NEJM: Real-life case hints at future care process with EMR
Modern medical education emphasizes the value of the randomized, controlled trial, and physicians learn early not to rely on anecdotal evidence. However, the application of such superior evidence can be constrained by trials' strict inclusion and exclusion criteria — or the complete absence of a relevant trial, according to a perspective paper published Nov. 2 in the New England Journal of Medicine.
“For those of us practicing pediatric medicine, this reality is all too familiar,” wrote Jennifer Frankovich, MD, from the division of rheumatology at Stanford University School of Medicine in Palo Alto, Calif., and colleagues. “In such situations, we are used to relying on evidence at Levels III through V or resorting to anecdotal evidence. What should we do, though, when there aren't even meager data available and we don't have a single anecdote on which to draw?”
The authors stated that they recently admitted a 13-year-old girl with systemic lupus erythematosus (SLE) and the patient’s presentation was complicated by nephrotic-range proteinuria, antiphospholipid antibodies and pancreatitis. “Although anticoagulation is not standard practice for children with SLE even when they're critically ill, these additional factors put our patient at potential risk for thrombosis, and we considered anticoagulation,” Frankovich and company wrote. “However, we were unable to find studies pertaining to anticoagulation in our patient's situation and were therefore reluctant to pursue that course, given the risk of bleeding.”
According to the authors, a survey of their pediatric rheumatology colleagues was equally fruitless which led to a new approach of using the data captured in their EMR and a research data warehouse. The platform, called the Stanford Translational Research Integrated Database Environment (STRIDE), acquires and stores all patient data contained in the EMR at the hospital and provides immediate advanced text searching capability. Through STRIDE, the authors could review data on an SLE cohort that included pediatric patients with SLE cared for by clinicians in their division between October 2004 and July 2009.
“Of the 98 patients in our pediatric lupus cohort, 10 patients developed thrombosis, documented in the EMR, while they were acutely ill. The prevalence was higher among patients who had persistent nephrotic-range proteinuria and pancreatitis,” the authors found. “As compared with our patients with lupus who did not have these risk factors, the risk of thrombosis was 14.7 among patients with persistent nephrosis and 11.8 among those with pancreatitis.”
The cohort review was conducted in less than 4 hours by a single clinician. On the basis of this real-time, informatics-enabled data analysis, the decision was made to give our patient anticoagulants within 24 hours after admission.
Thrombosis did not develop and the patient did not have any sequelae related to their anticoagulation, according to the authors admitting that they “truthfully, though,…may never really know” but asserted they made the decision on the basis of best data available.
“Our case is but one example of a situation in which the existing literature is insufficient to guide the clinical care of a patient,” the authors concluded. “But it illustrates a novel process that is likely to become much more standard with the widespread adoption of EMRs and more sophisticated informatics tools.”
“For those of us practicing pediatric medicine, this reality is all too familiar,” wrote Jennifer Frankovich, MD, from the division of rheumatology at Stanford University School of Medicine in Palo Alto, Calif., and colleagues. “In such situations, we are used to relying on evidence at Levels III through V or resorting to anecdotal evidence. What should we do, though, when there aren't even meager data available and we don't have a single anecdote on which to draw?”
The authors stated that they recently admitted a 13-year-old girl with systemic lupus erythematosus (SLE) and the patient’s presentation was complicated by nephrotic-range proteinuria, antiphospholipid antibodies and pancreatitis. “Although anticoagulation is not standard practice for children with SLE even when they're critically ill, these additional factors put our patient at potential risk for thrombosis, and we considered anticoagulation,” Frankovich and company wrote. “However, we were unable to find studies pertaining to anticoagulation in our patient's situation and were therefore reluctant to pursue that course, given the risk of bleeding.”
According to the authors, a survey of their pediatric rheumatology colleagues was equally fruitless which led to a new approach of using the data captured in their EMR and a research data warehouse. The platform, called the Stanford Translational Research Integrated Database Environment (STRIDE), acquires and stores all patient data contained in the EMR at the hospital and provides immediate advanced text searching capability. Through STRIDE, the authors could review data on an SLE cohort that included pediatric patients with SLE cared for by clinicians in their division between October 2004 and July 2009.
“Of the 98 patients in our pediatric lupus cohort, 10 patients developed thrombosis, documented in the EMR, while they were acutely ill. The prevalence was higher among patients who had persistent nephrotic-range proteinuria and pancreatitis,” the authors found. “As compared with our patients with lupus who did not have these risk factors, the risk of thrombosis was 14.7 among patients with persistent nephrosis and 11.8 among those with pancreatitis.”
The cohort review was conducted in less than 4 hours by a single clinician. On the basis of this real-time, informatics-enabled data analysis, the decision was made to give our patient anticoagulants within 24 hours after admission.
Thrombosis did not develop and the patient did not have any sequelae related to their anticoagulation, according to the authors admitting that they “truthfully, though,…may never really know” but asserted they made the decision on the basis of best data available.
“Our case is but one example of a situation in which the existing literature is insufficient to guide the clinical care of a patient,” the authors concluded. “But it illustrates a novel process that is likely to become much more standard with the widespread adoption of EMRs and more sophisticated informatics tools.”