Employees and theirfamily members frequently face tough questions about their healthcare: How do I know when it's time to get a mammogram? When does my child need a visionscreening? Is thyroid screening something I should get? If I havehigh blood pressure or diabetes, what is the best treatment forme?

For the providers who care for them, the key question is: How dowe implement appropriate, science-backed treatments for ourpatients, testing where needed, but avoiding potentially harmful orunnecessary (and expensive) care? The answer is to seek guidancefrom and use clinical guidelines —along with existing clinicalskills — wisely.

Establishing clinical guidelines

Clinical guidelines are sets of science-based recommendations,designed to optimize care for patients in areas such as screeningand testing, diagnosis, and treatment. They are developed after acritical review by experts of current scientific data andadditional evidence to help inform clinical decisions across aspectrum of specialties.

Based upon this process, guidelines are then released by anumber of sources and collaborations, including academic andnon-profit health care entities, government organizations, andmedical specialty organizations.

From preventive care to treatment protocols for chronicconditions, guidelines provide a framework health care providersuse with patients to help guide care. However, it is important tonote that clinical guidelines are not rigid substitutes forprofessional judgment, and not all patient care can be encompassedwithin guidelines.

The impact on health care and benefits

Clinical guidelines are used in myriad ways across the healthcare spectrum, and providers are not the only ones who utilizethem. Insurers may also use guidelines to develop coverage policiesfor specific procedures, services, and treatment, which can affectthe care your covered population receives.

To illustrate a key example of an intended impact of guidelineson health plan coverage, consider those issued by the U.S.Preventive Services Task Force (USPSTF), whose A and B levelrecommendations comprise the preventive services now covered at nocost under the mandate of the Affordable CareAct.

As another example, the National Committee for Quality Assurance(NCQA), which accredits health plans and improves the quality ofcare through its evidence-based measures, uses the American HeartAssociation guidelines when creating its quality rules for treating high cholesterolwith statin drugs.

Other examples exist among commercial coverage policies. Forexample, some cancer drug reimbursement policies use componentsfrom nationally recognized guidelines for cancer care.

The importance of up-to-date guidelines

Because science is rapidly changing, guidelines are oftenupdated, leading insurers to revisit their policies to decide ifthey will change how services and medications are covered for theirmembers. Providers and health systems may modify processes ofpatient care in response to major changes in guidelines and/orresultant changes in payer reimbursement.

Not all guidelines are updated on a set schedule, making it evenmore important for providers and organizations that rely onguidelines to stay on top of changing information, as it can have adirect impact on how they work. Attending conferences, visiting therecently established ECRIGuidelines Trust™ , and regularly reviewing relevantprofessional association websites and journals can help ensureneeded guidelines are current. Lack of current information canaffect care decisions and potential outcomes for patients. Thosewho have access to the most up-to-date, evidence-based informationare able to work together to make well-informed healthcaredecisions.

The value of clinical guidelines foremployers

As employers or benefits consultants, it is critical to ensurethat your health plan, advocacy or decision support providers, andother partners that depend on this information to guide theirpractices and decisions understand and follow current, relevantguidelines.

Further, by combining information from relevant guidelines anddata from biometric screenings, health risk assessments, claims andother sources, it is possible for clinical advocacy and otherdecision support providers to identify employees with gaps in careand generate targeted communications (through a member websiteand/or mobile app) to help them take action to improve theirhealth.

Clinical guidelines are science distilled into practicalrecommendations meant to be applied to most patients for qualityhealth care. By maintaining current, relevant guidelines,organizations and providers who work with your covered populationcan ensure that all parties have the key information they need tomake the best decisions for their health.

About the author

Jocelyn Sivalingam, M.D., F.A.C.P., is a Medical Directorwith West's Health Advocate Solutions, a company that provideshealth and well-being solutions for over 12,500 organizations usingclinical guidelines to inform preventive screening recommendationsas well as ongoing disease management. Dr. Sivalingam isboard-certified in Infectious Diseases and leads the ClinicalGuidelines working group at Health Advocate. She also serves as akey leader of clinical operations for the Chronic Care Solutionsprogram and provides clinical expertise across a number of areas atHealth Advocate.