In 1996 my nephrology practice began to use the basic pieces of an EMR (yes, Electronic Medical Record, literally the digitalization of our paper medical record) that would later become the cornerstone of Acumen. For the first time, the data in our paper records from iron studies, hemoglobins and EPO therapy used to treat anemia were available in digital form and we could run reports. Before that first “Anemia Report” our group of diligent, compulsive nephrologists would have sworn that we were providing state-of-the-art Anemia Management in our clinic. In 1996 when we saw for the first time our Anemia Program performance, we were stunned to find that we were only achieving hemoglobin targets with appropriate iron and EPO therapy 30% of the time. Somewhere between science-based recommendations and patient care, we had gotten lost.
If we had been able to measure ACEI/ARB use, BP control and comprehensive diabetic control as easily as Anemia in 1996, we surely would have found similar difficulties in achieving goals supported by scientific study. The “translation” of clinical research recommendations for care into implementation of the care for individuals or patient populations was then, and continues to be now, a difficult problem.
Claude Lenfant wrote about this issue in 2003 in his article, “Clinical Research to Clinical Practice – Lost in Translation?” Dr. Lenfant wrote, “…we in the United States, both health providers and members of the public, are not applying what we know.” He made the point that we have scientific knowledge and clinical research that fills libraries, but we are not effectively using that knowledge to improve patient care and patient outcomes.
There are plenty of smart, hardworking nephrologists and a lot of compliant, capable patients who still struggle with implementing best-practice, guideline-based care. Despite the best efforts by all, over 80% of patients start hemodialysis with a central venous catheter, only 27% of diabetic CKD patients get recommended comprehensive diabetic care, and only 45% of CKD patients achieve recommended blood pressure targets.
Perhaps it is not as simple as “Lost in Translation” and it is more like “Lost in Transformation.” Certainly there are features to this problem that require the healthcare provider to transform the information from a randomized control trial into an intervention that can be implemented with an individual patient within a local healthcare culture. Patients, too, must take the medical recommendations from the provider and transform them into the activities of daily life.
The good news is that compared to 2003 we now have some powerful tools to support this complex transformation. In a recent CJASN article entitled, “Type 2 Translation Research for CKD”, the authors identify tools that support providing high-quality care, including “key facilitators” such as guidelines and metrics and “essential elements” like health information technology and multidisciplinary team care. Acumen nEHR™ and similar EHRs create the opportunity for patient-specific scientific knowledge and guidelines to be visible at the point of care. Data collected in an EHR has the potential to provide critical process and outcomes metrics to facilitate delivery of the right care to the right patient at the right time.
For the first time it seems that all of the tools are gathered. Improvement in quality of care couldn’t be accomplished without assessment of the literature and well-articulated KDOQI and KDIGO guidelines. Achievement of quality care goals and the potential for population management, continuity of care, decision support, and metrics wouldn’t be possible without EHRs. Quality care couldn’t consistently be delivered without a multidisciplinary care team and informed patients. For goodness sake, it wouldn’t even be possible without Al Gore and the Internet! So, perhaps it’s the “perfect storm” time to find our way to a “Transformation” in the delivery of high-quality patient care.
What do you think about translation or transformation? Post a comment and weigh in.
Sources:
Lenfant C. Clinical Research to Clinical Practice—Lost in Translation? NEJM. 2003;349(9):868-74.
Tuttle KR, Tuot DS, Corbett CL, et al. Type 2 Translational Research for CKD. CJASN ePress. Published on April 25, 2013 as doi: 10.2215/CJN.00130113.
U.S. Renal Data System, USRDS 2012 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2012.
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