Choosing wisely in practice: Integrating guidelines into electronic records

In the quest to improve resource utilization, reduce harm to patients, and decrease the carbon footprint in healthcare, Choosing Wisely Canada (CWC) has been a leading voice, providing guidelines that positively impact clinicians in delivering high-quality care.

A major barrier to scaling the impact of these guidelines, however, is efficiently incorporating them into clinical practice without negatively impacting workflow. Electronic Medical Records (EMRs) represent an important vehicle for implementing CWC’s guidelines, providing immediate access at the point of care in both hospital and outpatient settings.

To address this issue, a pilot project was launched in collaboration between TELUS Health and CWC to integrate recommendations from their “Cold Standard” viral toolkit into two EMR products: the Collaborative Health Record (CHR) and PS Suite.

This toolkit contained provider-facing recommendations and patient education tools aimed at helping patients manage viral upper respiratory tract infections and reducing unnecessary prescription of antibiotics. The aim of the pilot was to explore the feasibility of incorporating such recommendations into standard clinical content within EMRs, taking into account effort involved and uptake from clinicians.

“The Cold Standard”, one of many recommendations provided by CWC, was selected for the pilot due to its broad applicability in primary care and since antibiotic resistance is a significant issue facing the Canadian healthcare system.

The Strategic Counsel of Canada conducted a study surveying 3,000 people to gauge Canadians’ understanding of antibiotics. Approximately 32.5 percent believed that antibiotics “can kill viruses” or that they are “effective against colds and flu” (27.9 percent). This coincides with the current situation where antibiotic resistance in the country is attributed to overprescribing antibiotics to combat viral illnesses.

The pilot was launched in late 2021, with several primary care clinics across Canada implementing the toolkit into their practices across 2022. The first phase of the project, which involved integrating the recommendations into the clinical content of both CHR and PS Suite, required relatively little effort by the stakeholders. Of note, no software development was required and any changes to the EMRs themselves were not necessary. Stakeholders within the primary care community and with pilot sites were engaged for feedback on the approach and the content, following which some adjustments were made.

Patient-facing content, such as the “Viral Prescription” (which provides recommendations to patients on how to handle a viral cold), was made available as a form or document within the respective EMRs that can be sent or given to patients, allowing them to leave with something in hand.

Provider-facing content, such as guideline recommendations for point of care, were integrated into standard upper respiratory infection documentation templates. In the case of the CHR, where there is a built-in digital health questionnaire system, pre-visit educational infographics from CWC were incorporated into cough/cold questionnaires.

For the pilot launch, user instruction documentation was prepared for seamless implementation. However, as the toolset leveraged existing functions within the respective EMRs, there was little to no extra effort required on pilot sites and no change in their regular behaviour. The project received positive feedback within the pilot sites, leading to the addition of the developed materials into the standard content library for respective EMRs.

Early data suggests that between the two pilot EMRs, there is a greater uptake of the content within the CHR as opposed to the PS Suite. This may relate to workflow considerations within the CHR that automate patient engagement, thereby eliminating the need for any additional actions required from the provider. The developed content has now been deployed in dozens of clinics across five provinces and has become a standard part of the clinical content offered to clinics.

Overall, the pilot shows that the implementation of “The Cold Standard” into EMRs is an efficient, cost-effective means of improving resource utilization while adhering to CWC’s guidelines of antibiotic stewardship. The pilot’s success has opened the door to integration of additional recommendations from CWC.

While further research to better understand impact on both patient and provider experience must take place, along with an evaluation of the impact on end clinical outcomes, this pilot establishes a simple and pragmatic way to effectively leverage EMRs to improve the functioning of our overall healthcare system.