We Should Standardize Medical Standards
I recently read an article in the New York Times titled “The Joy of Standards: Life is a lot easier when you can plug in to any socket.” The authors begin by diving deep into the topic, discussing standards around the size, consistency, and design of the 8-by-16-inch concrete block. From there, we learn about standards-producing organizations and how they interact with governmental agencies. The article ends with a reminder that society needs a strong base upon which to build: “In an age of breathless enthusiasm for the new and “disruptive,” it’s worth remembering the mundane agreements embodied in the things around us. It’s [the] very ordinariness and settledness of standards that enable us to survive, and to move ahead.”
At first blush, one might think that healthcare as we know it in the United States suffers from way too many standards. We have codes for diagnoses (ICD-10-CM) and procedures (CPT). We have lab result codes (LOINC). We have codes describing medications (RxNorm). Sorry, I mean NDC. No, wait, I think it’s HCPCS. You get the picture: we’ve got codes coming out of the woodwork. Are these codes the standards that underpin how we practice medicine in the U.S.? I would argue not so much. These codes represent what we do, but don’t direct us how to do it.
What about practice guidelines? Those are standards, right? Various academic and professional societies produce recommendations about how to treat certain diseases. Don’t order a CT scan to diagnose lower back pain until the patient has had an x-ray study. Start treating a new-onset diabetic with this medication first and check those labs every two weeks. These guidelines are certainly closer to the standards described in the New York Times article. Guidelines and practice recommendations help direct us how to best practice medicine, but they lack universality. Every guideline I’ve read has some sort of specific exclusionary language such as: “This clinical practice guideline is not intended as a sole source of guidance in the management of X.” Hence, practice guidelines are not always applicable, so maybe they’re not so standard after all.
Allow me to propose some standards that I’d like to see physicians embrace. Mind you, most of the time when I’m asked to weigh in on one standard course of action versus another, I often end up concluding that I don’t care which direction we head, as long as we all head in that direction together. Or put another way: “Just pick one way, people!”
The term past medical history (or PMH) needs some standardizing. When I was a young lad 97 years ago, I was taught to begin every clinical presentation with something along the lines of “This is a 5-year-old male with a past medical history of diabetes mellitus, asthma, and severe eczema who now presents with wheezing and fever.” Back in the day, we doctors defined past medical history as a list of issues, diseases, and concerns with which the patient was actively struggling. Today, I would rather call such a thing by a different name: the problem list. Isn’t that a better term? If I were in charge of the world (and hence could write and enforce standards), I’d make the PMH and the problem list mutually exclusive. Put diseases, symptoms, and other clinically-significant issues on the problem list. If something on the problem list resolved or became less clinically important, it should be moved to the PMH. Why? Because the “p” in PMH stands for past, that’s why, smarty!
Can we talk about the medication list? You might not think we need standards around how to build a medication list, but I think we do. It certainly seems straightforward: a medication list must be a list of medications that the patient is taking. But when we dig a bit deeper, it gets confusing. If I prescribed a medication that the patient refuses to take due to minor side effects, should that med be on the list? If the medication list is a list of meds the patient is taking, then of course not, the med comes off the list. But perhaps the med list is a collection of medications that the patient is taking and further should be taking. Or does the med list include meds he sometimes takes, but hasn’t needed for many months? I’m not sure what the correct answer is, but it would be nice to have some standards so we’re all speaking the same language.
Standardization could help with physician orders. What’s included when a doctor orders a lab test called a CBC? If you order that test at different hospitals, I’m confident you’re likely to get different answers. Sometimes the results will include a platelet count, sometimes not. Sometimes there will be a WBC differential, sometimes not. If the patient’s blood sample is sent to lab A versus lab B, there will be even more variability. This is an area crying out for standardization.
Many doctors are rugged individualists. They often refer to standardization as “the s-word” and think about cookbook medicine. Despite all of that, I believe that many physicians would embrace some standardized definitions so that we can all try to speak the same language! Imagine if we standardized some of these things – perhaps our electronic health record vendors could help us exchange health information without the heavy lifts required today.