- Evidence, guidelines and practice: the way forward in a digital age - SYDNEY 11 April, 2013 Bill Runciman Professor – Patient Safety & Healthcare Human Factors – University of South Australia - Centre for Sleep Research Research Fellow, Australian Institute of Health Innovation, University of NSW Clinical Professor – Joanna Briggs Institute, Faculty Health Sciences – The University of Adelaide President, Australian Patient Safety Foundation

- The ideal healthcare system - The right thing In the right way At the right time For the right person

- The relationship between QALYS purchased and expenditure - - The relationship between QALYS purchased and expenditure - QALYs purchased Expenditure

Mindlines – Daniel Kahneman Mindlines – Daniel Kahneman Acumen – pattern recognition Acumen – pattern recognition Reference books Reference books Guidelines Guidelines Google Google “Up-to-date” “Up-to-date” - The right thing? -

“Appropriate” care – 57% of encounters “Appropriate” care – 57% of encounters Guidelines - voluminous Guidelines - voluminous - hard to assimilate - most are out-of-date - some overlap - not actionable - don’t usually guide - Guidelines – CareTrack -

Indicators:  Over 70% – consensus based  Only 15% – Level I or II evidence  Only 18% – Grade A or B recommendations BUT  Compliance with Level I & II, A or B: 54%  Compliance with consensus recommendations: 62% - Appropriate care - CareTrack - - agnostic selection -

- % of evidence/recommendation per indicator modality – CareTrack -

Guidelines are necessary and desirable – but not sufficient Guidelines are necessary and desirable – but not sufficient Internet – creates more confusion than enlightenment Internet – creates more confusion than enlightenment PCEHR – limited benefit in assiduously documenting what is done if we don’t know what to do in the first place PCEHR – limited benefit in assiduously documenting what is done if we don’t know what to do in the first place - What should we do? -

Clinical standards, indicators and tools For basic care – the “at leasts” For basic care – the “at leasts” National (& international) agreement National (& international) agreement Inclusive, transparent, succinct, useable Inclusive, transparent, succinct, useable Conflicts of interest taken care of Conflicts of interest taken care of Up-to-date and dynamic Up-to-date and dynamic A wiki process – “Apps” A wiki process – “Apps” - Proposal -

- Evidence - 77 RCTs/day, 11 meta-analyses 77 RCTs/day, 11 meta-analyses Some untrustworthy players - reputation Some untrustworthy players - reputation Systematic manipulation (bias, 24 ways) Systematic manipulation (bias, 24 ways) Often fails to get traction in practice Often fails to get traction in practice Cognitive dissonance – evidence on evidence Cognitive dissonance – evidence on evidence Whole area needs reconsideration Whole area needs reconsideration

A list of do’s (“at leasts”) A list of do’s (“at leasts”) A list of dont’s A list of dont’s Standard operating procedures Standard operating procedures - screening - monitoring - checklists - procedures Rehabilitation of consensus Rehabilitation of consensus Restoration of HOPE Restoration of HOPE - Challenges -

- Common sense - The only problem with common sense is that it is not all that common Voltaire Voltaire Will Rogers Will Rogers