Transcript The successful use of tools for Finnish professionals

EBMeDS - Evidence Based Medicine
electronic Decision Support
Kortteisto Tiina
Jousimaa Jukkapekka, Komulainen Jorma, Kunnamo Ilkka, Mäkelä
Marjukka, Mäntyranta Taina, Rissanen Pekka, Varonen Helena
Minna Kaila, MD, PhD, Pediatric Allergist
Adjunct Professor /University of Tampere
Director /Institute for Health & Welfare
minna.kaila(at)kolumbus.fi or (at)thl.fi
mobile +358 50 523 2021
No commercial conflicts of interest
EBMeDS: aim
to develop,
implement and
evaluate
a generic clinical decision support
system.
Electronic
EBM guidelines
Clinical Decision Support
Structured Electronic
Patient Record
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
Core
data
Ydintiedot
Hoitoprosessin
The
care process
tiedot
Tunnistetiedot
ID
data
Ongelmat and
Problems
ja
Potilas PIC
Patient
Toimintakyky
Function
diagnoosit
diagnoses
Tutkimukset
Investigations
Hoidon antaja
Caregiver
Fysiologiset
Physiological
mittaukset
measurements
Toimenpiteet
Procedures
Hoitojakso,
treatment
episode
Hoitotyöcare
Nursing
- individual
tapahtumaor
treatment chain
tai palveluketju
Yhteenveto
Summary
Lääkitys
Medication
Apuvälineet
Aids
Terveyteen
Health
factors
vaikuttavat tekijät
Muut tiedot
Other
info
Elinluovutus
Organ
donor statustestamentti
Lausunnot
Certificates
ja todistukset
Suostumus
Agreements
Jatkohoitoa
Future
treatment
koskevat tiedot
plans
Care
testament
Hoitotahto
Kristiina Häyrinen ja Jari Porrasmaa, 2006
EBMeDS - organization
Medical Society Medical Publisher
Duodecim
Duodecim
Product project
Lead group
Project manager
Project secretary
Project group
Rohto
KymSHP
P-SSHP
Pilot projects
Pilot lead group ProProject manager Wellness
Project secretary
Tekes
Project groups (2)
Advisory committee
Stakeholders
project plan 2005-06
Study project
Study lead group
Senior
Junior
Study group
FinOHTA
University of
Tampere
School of
Public Health
EBMeDS timetable
In practice
Implementations
Testing
EBMeDS Study
Pilot projects and technical development
EBM scripts and guidelines
Databases for drug treatment
Guidelines and DB
2008
Diabetes
2007
EBMeDS Demo
2006
Project funding
2005
Virtual health check
Project planning
2009
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 processes
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.
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 evidencebased 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
VHC
VHC
VHC
exclude:
*occupational health
VHC
Ri/Ni
Ri/Ni
0
time
Randomisation
─── patient, whose reminders are blocked (recorded only in log files)
------ patient, whose reminders are shown to his/her physician or nurse
VHC = virtual health check
R = 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.
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
In practice
Implementations
Testing
EBMeDS Study
Pilot projects and technical development
EBM scripts and guidelines
Databases for drug treatment
Guidelines and DB
2008
Diabetes
2007
EBMeDS Demo
2006
Project funding
2005
Virtual health check
Project planning
2009
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
Specific features that have promoted
acceptance and wide use of guidelines in
Finland
1. Homogeneity of health care (culture and value basis)
2. Municipal ownership of all (public) health care
facilities
3. Lack of any significant competition in health care
4. 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”
Lääkärin käsikirja (YKT)
Käypä hoito
1218
EBM Guidelines /concise & primary health care
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
Työterveyslääkäri
16141
432
Finnish Medical Journal
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)
Käypä hoito
1218
EBM Guidelines /concise & primary health care
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
All guidelines are available in
one search engine to
98 % of Finnish physicians
as a part of Physician’s Database
with 43000 documents
Lääkärilehi
Työterveyslääkäri
16141
432
Finnish Medical Journal
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
Use of EBMG, Current Care and related
databases in the Terveysportti Health Portal
12000000
10000000
8000000
1.6 guidelines opened
per every working-aged
physician every day
Number
of guideline
documents
opened
10 million/year
6000000
Total number
of documents
opened >20
million/year
4000000
2000000
0
2000 2001 2002 2003 2004 2005 2006 2007