine (EBM), chaired by Mayo Clinic CEO Denis Cortese, held a two day meeting entitled: "Commonground: Leadership Commitments to Improve Value in Health Care" in Washington in late July to examine how each of nine sectors (health care delivery organizations, employers, insurers, product developers, regulators, researchers, health professionals, patients/consumers and the IT sectors) could contribute to the IOM Roundtable goal: "By the year 2020, ninety percent of clinical decisions will be supported by accurate, timely, and up-to-date information, and will reflect the best available evidence."

The Kaiser Permanente Institute for Health Policy supported the work group on Health Care Delivery Organizations and wrote its report, which was presented at the meeting. Copies of all nine full and summary sectoral reports can be found online at IOM's website.

Major Themes: Each sector discussed how they could contribute to the development and use of evidence and was asked to identify several “Transformational Initiatives” to accomplish this work. Initiatives receiving the most consideration included:

• Create a national focal point (Comparative Effectiveness Board, National Think Tank) to guide this work, identify gaps in evidence, set priorities, and support the development and dissemination of evidence.

• Create a national research agenda (problem list) related to the above, establish more resources for research, including the secondary use of data. New approaches to HIPPA may be needed to effectively do this work.

• Support the adoption and use of IT to enable the generation and use of evidence (a competition might be used to spur innovation in use and impact)

• Pay for value and evidenced-based outcomes and align financial incentives to support EBM.

• Develop a better understanding of EBM throughout the sectors (and the population at large) and a wider understanding of the Roundtable goal.

• Support transparency in reporting on the use of EBM (there is a need for standard and comparable measures).

• Develop benefit designs that are evidence-based; use evidence in coverage and payment policies.

• Develop "good clinical practices" for observational studies similar to those for randomized clinical trials, as well as new rules of the road for these studies.

• Build EBM into lifelong health professional learning and create evidence-based practice support.

• Support patient decisions among alternatives and inform by evidence.

Other ideas that may be considered by the Roundtable:

• Is there an EBM equivalent of "To Err is Human" as a communication framework? What could be done to develop similar impact?

• What needs to be done to have patients see EBM as value added and not a form of "rationing"? How to create demand for EBM?

• Should we be talking about EBM or "Evidence-Informed Medicine" to recognize how little evidence we have that applies to whole populations, the issue of individual variability in response to treatment, and to recognize and support the importance of patient preferences in the consideration of evidence?

• How should we handle the fact that the quality of evidence is variable and complicates it use? When do we know enough to promote or discontinue the use of a treatment? How do we test innovation in treatment in the meantime?

Conclusion: The meeting identified a number of important initiatives using an innovative sectoral approach. There are many areas for improvement in EBM, it is more complex that many may think, and attaining the IOM goal will not be easy given how much work is required in each of the nine sectors. The Roundtable is in an excellent position to move things forward. Health Care Delivery Organizations can provide leadership in the generation and use of evidence and supporting good public policy on EBM.

The fourth meeting of the Roundtable will be held September 24, 2007 at the National Academy of Sciences (NAS) building and will focus on emerging developments intended to improve post-market monitoring and learning for healthcare products and procedures. The day-long public forum of the Annual IOM Members Meeting will be held at the NAS on October 8, 2007, and will focus on Evidence-Based Medicine and the Changing Nature of Health Care.

Final sector statements and the summary of common themes and follow-up will be incorporated into the proceedings scheduled for release in winter 2008.

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