Standardized clinical practice guidelines (CPGs) are evidence-based algorithms that
doctors and other providers use to precisely follow patients to ensure that they receive the best possible care. The goal is to standardize care around guidelines that are most beneficial to the patient. CPGs seem like a good idea to me because they move medicine to a higher scientific level where treatment plans are based on what has been firmly established to yield the most desirable clinical outcomes. However, as with most things, CPGs, while great in theory, have some practical constraints.

For example, a recent study published in The Journal of the American Medical Association (JAMA) determined that of the 619 cardiac guideline recommendations promulgated between 1998 and 2007, only 495 remained unaltered in 2013. Mark D Neuman, MD, MSc and colleagues at the Perelman School of Medicine in Philadelphia examined CPGs and concluded that there is a need for frequent reevaluation of guideline recommendations.

Here are a couple of reasons to reevaluate these recommendations. First, we need to take a look at how the sample of patients were selected for the research. The process to draw up a representative sample of patients from which generalizations can be made to a larger group of patients is complicated. Most research takes place in tertiary hospitals and is often lead by researchers of medical schools who have the option to select patients without comorbiddity. Unfortunately, these patients are often dissimilar to those seen in a primary care setting, where a large portion must be treated for more than one disease. Some CPGs do not take into consideration comorbid conditions.

Another reason for frequent reevaluation, simply put, is that things change. New drugs are developed, and new technologies emerge. A CPG cannot be “adopted and forgotten.” These guidelines need to be continuously revisited in light of how patients are responding to treatments and new developments in the field.

A great benefit to CPGs is they can be integrated into the electronic health record (EHR) and its computerized physician order entry (CPOE) feature. The EHR can prompt clinicians to either adopt recommendations or indicate why they chose an alternative plan. The doctor actually directing the care should always have the right to explain why they prefer and choose an alternative method of care. From the EHR we can do “big data” type studies and see what approach really does work best and continuously improve CPGs. An example of the cycle of plan-do-check-act (or adjust).

Here at Texas Tech Physicians, we have experts working with our EHR experts on how to address CPGs and tying them to CPOE. It is an exciting pursuit.