Denise Basow, MD is president and CEO of the Clinical Effectiveness business unit of Wolters Kluwer, which includes UpToDate, Lexicomp, Medi-Span, and Facts & Comparisons.
Tell me about yourself and the company.
I’m a primary care physician by training. I practiced internal medicine for about four years. In 1996, I had the good fortune of meeting the founder of UpToDate and decided to join at a fairly early stage of the business as an editor. I then held a variety of roles in the business on the editorial side for many years.
In 2008, when UpToDate was acquired by Wolters Kluwer, I became the general manager. I led the business operations of the business until around 2015, when we did some reorganization of the Health division at Wolters Kluwer and decided to form this Clinical Effectiveness business unit. Since 2015, I’ve been the CEO of Clinical Effectiveness, which includes UpToDate; our clinical drug information solutions Lexicomp, Medi-Span, and Facts & Comparisons; and our newest acquisition on the patient engagement side, which is called Emmi.
What’s the process of reviewing ever-changing medical literature in huge quantity, assessing those new findings, and then figuring out how to present the new information to clinicians?
It’s interesting that you asked the question in that way, because in the early days of UpToDate, we used to say that we wanted to be the first place that doctors would go to when they needed an answer to a clinical question. Then when we realized that was happening, we said, wow, we need to really put a lot of thought into how we put together an editorial process so that we get things right. We felt like we had this tremendous responsibility to do this in a very high quality way, because not only were people looking at the content, they were acting according to what we said.
I put all of that into the editorial process that we’ve developed over many, many years. It involves a number of in-house experts who edit the content, but then also the 5,000-plus contributors that we have around the world and multiple layers of review. Having the right people looking at the content with the right expertise. Always having a focus on the patient, having a focus on the provider who needs an answer to a clinical question, and making sure that we’re giving them the best answer that we can provide.
The style of medical journal articles makes it hard to extract what’s important and actionable. What’s involved once you’ve decided that an article is clinically useful to present it in context to a busy physician at the point of care?
As physicians, we are all trained to read the medical literature. We can take any individual study and understand what it says, understand at a reasonable level whether it’s a good study or whether it has some limitations. The real challenge is not in reading any single study. It’s how you take that particular study and put it in the context of everything else that’s been written and decide how that applies to the patient sitting in front of you.
A simple example would be a new drug for hypertension that’s studied in literature. Study X comes out and says that it’s effective for patients with hypertension. That raises a whole series of questions. Should it replace other medications that my patient is on? Do I need to call in every patient that I have who’s on another drug and change them to this one? What are the side effects of this drug? So many questions come up.
That’s what we focused on early on. What are those questions? How do we train our editorial team to think about those questions, but also to write the information in a way that is accessible to people at the point of care? Even if people have the expertise to put of that together, nobody has the time.
Physicians are often resistant to having someone else summarize literature for them, but they are accepting that by using a trusted reference. How does that change the way they practice?
One of the things that attracted me to this business early on was that I understood how hard it was to get this information, because I was out there practicing. It’s a very uncomfortable feeling to be sitting in front of a patient and wanting to do the best job that you can, but feeling that it’s difficult to get that information. And, knowing that even if you have the expertise to understand the medical literature, you don’t have the time to do it.
I don’t feel like there’s a lot of resistance, in that sense, for clinicians to look at a resource that they trust and to look to it to give them help. All physicians want to do the right thing. I haven’t seen that there’s been much resistance at all. We’re not trying to tell people what to do. We’re trying to help them make the best decisions that they can. I think some of the resistance that you’re speaking of is more along the lines of being told what to do versus our approach of, let’s help you do your job.
Is there a place to incorporate evidence that’s accumulated from actual physician experience rather than being generated by a study?
I’ll give you a little anecdote, which may be a piece of trivia. The original name of UpToDate was Consultant, but the name couldn’t be trademarked, so it was changed. But the original concept was almost as you’re saying — to be a consultant for the clinicians along the concept of what you described.
The editorial process has been built around that. What we’re saying is that we’ve been able to work with the best experts in the world to deal with all of the clinical issues that we address. We’re giving every physician, every healthcare provider, access to the best consultants.
As we grade our recommendations, we have some very strong recommendations and some weaker ones. Usually that’s because we have very good evidence for the stronger ones and much weaker evidence for the others. The strong recommendations are in the minority, unfortunately. That’s just the state of the medical literature.
We very much consider that not only what’s in the published literature, but the experts that we have involved in the content are a part of the evidence. Our responsibility to the provider, or to the person looking at our content, is to be transparent about how strong that recommendation is. Is it based on solid medical literature, or is this based more on the expertise that we have because that’s the best evidence that’s available? We have always considered all of that to be evidence — it’s just a matter of how strong or weak that is.
Do you collect user feedback to harness their collective opinion on how useful a particular recommendation is in their actual practice?
We get a lot of feedback from our subscribers. Sometimes it helps us understand gaps, where maybe there’s a particular clinical question that we haven’t answered. That’s very useful for us because we try to intuit the questions, but we can’t get all of them. That’s kind of one category of feedback.
We also get feedback from some subscribers who may not agree with our recommendations. All of that feedback goes to our editorial team and is answered by our editorial team. We consider the whole world to be our peer review, in a sense, and we encourage getting that feedback. It makes a big difference in our content.
What makes physicians practice in ways that don’t reflect best practice or best available evidence?
That’s the billion-dollar question. More of a trillion-dollar question, actually, if you think about how much we spend on healthcare.
What you’re describing is what has been talked about for 40-plus years –unwanted variability in care. There are a lot of things that contribute to that. Some of it is certainly access to the right information, and we have lots of examples of that. Some of it is that we come out of training and we practice in a certain way and we tend to stick with that level of practice. Some of it is that our clinicians are making very good decisions, but things break down somewhere else in the process.
That’s why we have tried to broaden things from saying that, as UpToDate, we’ve been able to make an impact on clinical decision-making. We’ve been able to demonstrate that that impact on decision-making influences outcomes, but that’s only a piece of the puzzle. The whole thought behind broadening this to a clinical effectiveness mission was to say, how can we begin to attack some of the other areas where this breaks down?
Office physicians used to excuse themselves from the patient to look something up in a paper reference. How has that changed with EHR workflow and clinical decision support?
That still happens. “Excuse me, I’ll be right back” and go look something up. What we’ve seen over the years is more and more providers trying to involve patients directly in the decision-making. More and more we’re seeing physicians looking those things up while sitting with the patient and being comfortable saying, we’re going to look this up together and make sure that we’re doing the right things here.
I think that’s a very good thing. Patients are the most underutilized resource in our healthcare system. We need to continue to involve them more in their care. Educating them directly and giving them access to what our providers are looking at is a way to do that. That’s the biggest change that I’ve seen. Certainly when I was practicing, I would excuse myself and go look at a textbook, which is what we had available at the time. Now a lot more of that is happening with the patient in the room.
Doctors spend a lot of time debunking irrelevant or inaccurate mass media information patients ask about. Is there value in presenting objective information that’s more patient-focused?
Part of it is that. Early on when we were thinking about how we would address the patient education side of things, I would occasionally hear people say, doctors don’t really want to educate patients. That’s absolutely false. What providers want is for patients to have good information. Not to spend time debunking, but let’s spend time making sure you have the best information because you’re an important part of the healthcare continuum. To achieve our vision for clinical effectiveness, that has to happen.
What we’ve tried to do is say, how do we provide information that clinicians feel comfortable sharing with patients? How do we build information that doesn’t just provide information to patients, but engages them in their care? There’s a big difference between handing patients a leaflet or a monograph of information and understanding how to speak with them in a way that allows them to take action.
We’ve focused on the behavioral science behind that. How do we truly engage patients in their care, and do it in a way that physicians don’t feel like they have to debunk things, but where the patients become an active participant in their care?
As to the behavioral aspect, physicians are the target of multi-million dollar drug company and medical device campaigns intended to sway their opinion. Is it difficult for practicing physicians to go back to the literature and double check what the sales rep is telling them?
There’s been a lot of studies that have looked at the influence that third parties, like pharmaceutical companies, have on providers. Most of it has shown that providers don’t think that they have any influence, but the studies show that they do.
There’s always that little bit of disconnect, but we don’t spend a lot of time thinking about that. What we’re trying to do — whether you’re a doctor, nurse, pharmacist, physical therapist, or anybody touching a patient – is that if you’re the patient, making sure that we provide the best information that we can to help that provider make a good decision to help that patient be as informed as they can be to participate in their care. In that respect, try to begin to solve this problem of variability in care and improve clinical effectiveness.
Do you have any final thoughts?
When I think about the challenges that we have, I always keep a vision of a patient sitting in an exam room and the responsibility we have to to provide the best care that we can and to make good decisions for that patient. Whether it’s in providing information, whether it’s in educating that patient, for those of us involved in helping provide good healthcare, if we always keep those patients in mind and the ultimate mission and vision of what we’re trying to do, it’s very helpful in the decisions that we make in staying true to what we’re trying to achieve.