Making guidelines better

It would be amazing to see a shift from just publishing some guidelines on a website into more active provision. So, we are looking at things like active clinical decision support. Bringing guidelines to health professionals rather than health professionals always having to go to the guidelines.

[Music] Welcome to the Australian Prescriber Podcast. Australian Prescriber, independent, peer-reviewed and free.

Our clinical world is full of guidelines. They're everywhere and almost anywhere. And they help us build a consensus around the best way to broadly navigate tricky areas in clinical practice and to standardise that practice for the betterment of our patients. They are, in short, the first line against making sure that our patients don't get substandard care. But if you are raising your eyebrows at this point, it's because as they are, they've become often unwieldly, as a whole, sometimes unworkable, seemingly unavailable a lot of the time when you need them, and grossly underutilised because of that.

I'm David Liew, today's host and a clinical pharmacologist and rheumatologist. With me is Associate Professor Jo-Anne Manski-Nankervis, an academic GP from the University of Melbourne with a strong focus on quality improvement related to digital implementation and chronic disease management. She's written an article for us in the June 2022 edition of Australian Prescriber, entitled Guidelines: Innovation Needed to Overcome Barriers to Use. And I'm very glad to be exploring a bit of that with her today. Jo-Anne, welcome to the program.

Thanks very much, David.

Tell me, in short, what's wrong with guidelines right now?

Guidelines have so much to offer, but they've got so many challenges. I think that they boil down to a few different things. Firstly, their accessibility, secondly, their passivity, and thirdly that we've got so many different guidelines in Australia that can say different things, and not all of which are actually even freely available to the people that would benefit from having access to them.

Perhaps we can understand that that's a lot to take on. And I think that speaks to the wall that we face in trying to be able to get the most out of guidelines. Maybe we can talk a little bit about how guidelines and the guideline landscape have evolved to be where we are now. How do guidelines get developed? And maybe that might tell us a little bit about what's wrong with them.

I think one of the challenges, David, is guidelines are developed in lots of different ways. They might be developed by industry-funded groups. They might be funded by the NHMRC and be very evidence-focused and have a lot of frameworks around their development. But they also might be developed by consumer organisations and other healthcare groups. And so, what we end up with are lots of different guidelines that may have different levels of evidence behind them, different levels of things that are just based on expert opinion and actually guidelines that can even contradict each other, which puts clinicians in a pretty difficult space.

I think we're all so conscious of these conflicting guidelines that often seem to invade our clinical space, not knowing which one to turn to. And, certainly, it seems as well the fact that they're all developed in different places, in different ways, makes it hard to know which one to trust as a clinician or where to find them even.

Yes, that's right. And when you add to the mix, GPs need to have a good working knowledge of over 167 conditions just to manage about 80 to 85% of their presentations. You could imagine the sheer number of guidelines that are potentially relevant to them in practice as well. So, it's a very challenging landscape. But it also relies on people keeping up to date about when guidelines are changing and having to think in their practice, "Oh I wonder if I should just check that guideline's being updated or not." And that's where the fact that we've got guidelines that are so passive, just sitting in the background and maybe not even implemented properly, really, that is another major barrier to their effective use.

I mean, even when we found those guidelines, and we think about them, it's often hard to know how they translate to the patient in front of us within the limitations of the practice that we have, I guess.

That's right. And I think that's the key thing, is the word guideline. It is just a guide. And so we really do need to be able to tailor it to our patients. And it's quite possible that a guideline recommendation will not be appropriate to the patient sitting in front of us. I think that's one of the things that people find so challenging too about perhaps having different process measures or guideline adherence now being reported on, is that tension between what a guideline says we should be doing and what we think might be right for our patients in front of us.

I guess that expresses itself in a hard stop way a lot of the time with guidelines, which don't necessarily align with what's funded for us in terms of clinical practice, that the PBAC or the PBS allows for funding in a certain way. And then guidelines may go well beyond that. We've seen that a lot around diabetic therapeutics in recent past, for example. How does that happen? Why does that happen? And what can we do about that?

Yeah, look, that's a really good point. When you're making decisions about what medicines are going to be subsidised and for what kind of people, you really are thinking about things like obviously safety and effectiveness, but also cost effectiveness, and how you can make the most use of the health dollar that you've got available to you. So, I think when we've got guidelines that are changing so rapidly, that can be challenging for policy to keep in check with that. And I guess that's probably a pretty good example with the diabetes medicines and such a huge change in some of the recommendations that are being made, is how do we keep up to date to make sure that the Australians that are most likely to benefit from these medicines will be able to have access to them.

In amongst this wild west of guidelines that we seem to have in Australia, you have to think that surely this is not a problem that exists everywhere in the world. The UK seems to have a much more curated guideline landscape, but I suspect they still have an imperfect approach to guidelines as well. What do you think about that?

I think one of the potential benefits is, if you're looking for a guideline in the UK, you know where to go. Whereas if you're looking for a guideline in Australia, then there's lots and lots of different places you can go. And some of them are freely available and some of them are subscription based. And so, I think that this is another challenge that we've got, is that really what we do want is to have the best quality guidelines that work across the field, that account for people with multimorbidity to be available to health professionals without barriers. And I think that that's a really important thing for us to be able to work towards in Australia.

So we don't know when to look for those guidelines, where to look for those guidelines. We might not be able to find them when we want, might not be able to get through to them when we want to access them. And then we don't know if they're necessarily applicable to what we do. And then on top of that, we don't know who they've been designed, what intention they've been designed with, which may not necessarily make them useful for us. Is that the list of all the sins? I mean, even if we had guidelines that were to overcome all those things, do you think that this would solve the problem in terms of guidance for our practice?

Well, my answer to that is no, I don't think so. And I think that this is about that issue around that passivity that I mentioned. It would be amazing to see a shift from just publishing some guidelines on a website. Which is amazing, and there's some really high-quality ones out there, into more active provision. So, we are looking at things like active clinical decision support. Bringing guidelines to health professionals rather than health professionals always having to go to the guidelines.

And this is where it's going to be really important to see how some recent policy announcements that came out before the election, pan out. So for instance, there was recently a government consultation on the use of general practice data and clinical decision support. And so, it's great that this is kind of on the plans, but what we need to be able to see now is take away from just writing it on some paper, and really moving forward into making this a reality to get this active clinical decision support underpinned by high-quality guidelines into practice.

That sounds like it could really change the game, but let's talk about what this looks like in practice. What does active clinical decision support mean? You and I both work in frontline practice. What does this mean for us when we are doing our thing with our patients?

At the moment, there's probably not a lot of great examples in the general practice setting. And we do have some alerts that kind of come up in our electronic medical record when we're doing something that might be dangerous, like a drug interaction or prescribing a medicine that might not be safe with a person's kidney function. But as part of a research program that I've been leading in our department with a really great team, we've been looking at applying guidelines.

So, writing algorithms, applying them to electronic medical records and creating prompts, if there's a patient that isn't receiving care, according to guidelines. And suggesting for the GP to consider, whether or not that guideline's appropriate and then linking them through to the resources, if they want to learn more. And so, what we're trying to do is use technology to bring guidelines into practice. So, we're looking at providing proactive care. So, David, if you do go to GP and you're going there for an immunisation, if they work out that you might be at risk of chronic kidney disease and you haven't had your kidney health checked, then we can flag that. And that's a way of bringing the guidelines alive.

That sounds wonderful. And as we talked about, I go to your general practice, and I had a vaccination the other day. What stops that from happening in practice, in that kind of environment? That sounds really great, but I guess I think a lot of people would say, "Well, if it was so easy, then why hasn't it just happened already?"

Yeah, that's a really good question. And I think a lot of general practices really try to provide really active and proactive care. Sometimes the way that our funding's designed doesn't necessarily support that to the full extent that it should. But one of the other things to consider is, GPs have had electronic medical records for decades, really. I mean, we hear about new electronic medical records going into hospitals, but they've been in general practice for ages.

So, it's really about how can we look to utilise that technology to its full extent to assist GPs with their work? And to do it in a way that fits with their clinical workflow. For instance, if somebody's booked a quick five-minute appointment to get a flu immunisation, the GP's not going to be able to fit in a full health assessment on top of that, and hope to go home sometime that day. But they might see a prompt there and they might think, "Oh, David, we need to bring you back and have a discussion about a particular health issue next time." And so it can work in a couple of different ways.

And I guess that, I think every time that we think about these kind of alerts, I think all of us have been on the end of alert fatigue at different points, trying to just click through those buttons to get done what we want to get done.

A hundred percent.

Is that something that stops this from being impactful and in a real world practice, and how do we try and find the balance there? How do we try and get around that?

Look, it's a really good point. In all the literature and experience that's lived out every day by people. And the last thing we want to do is basically have people start looking at their computer screens and not interacting with their patients to understand why they've come, and to create that rapport that's really, really important. But I think this is where elements of things like co-design come in, and making sure that we are providing prompts and clinical decision support that's relevant and important in the clinical setting. Not providing outdated information, and not providing prompts about things that aren't going to change our practice. So, I think it's all about making sure that we're being helpful and not a hindrance, as you've mentioned.

And maybe you can talk us a bit through as to what that co-design process looks like when you do use that. When it does happen, how does that go about to try and find that right balance? What kind of consultation does occur as part of that?

It's been a really interesting process because, of course, when you've got literally over 20,000 GPs, everyone's going to probably have a different opinion and a different way of practicing. So, what we have tried to do when we've been doing our work is to get a broad range of opinions and experience. And there's also, obviously, a really big breadth of digital literacy and engagement with technology across general practices. With some doing absolutely amazing stuff with technology, and others maybe not engaging with it so much.

We literally started off our process by getting some GPs and some general practice nurses and some practice managers in a room and saying, "All right, let's work through a process of what happens when you're either looking at recalling a patient or a patient comes into your consultation room. What's the workflow? And what would be important for you to provide some more proactive care? Where on the screen would you want it? How big would you want it? What information do you want it to link to? All of those kinds of things are really taking it back to basics, so that you can create something that's truly designed for general practice by general practice, and hence is more likely to be used and hopefully effective.

I guess an understanding of that workflow is so critical for designing the guidelines in the right way in the first place.

Yes.

But I guess these guidelines also need to be designed with the idea that there might be this active clinical decision support that's happening. Is that something that occurs at the moment? And if not, then how does this change the way that we need to develop guidelines?

I think that it's really important when guidelines are being developed, that we have an implementation plan that's part of that process. As I mentioned, you can have some really great quality guidelines, but if they're in a format that's 200 pages long, and you find in the middle of a consultation that you want to look something up, then that is just going to be impossible for you to use. So, it's about having that implementation and dissemination plan, having the guidelines in a format that people can use, written it in a language that's acceptable to people. And also of course, increasingly as well, people and consumers are looking up guidelines on the internet. They're researching things that might influence their health. So, we're also writing our guidelines in a way that's acceptable to them as well.

Is there something that's already going on? Are guidelines, at the moment, taking these implementation plans into consideration, or how far away are we from seeing this more widely adopted?

I think we're seeing some really good examples of some guidelines that have really tried to make their guidelines more usable and more accessible. I think the Kidney Health Australia ones are a really good example and they've got an app that can be used, that's really quite easy. And they've got some great consumer resources that also link directly to their guidelines so that there's materials from the health professional, but also from the consumer or such patient angle. I think that's great.

But again, that is a little bit still passive in that it relies on somebody identifying that they need to look at a guideline for a reason. I think that clinical decision support, the government in their 10-year Primary Care Plan, said that they want to see it happening in general practice in the next seven years. So, now that we've got that there, I'm hoping that will be a driver for people really to engage in more active clinical decision support and how we can bring guidelines to health professionals at the point of care.

Where do you think this is going to evolve? Because we're hoping that it goes just beyond a little popup that comes up on your screen. And this might be something which really changes the way that we approach practice, much in the way that the electronic medical record as a whole has changed the way we practice. How do you see it changing?

I think that we've got lots of new opportunities with people, especially with the general practice record, to be able to do things like natural language processing. To be able to use machine learning and the like, to be able to provide order and feedback results, not only on volumes of prescribing for instance, but also appropriateness of prescribing, to be able to provide people meaningful feedback on how their practice aligns or not with guidelines. And then, of course, the active clinical decision support is another kind of spoke in trying to achieve that guideline implementation. So, I think that there's plenty of work to keep a lot of people going. And I think for it to be effective, it's going have to be a really strong partnership between different health organisations, clinicians, consumers, but also partnering with people like our computer scientists and the like to be able to work out ways that we can deliver these things efficiently, appropriately, and also at scale in a really useful way that's supportive and not punitive.

Well, I'm very glad that there are clinicians like yourself who are working hard in this space to try and make the world better for all of us. So, thank you so much, Jo-Anne. Thanks for joining us today on the program.

Thanks very much for having me, David.

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The views of the guests and the host on this program are their own and may not represent Australian Prescriber or NPS MedicineWise. Jo-Anne Manski-Nankervis has conflicts of interest in that she's received funding from the RACGP Therapeutic Guidelines grant. She has received funding from the Paul Ramsay Foundation and the Medical Research Future Fund Targeted Translation Research Accelerator to develop and evaluate Future Health Today, a platform to optimise chronic disease detection, management, and general practice. She's also on the Pharmaceutical Benefits Advisory Committee. I am on the Drug Utilisation Sub-Committee of the PBAC. I'm David Liew, stay safe and look forward to seeing you next time.