EBMeDS - Evidence Based Medicine electronic Decision Support

Kortteisto TiinaJousimaa Jukkapekka, Komulainen Jorma, Kunnamo Ilkka, Mäkelä Marjukka, Mäntyranta Taina, Rissanen Pekka, Varonen Helena

Minna Kaila, MD, PhD, Pediatric AllergistAdjunct Professor /University of TampereDirector /Institute for Health & Welfareminna.kaila(at)kolumbus.fi or (at)thl.fimobile +358 50 523 2021

No commercial conflicts of interest

EBMeDS: aim

to develop, implement and evaluate a generic clinical decision

supportsystem.

ElectronicEBM guidelines

Structured ElectronicPatient Record

Clinical Decision Support

Decision support combines medical evidence with individual patient data. It produces tailored alerts, prompts and guidance to physicians and other professionals.

Varonen H, Kaila M, Kunnamo I, Komulainen J, Mäntyranta T. Tietokoneavusteisen päätöksentuen avulla kohti neuvovaa potilaskertomusta. Duodecim 2006:122:1174-81.

Decision support: Features critical to success

• Objective: To identify features of clinical decision support systems critical for improving clinical practice.

• Method: Systematic review, MEDLINE, CINAHL, Cochrane controlled trials register, up to 2003.

• Study selection: Studies had to evaluate the ability of decision support systems to improve clinical practice.

• N = 70.• Decision support systems significantly improved clinical

practice in 68% of trials.

Kawamoto et al, BMJ, 2005

Predictors of improved clinical practice

• Automatic provision of decision support as part of clinical workflow (OR=112.1; p<0.00001)

• Provision of recommendations rather than just assessments (OR=15.4; p=0.019)

• Provision of decision support at the time and location of decision making (OR=7.1; p=0.026)

• Computer based decision support (OR=6.3; p=0.029) • Of 32 systems possessing all four features, 30 (94%)

significantly improved clinical practice. Kawamoto et al, BMJ, 2005

Ydintiedot

Potilas

Hoidon antaja

Hoitojakso,

- tapahtuma

tai palveluketju

Tunnistetiedot

Hoitotyö

Toimenpiteet

Toimintakyky

Tutkimukset

Ongelmat ja

diagnoosit

Fysiologiset

mittaukset

Terveyteen vaikuttavat tekijät

Suostumus Hoitotahto

Jatkohoitoa

koskevat tiedot

Elinluovutus -

testamentti

Apuvälineet

Lausunnot

ja todistukset

Hoitoprosessin tiedot

Yhteenveto

Lääkitys

Muut tiedot

Core data

Patient PIC

Caregiver

treatment episode

- individual or treatment chain

ID data

Nursing care

Procedures

Function

Investigations

Problems and

diagnoses

Physiological

measurements

Health factors

Agreements

Future treatment

plans

Organ donor status-

Aids

Certificates

The care process

Summary

Medication

Other info

Kristiina Häyrinen ja Jari Porrasmaa, 2006

Care testament

EBMeDS - organization

Product projectLead groupProject managerProject secretaryProject group

Pilot projectsPilot lead groupProject managerProject secretaryProject groups (2)

Study projectStudy lead groupSeniorJuniorStudy group

Medical SocietyDuodecim

Tekes

KymSHPP-SSHP

Medical PublisherDuodecim

Advisory committeeStakeholders

Rohto University of TampereSchool of Public Health

FinOHTA

Pro-Wellness

project plan 2005-06

EBMeDS timetable

2005 2006 2007 2008 2009

Project planning

Databases for drug treatment

EBM scripts and guidelines

Pilot projects and technical development

EBMeDS Study

Implementations

Testing

In practiceN

ati

on

al EP

R

defi

nit

ion

s

Pro

ject

fun

din

g

EB

MeD

S D

em

o

Nati

on

al EP

R

leg

isla

tion

s

Vir

tual h

ealt

h c

heck

Dia

bete

s

Gu

idelin

es a

nd

DB

Nati

on

al EP

R

arc

hiv

e

EBMeDS study project

• Baseline study at pilot sites 2006-2007– Survey

• Health Care professionals

– Interviews • Health Care Managers• IT-experts

Focus group study

• 39 physicians in 7 groups• Both urban and rural physicians of

different ages around Finland• Between October 2005 and January

2006 by two moderators • Audiotaped, transcribed, coded and

interpreted

Varonen H, Kortteisto T, Kaila M for the EBMeDS study group. What may help or hinder the implementation of computerized decision support systems (CDSSs): a focus group study with physicians. Fam Pract 2008;25:162-7.

Subjects

• Age, median (range) 46 (27-56)• Gender, per cent female 44%• Work experience as physician,

median (range) 17 (0.5-30)• Estimated daily computer use, hours,

median (range) 5.5 (0.5-10)

Varonen H, Kortteisto T, Kaila M for the EBMeDS study group. What may help or hinder the implementation of computerized decision support systems (CDSSs): a focus group study with physicians. Fam Pract 2008;25:162-7.

Results: Barriers of CDS

• Previous problems with health care IT• Potential harm to doctor-patient

relationship• Threats to clinician’s autonomy • Potential extra workload due to

excessive reminders

Varonen H, Kortteisto T, Kaila M for the EBMeDS study group. What may help or hinder the implementation of computerized decision support systems (CDSSs): a focus group study with physicians. Fam Pract 2008;25:162-7.

Facilitators of CDS

• Flexibility of the system; tailored topics and possibility to switch off

• Reliability; reliable knowledge-base and that trusted peers are developing the system

• Simplicity and ease of use• Concise reminders that facilitate and

help work processesVaronen H, Kortteisto T, Kaila M for the EBMeDS study group. What may help or hinder the implementation of computerized decision support systems (CDSSs): a focus group study with physicians. Fam Pract 2008;25:162-7.

The main RCT study questions:

1) Do patient and problem specific EBMeDS reminders shown to professionals during clinical work have an effect on patient care measured by the number of all reminders triggered in repeated Virtual Health Checks (VHC, see below)? Reminders on drugs, e.g. interactions or contraindications, and other types of evidence-based reminders will be analysed separately.

2) In addition, we will explore the effect of the reminders on intermediate patient outcomes in specific groups of diagnoses. Also these outcomes are measured on the basis of reminders triggered in repeated VHCs. Mean values of laboratory parameters are also measured in the explanatory analyses.

EBMeDS RCT study

Ri/Ni

time0

VHC VHC VHC VHC

Ri/Ni

Randomisation─── patient, whose reminders are blocked (recorded only in log files)------ patient, whose reminders are shown to his/her physician or nurseVHC = virtual health checkR = number of reminders N = total number of patients The outcome variable is a number between 0 and 1. No patient data need to be analysed when the values of the outcome variables are derived.

exclude:*occupational health

Hypothesis

in the intervention group the total number of EBMeDS reminders triggered in the repeated Virtual Health Checks (VHC) will decrease compared to the control group, indicating an improvement in the patient care.

In a VHC all available reminders are triggered as a batch run in the group of patients to be able to compare their number in the intervention and control group.

Intervention:• Visits or practitioner use of the patient

record from group A /intervention = patient specific reminders shown on screen to the practitioner during the visit,

• Visits or practitioner use of the patient record from group B /control = reminder not shown on screen (= usual practice),

Patient groups /exploratory:

- patients with diabetes (quality indicator level of HbA1c), dyslipidemias (quality indicator LDL cholesterol level, body mass index) or hypertension (quality indicator blood pressure level), and the UKPDS risk score [xxx].

- patients with cardiovascular risk factors (quality indicator cardiovascular risk according to SCORE [xx] or cardiovascular disease (quality indicator LDL cholesterol and total cholesterol)

To assess the safety of drug therapy we will study patients with multiple medications (a minimum of 7 drugs with adult and one constant drug with child; quality indicator: proportion of patients with contraindication or interaction alerts in relation to the number of drugs in use)

In addition, the result will be evaluated according to level of urgency of the reminders (three levels) and according to the treating professional (physician, nurse).

• Practitioners: Altogether 50 professionals (physicians, nurses, physiotherapists, speech therapists, and psychologist) in Sipoo Health Centre using the Mediatri patient record system during patient encounters, also at the inpatient wards (two wards where inpatients are treated by their primary care physicians).

• Population: All patients of Sipoo Health Centre during the study (in the beginning of 1.3.2009) will be randomised into two groups. People moving into or out of the community during the study period will not be included in the study.

The EBMeDS reminders*based either on global EBM guidelines, national Current Care

guidelines, or international and local drug databases. *There are around 300 reminder script descriptions in the

EBMeDS database. Many more reminders are generated using available drug databases, e.g. those on interactions, contraindications and indications. The total number of possible reminders is estimated to be about 16000.

*Categorized according to level of urgency: level I (do this! Imperative), II (consider this and justify your decision of noncompliance) and III (this is relevant information for you).

*A set of reminders will be selected for this study before commencement depending e.g. on possible special interests due to ongoing development projects of Sipoo Health Centre and based on a pilot VHC. Disease entities relevant from the public health perspective will be targeted, such as type 2 diabetes and cardiovascular diseases. As new reminders are being generated the final decision on the study reminders will be made on February 2009.

EBMeDS timetable

2005 2006 2007 2008 2009

Project planning

Databases for drug treatment

EBM scripts and guidelines

Pilot projects and technical development

EBMeDS Study

Implementations

Testing

In practiceN

ati

on

al EP

R

defi

nit

ion

s

Pro

ject

fun

din

g

EB

MeD

S D

em

o

Nati

on

al EP

R

leg

isla

tion

s

Vir

tual h

ealt

h c

heck

Dia

bete

s

Gu

idelin

es a

nd

DB

Nati

on

al EP

R

arc

hiv

e

More information on EBMeDS:

www.kaypahoito.fi/decisionsupport/decisionsupport.htm

Thank you for your attention!

1. Kortteisto T, Kaila M & Komulainen J. Päätöksentuen tutkimus (EBMeDS). Stakes: Tutkimuspaperit 18/2006

2. Kortteisto T, Kaila M, Komulainen J. & Rissanen P. Esimiesten kokemuksia sähköisistä potilaskertomusjärjestelmistä: Päätöksentuki-tutkimuksen (EBMeDS) haastattelut lähtötilanteessa. Stakes: Tutkimuspaperit 14/2007

3. Varonen H, Kaila M, Kunnamo I, Komulainen J, Mäntyranta T. Tietokoneavusteisen päätöksentuen avulla kohti neuvovaa potilaskertomusta. Duodecim 2006:122:1174-81.

4. Kortteisto T, Mäntyranta T, Komulainen J, Kaila M. Lääkäreillä vielä paljon sanottavaa sähköisistä potilaskertomusjärjestelmstä. Suom Lääkäril 2008;63:1297-301

5. Komulainen J, Kunnamo I, Nyberg P, Kaila M, Mäntyranta T, Korhonen M. Developing an evidence based medicine decision support system integrated with EPRs utilizing standard data elements. Proceedings of the workshop AI Techniques in Healthcare: Evidence-based Guidelines and Protocols. Ten Teije A, Miksch S, Lucas P (eds.) Riva del Garda, Italy, 28 August - 1 September 2006.

6. Varonen H, Kortteisto T, Kaila M for the EBMeDS study group. What may help or hinder the implementation of computerized decision support systems (CDSSs): a focus group study with physicians. Fam Pract 2008;25:162-7.

7. Kunnamo I, Kaila M, Komulainen J, Mustonen P, Nyberg P, Varonen H, Guyatt G. Electronic guidelines, decision support and standardized health records in Finland. Käsikirjoitus.

8. Kaila, Kortteisto, Kunnamo, Nyberg, Jousimaa, Komulainen, Mäkelä, Mäntyranta, Varonen, Rissanen. Virtual health check – a new automated quality measure for specified patient populations. Käsikirjoitus

9. Miettinen M. Gradu 2009 /JY. TIEDON LAATU TERVEYDENHUOLLON SÄHKÖISISSÄ POTILASTIETOJÄRJESTELMISSÄ

10. Korhonen H. Gradu 2009/Tay. TYÖN PIIRTEIDEN YHTEYS TERVEYDENHUOLLON AMMATTILAISTEN HOITOSUOSITUSASENTEISIIN

1. Homogeneity of health care (culture and value basis)2. Municipal ownership of all (public) health care

facilities3. Lack of any significant competition in health care4. Practically identical university curricula in the 5

medical faculties;

5. High national penetration of the internet technology and high computer proficiency; and

6. One respected medical scientific society responsible

of the service, “physicians producing guidelines for physicians”

Specific features that have promoted acceptance and wide use of guidelines in Finland

 Lääkärin käsikirja (YKT) 1218 EBM Guidelines /concise & primary health care

Käypä hoito 278 Current Care / thorough & all of health care

  Hoidon perusteet 247 National criteria for non-emergency care

 Potilasohjeet 555 Patient information

Sairaanhoitopiirien hoito-ohjelmat 631 Hospital Districts’ localized guidelines /care pathways

Kuvat 2062 Pictures

 Aikakauskirja Duodecim 9328 Finnish Medical Journal Duodecim

 Lääkärilehi 16141 Finnish Medical Journal

 Työterveyslääkäri 432 Occupational physician (journal)

Laboratoriotutkimukset 6631 Laboratory investigations

Näytönastekatsaukset 3596 Evidence summaries

Evidence summaries 3087

 Matkailijan terveysopas 89 Travelers’ health guide

Rokottajan käsikirja 84 Vaccinators’ hand book

FinOHTA 132

Kela 131 Social Insurance Institution’s guidelines

Puolustusvoimat 52 Defense forces

Lääkärin etiikka 99 Physician’s ethics

 Äänet 77 Sounds

Laskurit ja lomakkeet 26 Calculators and forms

Info 30 Information

Calculators • Alkoholin käyttö Alcohol use• Antikoagulanttiannostelu Anticoagulant dosing• Ejektiofraktio Ejection fraction• Energiankulutus Energy expentiture• GFR-laskuri Glomerular filtration rate• Haittaluokka ja –prosentti Disability classification • Kehon painoindeksi Body Mass Index• Korjattu QT-aika QT time• Kuivuman korjaus Rehydration• LDL-laskuri LDL-cholesterol calculator• PEF-laskuri PEF-calculator• Reynolds Risk Score (naisille)• SCORE-laskuri SCORE calculator• Tavoitesyke Target rhythm• UKPDS • Veden vajaus hypernatremiassa Water deficit in hypernatremia

 Lääkärin käsikirja (YKT) 1218 EBM Guidelines /concise & primary health care

Käypä hoito 278 Current Care / thorough & all of health care

  Hoidon perusteet 247 National criteria for non-emergency care

 Potilasohjeet 555 Patient information

Sairaanhoitopiirien hoito-ohjelmat 631 Hospital Districts’ localized guidelines /care pathways

Kuvat 2062 Pictures

 Aikakauskirja Duodecim 9328 Finnish Medical Journal Duodecim

 Lääkärilehi 16141 Finnish Medical Journal

 Työterveyslääkäri 432 Occupational physician (journal)

Laboratoriotutkimukset 6631 Laboratory investigations

Näytönastekatsaukset 3596 Evidence summaries

Evidence summaries 3087

 Matkailijan terveysopas 89 Travelers’ health guide

Rokottajan käsikirja 84 Vaccinators’ hand book

FinOHTA 132

Kela 131 Social Insurance Institution’s guidelines

Puolustusvoimat 52 Defense forces

Lääkärin etiikka 99 Physician’s ethics

 Äänet 77 Sounds

Laskurit ja lomakkeet 26 Calculators and forms

Info 30 Information

All guidelines are available in one search engine to 98 % of Finnish physicians as a part of Physician’s Database with 43000 documents

Use of EBMG, Current Care and related databases in the Terveysportti Health Portal

0

2000000

4000000

6000000

8000000

10000000

12000000

2000 2001 2002 2003 2004 2005 2006 2007

Numberof guidelinedocumentsopened10 million/year

Total numberof documentsopened >20 million/year

1.6 guidelines openedper every working-agedphysician every day