[In this short description, Doctor Clayton Reynolds discusses his concept of the three R's as an answer to the P4P approach being brought forward by insurance companies. With Praxis EMR and the three R's, every physician scores 100% in P4P programs while practicing medicine their own way. One could argue that this approach is cheating, but one could also argue that this is practicing better medicine, and in that case, why should we want any physician to score less than 100%?]

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"A clinical practice guideline, to be successful, must be accepted by the user. It must be accessible at the point of care.  It must be up-to-date. It should have the ability to be queried, automatically. It must be user-friendly. No paper-based system can hope to meet these requirements. In the USA, I saw the vast amount of time that was wasted in developing guidelines, in distributing them, in keeping them up-to-date, in keeping them available to the physicians in their offices, in doing queries to check for compliance and finally in revising the guidelines as new "super guidelines" were developed by national agencies.

I saw a disconnect between those who invented or constructed the guidelines and those who were expected to follow them.  Dr. Barry Schifrin, Dr. Allen Wenner, and I came up with a set of truisms that did not appear to be apparent to anyone else.  It seemed to us that: "A clinical practice guideline is a query in reverse," and "a query is a clinical practice guideline in reverse."  If these two statements are true, then it follows that: "A clinical practice guideline and a query differ only in their time sequence."

In other words, if a guideline reads: "Every woman over age 50 should have a mammogram annually until age 70," then the query applied to this guideline is the guideline itself. The only difference is that the guideline comes first and the query comes second. To apply that guideline, a review agency must ensure that the physicians have had the guideline available at the time that service was rendered to the patient of the specified age and gender. Many review agencies do reviews (i.e. they apply queries) of physicians' practices without the physicians' knowing what the guidelines are. They sometimes apply guidelines, which were constructed and disseminated after the actions were carried out by the physicians whose work they are reviewing.

Having seen these factors at work, and having thought about the theoretical aspects of the medical record, I developed the "3 R's" of health care quality review.  The clinical practice guideline is a Reminder to the physician of what is required to be done for particular patients or groups of patients.  The physician performs the work (follows the guideline) and enters the information in the medical Record . Then someone else (or the physician himself/herself) does a Review of the data, to see if the guideline was followed.

Now, to understand how this theory applies to all aspects of patient care, we have to expand our idea of what a clinical practice guideline is. A clinical practice guideline is any rule that a clinician uses to determine the management of any patient under any given set of circumstances. A clinical practice guideline can be formal or informal. A clinical practice guideline can be written or verbal. A clinical practice guideline may be old or recent. A clinical practice guideline can be explicit or implicit. A clinical practice guideline can be valid or invalid. The origin of a clinical practice guideline can be remembered or forgotten. The clinician may or may not be able to articulate the clinical practice guideline followed for any given clinical decision.

Regardless of any other statement contained herein, the following statement is true: A clinical practice guideline exists for every clinical decision the healthcare provider makes. Let me briefly give 2 examples (drawn from endocrinology since that's me!): A physician encounters a patient with anxiety, a goiter, a low TSH and a normal free T4.  The physician decides that the patient has hyperthyroidism and starts treatment with antithyroid medication.  The clinical practice guideline being followed is that a patient with symptoms of hyperthyroidism and a goiter and with a low TSH (even with a normal free T4) has hyperthyroidism and should be treated.

Example 2: A physician encounters a patient with anxiety, a goiter and a low TSH and normal free T4.  The physician orders a serum free T3 measurement. The clinical practice guideline being followed here is that a patient with symptoms of hyperthyroidism and a goiter with a low TSH and a normal free T4 does not have hyperthyroidism diagnosed until one of the thyroid hormones is shown to be elevated in the blood.

I went through this discussion to get to one of the capabilities of Praxis and to explain why I have become a "content developer." There are so many guidelines available, such as those dealing with diabetes care, and they are becoming so essential to the management of chronic diseases, that we should take advantage of technology, such as the Concept Processor that constitutes the semantic engine of Praxis, and embed them in the EMR.  Using the Internet, the guidelines can be constantly updated and made available to users whenever they link up to the Praxis site.  I am developing those subprograms and embedding them in Praxis.

Clayton Reynolds, MD (view CV)

[NOTE FROM PRAXIS: We believe that in addition to Reminder, Record, and Review, there may be a fourth “R” in this equation: "Response": A doctor may believe that he/she has a good reason for not following a certain norm, and perhaps he or she may be right. In any case, the transmission of this Response to the maker of the practice guideline would enable the guidelines to be improved, therefore benefiting us all.]

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