Reference Manuals May Be Facing Obsolescence

We must ensure their relevance to contemporary patient care


It’s 1992 and disruptive technologies of the day are making headlines: AT&T releases the first color videophone; scientists start accessing the World Wide Web; Apple launches the PowerBook Duo.

In healthcare, with less fanfare, a Harvard physician named Dr. Burton “Bud” Rose converts his entire nephrology textbook onto a floppy disk, launching the clinical tool that would ultimately become UpToDate. Instead of flipping through voluminous medical reference texts, such as the Washington Manual, doctors could for the first time input keywords to find the clinical guidance they needed to make better treatment decisions.

The medical community embraced UpToDate’s unique ability to put knowledge at their fingertips. Today more than 1.7 million clinicians around the world use UpToDate to provide evidence-based patient care with confidence. For many, it along with other reference sources has become foundational to providing high quality medical care.

More than just an easy-to-use reference, UpToDate has gone on to improve patient outcomes, according to the Journal of Hospital Medicine.

In the new era of 21st century digital medicine, however, there are opportunities to go further in support of clinicians and patients. Reference tools must be powered by predictive and prescriptive analytics, be personalized to individual patient circumstances, and be integrated into clinician workflow. In some cases, clinicians may be unaware of which questions to ask of a computerized reference manual, or how to incorporate the nuances of an individual patient’s case into the general insights of a reference. Searching for heart failure treatment, for example, may be too broad a query and the resulting recommendations therefore may not provide optimal care for a specific patient’s unique medical circumstances. New digital health solutions that consider patients’ co-illnesses, contraindications, symptomatology, current treatment regimens, and hereditary risks are essential.

Additionally, the pace of change in medical science continues to accelerate, and with it, the proliferation of life-saving treatments and diagnosis. When I enrolled in med school in the 1970s, medical knowledge was doubling every seven years; now it’s closer to every two months. That makes it virtually impossible for clinicians to truly be informed regarding the latest studies and guidelines – therefore making it ever more challenging to effectively query medical reference materials.

This heightened pace of evidentiary change has exacerbated the historically slow diffusion of new medical knowledge into general practice, to the detriment of patients. As a member of the American College of Cardiology’s Science and Quality Committee, I spend countless hours each year reviewing the guidelines for cardiac care, knowing full well that it will be years before these new evidentiary approaches become adopted into mainstream practice.

We need 21st century solutions to support increasingly complex medical care. Just as we made the leap from paper to floppy disks to apps, we must now take advantage of recent developments in clinical AI to make another leap: this time to a dynamic and proactive approach to applying medical guidelines to individual patients.

Here’s how clinicians can bring the reference manual truly “UpToDate” for our modern medical times:

1. Personalize for Every Patient

Historically, clinical decision support tools have been used for universal, population level alerts or gaps in care based on simplistic quality measures that apply to all patients…smoking cessation, healthy diets, and exercise. With the advances in AI, nuanced medical guidelines can now follow each patient.

For example, clinical AI tools now exist that can interrogate a variety of patient data – such as electronic health records (EHRs), insurance claims, and patient-generated data – and drill down into clinical, genomic, social and behavioral factors to align patient care with the individualized guideline-directed treatment. This individualized approach ensures each patient receives optimal diagnostic and therapeutic care that is designed to improve outcomes.

2. Dynamically  and Proactively Deliver within Clinical Workflow

Today, most clinicians live their daily lives toggling between their EHR, reference apps like UpToDate and a myriad of other portals. Have a question about the best treatment for your patient with atrial fibrillation and a high bleeding risk? Open a reference app and you will find a multitude of articles to read which may not provide all pertinent information. For example, you may not know to search for “non-pharmacologic treatment” to find information on Left Atrial Appendage Closure (LAAC) device alternatives for a particular patient who is unsuitable for long-term oral anticoagulation. A clinician cannot know to query what they don’t know exists as an alternative for a patient.

Clinical AI tools can proactively deliver these patient-specific recommendations based on the latest medical guidelines directly within a clinician’s workflow, thereby eliminating the need to go searching for the optimal treatment for patients with complex medical needs.

 3. Apply the Guidelines for On-Demand Care

Clinical decision support tools have largely been limited to use at the point of visit, but traditionally offer little insight into recommended patient care outside the four walls of an office visit. Today’s technology can continually analyze new patient data, identify rising health risks,  and promote opportunities to provide optimal care. When lab results, new medications, EHR orders, or third-party data from wearable devices indicate an alteration in patient health status that warrants consideration of a guideline-directed diagnostic or treatment intervention, new guidance can be proactively sent to the clinician and patient – driving purposeful virtual or in-person engagement.

Digitized reference materials have come a long way, but clinicians and health systems today must evolve these capabilities to continually and efficiently apply the medical guidelines – the bedrock of medicine – for the patients they serve.

Dr. Lonny Reisman is the founder and CEO of HealthReveal, and former chief medical officer of Aetna

3 replies »

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  2. Thank you. My hope is that platforms like UTD will replace antiquated models like the ABMS. Far more useful to engage a useful platform actually shown to improve patient care and updated faster than the ABMS can write useless questions. Physicians do not need to waste time with questions. We need to be providing answers at the cutting edge of care instead of answering trivial basic science questions from the cobweb filled corners of med school. Updated information, CME, quality care guidance, and not bound by specialty, all at a reasonable price. UTD gets serving a community of professionals to ultimately improve patient care. Hopefully the ABMS will go the way of leaches and blood letting… a pretty good description of their current business model.