What Happened to EBM?

The drumbeat of EBM — Evidence Based Medicine — seems less vigorous in the wake of enthusiasm for new models of care — Medical Homes and Accountable Care Organizations — and reimbursement based on performance, outcomes, or episodes of care. A good definition of EBM from Sackett, et. al:

Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. http://www.bmj.com/content/312/7023/71.full

In my view, evidence based medicine and evidence based practice will be central to the success of these delivery, risk sharing or risk shifting reimbursement models. A useful construct for implementation of EBM or EBP:

  1. Translation of uncertainty to an answerable question
  2. Systematic retrieval of best evidence available
  3. Critical appraisal of evidence for validity, clinical relevance, and applicability
  4. Application of evidence in practice; and
  5. Evaluation of performance

Managed Care Organizations can and should play a key role in numbers 1–3 and number 5 above. Payers and their provider networks will need to effect collaboration, share knowledge and learning, and orchestrate some degree of administrative and clinical data integration to put meaning into meaningful use and to achieve meaningful improvement in outcomes and affordability.

Steven R. Peskin, MD, MBA, FACP is executive vice president and chief medical officer of MediMedia USA, which publishes Managed Care. He is Associate Clinical Professor of Medicine at the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School


Evidence Based Medicine - Not So New..........

Dr. Peskin,

I find it interesting that the reference you provided on defining EBM is from 1996, so perhaps the answer to your question "What Happened to EBM" is the simple reality that it is not a new concept, idea, or construct.

Also, Providers must certainly believe they use EBM and EBP everyday in their clinical decision-making every day (as learned in Medical School, Peer-reviewed Journals, Medical Meetings, etc.) and will continue to do so under what you know so well, evolving/new "delivery, risk sharing or risk shifting reimbursement models" as yet another solution to our healthcare/cost crisis.

That said, I agree with your eloquently written final paragraph on the importance of Payer and Provider collaboration, share knowledge and learning, and clinical integration of disparate data sets to "put meaning into meaningful use and to achieve meaningful improvement in outcomes and affordability."

Bradley K. Kozar

EBM back to the future????

Good thoughts, the industry has been talking about EBM for years (like disease management). While clinicians think they are making evidence based decisions, in fact without relevant consistent measures there is no EBM. It's when EBM gets boiled down to the decisions for 1 patient that the 'forest' of evidences is thrown out the window and the clinician frequently relies on what they know or have personally experienced.

Integrated electronic health records have the potential to enhance the analysis and create consistent measures. The query tools to amass the evidence are still in development. When large scale measurement tools are in production the amount of evidence will be consistent and ad-hoc measurement projects will no longer be needed.

It has been a long journey, but there could be a new beginning of EBM as information systems allow routine, consistent collection and analysis of the practice of medicine.

Happy New Year,

Brian Bamberger