An Interview with Dr. Peter Bonis, by Geri Lynn Baumblatt
The clinical knowledge base is vast, and growing every day. It creates a challenge for clinicians to keep up on it and apply it. How can they navigate and organize this growing body of knowledge and combine it with their and their patients’ experiences and insights to meet the needs of the individual sitting in front of them? And how can technology also help patients better understand their conditions and their treatment plan?
Peter Bonis, M.D., is the chief medical officer for the Division of Clinical Effectiveness of Wolters Kluwer Health, the international publisher of medical textbooks, journals, and support tools for clinicians. Emmi was recently acquired by Wolters Kluwer. So, the Wolters Kluwer suite of resources for advanced clinical decision support now includes UpToDate®, Clinical Drug Information® (CDI), Lexicomp®, and Medi-Span® along with Emmi multimedia programs and interactive calls.
I asked Dr. Bonis to elaborate on how these technologies can be combined to help improve health literacy for clinicians and patients.
How do clinicians go about making clinical decisions? And how does their decision-making process impact the patients’ understanding of, and ability to participate in, their care?
At the core of healthcare are decisions being made between caregivers and patients. The quality of those decisions has a tremendous bearing on health outcomes, and the cost and quality of care.
Clinical decision-making can be a complex process that involves weighing scientific evidence, clinical experience and patients’ values and preferences. Context is also important such as the availability of local resources, costs, and expertise and an appraisal of relevant social determinants of health that can, for example, influence the patient’s ability to engage in, and adhere to, a specific treatment.
Unfortunately, there are many points where the process can break down, which in part, helps to explain why clinical decisions and ultimately the care that is delivered can appear so variable. If we can support that decision-making process between patients and their care teams, we stand to reduce unwanted variability and improve outcomes and experiences for all.
What are the gaps and challenges as we help patients understand their condition and treatment plan? How do we encourage them to participate in their care?
Many things need to go right to achieve consistent, high quality decisions between caregivers and their patients and ultimately ensure that patients receive the best care for their individual needs. The clinician needs to understand the clinical knowledge base and any factors that may influence their decision. They also need to faithfully understand the person before them and the totality of that individual’s experience including their comorbidities, medical, surgical, family and social history.
Considering the brevity of a visit, this creates a formidable challenge. Furthermore, even the best decisions to not achieve optimal health outcomes unless the plan is faithfully implemented. This is likely to be the case when patient do not have a suitable understanding of their condition and the rationale for a care recommendation. Adherence with care recommendations is more likely to be successful when patients continue to be engaged in their care. Engaged patients may also help to inform their caregivers about care gaps or options that may have not been fully considered thereby helping to ensure not only better care for themselves but for other similar patients.
Helping caregivers and patients concurrently makes it more likely that proper decisions will be made and adhered to.
- On the clinician side, there are tools like UpToDate, which is an online library of current best-practice information that helps them make choices at the point of care. Lexicomp and Medi-span are resources that provide accurate information about drugs, dosing, administration, and precautions. Together, these tools make it easier for clinicians to do the right thing.
- And on the patient side, the Emmi multimedia programs and interactive calls help patients understand their condition and the options available to them so they can participate in their care.
It is important that the information used by healthcare professionals is harmonized with the information used by patients so that we are all reading off the same playbook. If you look at it from a population perspective, reading off the same playbook has the potential to reduce unwanted care variability, thereby ensuring that we all receive the best care wherever we are seen.
How does technology augment health literacy and engagement?
The science of patient engagement is continuing to mature; access to the tools is always getting better. Ideally, we want to make those as personal as possible by having a deep understanding of what’s important to individuals and their disease states. We want to understand how each person can be best engaged so they can participate.
At the same time, new tools can help us collect information from patients to add to the knowledge base (such as their personal experience with the suggested treatments). Patient-reported outcomes can be systematically collected and incorporated into the knowledge-base. All of those things, even though they've been discussed for decades, are still at their earliest stages. The technology is evolving to make them possible and scalable.
How will integrating these technology solutions help clinicians, patients, and families really understand what is going on? For example, even when people report side effects, there’s studies showing clinicians often dismiss them. Then they get frustrated when patients stop taking their medication, but they didn't really respond to their concerns. I know a number of people who just stopped taking a medication, like statins, because they had a side effect like leg pain. It was frightening, and they didn't know what to do.
The example of statins is a good one. Up to 50% of pharmaceutical treatments are not followed as recommended, and statins are no exception. The clinician can provide information about common side effects and how to address them. That information is well documented and catalogued within UpToDate. At the same time, tools to help patients understand, manage, and avoid side effects (such as Emmi and Integrated Patient Information) can help avert non-adherence as well as potentially complications.
What’s the potential of technology to help patients and their care team achieve more personalized care?
People talk a lot about using technology to personalize and tailor information to patients. But I don't know if people are really clear on what that means and why it should improve patient understanding or give their care team insights.
Our understanding of how personalization leads to better health outcomes is still evolving. The simplest format is to make a recommendation that's tailored to that specific patient or some dimension of that particular patient. For example, it is more helpful to provide information to a patient (such as an Emmi video) with diabetes based on their most recent laboratory values rather than simply providing generic information about diabetes.
We also have to understand where the patient is on their journey. People are not interacting only episodically with the healthcare system; they are interacting over a very long period of time. We want to continue to refine the technology and the services that meet the patient at each stage of their journey. We want to inject support in a way that's meaningful to the patient all along that continuum of their experience.
The promise of personalized care recommendations will also be achieved with advances in pharmacogenomics and data science. These will help to provide customized, tailored information on treatment recommendations, specific drugs, or other interventions that are more likely to be successful for individuals.
The ability to collect experiential data and patient reported outcomes is important. Data gathered from wearables and other self-monitoring technology is being added to the mix. How these should be all wrapped together to improve health outcomes is still evolving.
Peter Bonis, MD is the Chief Medical Officer for Wolters Kluwer Health Clinical Effectiveness organization (UpToDate, Clinical Drug Information, and Emmi). Prior to joining UpToDate in 1998, Dr. Bonis served as a full-time faculty member at Yale University School of Medicine. He is currently an adjunct professor of medicine at Tufts University School of Medicine and an internationally recognized authority in study design, evidence-based medicine, meta-analysis and systematic reviews. Dr. Bonis is a graduate of Harvard University and New York University School of Medicine, and he trained in gastroenterology and health services research at Tufts Medical Center.