Evidence Based Medicine in the Patient Care Process

Evidence Based Medicine (EBM) has been used for decades to streamline the patient care process, but it's only lately been partnered with Workers' Compensation to create a seamless relationship between claim approval and treatment, promoting value based care and improved service.

What is Evidence Based Medicine?
EBM aims to use the best, most current validated evidence to support a health care regime which works in the patient's best interest. Usually the evidence comes in the form of current studies and/or other forms of systematic research. This is largely supported by Australia’s Clinical Framework for the Delivery of Health Services, endorsed by all of Australia’s personal injury jurisdictions and the major medical and allied health peak bodies.

Different forms of research are valued differently, according to a hierarchical ranking of reliability. The idea is that practitioners and patients can choose treatments with a significant amount of scientific support behind them, thereby reducing the chances of administering ineffective treatment and wasting time and resources, or worse, risking exacerbation of the condition. EBM is therefore a key initiative in achieving value based care.

But EBM involves more than just the mechanics of science and research. This approach does involve a fair amount of common sense as well, since no two patients are alike, nor does anyone find themselves in exactly the same situation. Therefore there is an art to the application of Evidence Based Medicine in practice. Some organisations choose to integrate evidence-based and analytics/data-driven guidelines to provide a credible and practical solution.

How Does Evidence Based Medicine Relate to Workers' Compensation

Evidence Based Medicine has been adopted widely by organisations within North America and worldwide. In New South Wales, the aim of compensation authorities is to deliver world-class insurance and care services, supporting long-term needs to improve quality of life, including helping people return to work and this is being supported by the introduction of EBM.

As EBM increasingly becomes incorporated in Workers' Compensation, it is widely recognised for its use in managing medical and like costs, most commonly to reject or reduce inappropriate and expensive services.

However it is important that the broader benefits of EBM in supporting the insurer and the customer are also recognised. EBM should be used in an appropriate way to deliver personalised service that is appropriate and reasonable for the customer (a principle embedded in many contemporary compensation schemes).

EBM can be extremely effective as a tool when combined with personal engagement and procedural fairness to deliver sound decisions and improved service, as shown in the Clinical Framework, setting EBM as one of 5 guiding principles for the delivery of health services.

Appropriate practice criteria often categorise and summarise medical literature to create guidelines which take much of the guesswork out of determining appropriate treatment. EBM can also educate and inform case managers enabling them to engage in appropriate, meaningful dialogue with health professionals and their customers.

Case managers are better equipped to set expectations, support customer engagement with their health professionals and seek further information about treatment plans and expected outcomes. EBM also allows case managers to pre-approve services or even eliminate the need for approval with straight through processing of payment.

EBM tools and software are also being combined with data analytics to provide more reliable risk assessment and ensure that the right customers get the right services at the right time.

What are the Benefits of the EBM Approach?

Some proven benefits are:

  • Improved treatment outcomes: This may be the ultimate reason to go with an Evidence Based Approach. By choosing to implement only those treatments which have the greatest clinical efficacy, healthcare professionals improve overall chances of positive outcomes, including a positive patient experience.
  • Improved quality of care: Evidence Based treatments are proven to be effective, and this can weed out a lot of other potentially expensive and time consuming treatment options. This quality over quantity approach makes it especially appealing in a Workers' Compensation context.
  • Greater accountability and transparency: This assists in proving all parties with confidence regarding effectiveness and likely outcomes, improve relationships and provides greater financial security.
  • Medical knowledge becomes uniformly current: While it may seem like a good idea for healthcare professionals to keep up with the latest studies and research, this can be a difficult to maintain on an individual level. The EBM Approach standardises common practice with the most current science, which lifts the burden of continuous self-education from the medical community.

How does such a tool work?

EBM guideline tools give an overview summary of all evidence based data for treating a given condition. All representative studies are ranked with a grading system.

Claims managers can evaluate all the evidence based data and relevant analytical outcomes and make a more informed decision about whether or not to approve specific treatments for an ailment or injury.

Some of the data presented by this tool would be:

  • risk/benefit assessment
  • efficacy of treatment
  • availability of treatment sources
  • whether providers are experienced with the particular treatment
  • predictability of outcomes
  • treatment variability
  • average number of days needed before returning to work
  • comparative utilisation and cost of services across relative data cohorts

There are certainly many advantages to claims managers for using an automated EBM tool and research should continue into its effectiveness and use in a workers' compensation setting.

One significant hurdle would be to overcome negative attitudes within the medical community toward an automated, data-based approach. But with appropriate application by both health care professionals and skilled personal injury management and claims specialists, EBM will be invaluable in improving communication, decision making, service experience and health outcomes.


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