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 No commercial conflicts of interest

EBMeDS: aim to develop, implement and evaluate a generic clinical decision support system.

Electronic EBM guidelines Structured Electronic Patient 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:

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 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< ) 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

Kristiina Häyrinen ja Jari Porrasmaa, 2006 Care testament

EBMeDS - organization Product project Lead group Project manager Project secretary Project group Pilot projects Pilot lead group Project manager Project secretary Project groups (2) Study project Study lead group Senior Junior Study group Medical Society Duodecim Tekes KymSHP P-SSHP Medical Publisher Duodecim Advisory committee Stakeholders RohtoUniversity of Tampere School of Public Health FinOHTA Pro- Wellness project plan

EBMeDS timetable Project planning Databases for drug treatment EBM scripts and guidelines Pilot projects and technical development EBMeDS Study Implementations Testing In practice National EPR definitions Project funding EBMeDS Demo National EPR legislations Virtual health check Diabetes Guidelines and DB National EPR archive

EBMeDS study project Baseline study at pilot sites –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 female44% 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 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 Ri/Ni 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. 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 ) 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 *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 Project planning Databases for drug treatment EBM scripts and guidelines Pilot projects and technical development EBMeDS Study Implementations Testing In practice National EPR definitions Project funding EBMeDS Demo National EPR legislations Virtual health check Diabetes Guidelines and DB National EPR archive

More information on EBMeDS: t.htm Thank you for your attention!

1.Kortteisto T, Kaila M & Komulainen J. Päätöksentuen tutkimus (EBMeDS). Stakes: Tutkimuspaperit 18/ Kortteisto T, Kaila M, Komulainen J. & Rissanen P. Esimiesten kokemuksia sähköisistä potilaskertomusjärjestelmistä: Päätöksentuki-tutkimuksen (EBMeDS) haastattelut lähtötilanteessa. Stakes: Tutkimuspaperit 14/ Varonen H, Kaila M, Kunnamo I, Komulainen J, Mäntyranta T. Tietokoneavusteisen päätöksentuen avulla kohti neuvovaa potilaskertomusta. Duodecim 2006:122: Kortteisto T, Mäntyranta T, Komulainen J, Kaila M. Lääkäreillä vielä paljon sanottavaa sähköisistä potilaskertomusjärjestelmstä. Suom Lääkäril 2008;63: 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 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: 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 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” Specific features that have promoted acceptance and wide use of guidelines in Finland

Lääkärin käsikirja (YKT) Lääkärin käsikirja (YKT) 1218 EBM Guidelines /concise & primary health care Käypä hoitoKäypä hoito 278 Current Care / thorough & all of health care Hoidon perusteet Hoidon perusteet 247 National criteria for non-emergency care Potilasohjeet Potilasohjeet 555 Patient information Sairaanhoitopiirien hoito-ohjelmatSairaanhoitopiirien hoito-ohjelmat 631 Hospital Districts’ localized guidelines /care pathways KuvatKuvat 2062 Pictures Aikakauskirja Duodecim Aikakauskirja Duodecim 9328 Finnish Medical Journal Duodecim Lääkärilehi Lääkärilehi Finnish Medical Journal Työterveyslääkäri Työterveyslääkäri 432 Occupational physician (journal) LaboratoriotutkimuksetLaboratoriotutkimukset 6631 Laboratory investigations NäytönastekatsauksetNäytönastekatsaukset 3596 Evidence summaries Evidence summaries 3087 Matkailijan terveysopas Matkailijan terveysopas 89 Travelers’ health guide Rokottajan käsikirjaRokottajan käsikirja 84 Vaccinators’ hand book FinOHTAFinOHTA 132 KelaKela 131 Social Insurance Institution’s guidelines PuolustusvoimatPuolustusvoimat 52 Defense forces Lääkärin etiikkaLääkärin etiikka 99 Physician’s ethics Äänet Äänet 77 Sounds Laskurit ja lomakkeetLaskurit ja lomakkeet 26 Calculators and forms InfoInfo 30 Information

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

Lääkärin käsikirja (YKT) Lääkärin käsikirja (YKT) 1218 EBM Guidelines /concise & primary health care Käypä hoitoKäypä hoito 278 Current Care / thorough & all of health care Hoidon perusteet Hoidon perusteet 247 National criteria for non-emergency care Potilasohjeet Potilasohjeet 555 Patient information Sairaanhoitopiirien hoito-ohjelmatSairaanhoitopiirien hoito-ohjelmat 631 Hospital Districts’ localized guidelines /care pathways KuvatKuvat 2062 Pictures Aikakauskirja Duodecim Aikakauskirja Duodecim 9328 Finnish Medical Journal Duodecim Lääkärilehi Lääkärilehi Finnish Medical Journal Työterveyslääkäri Työterveyslääkäri 432 Occupational physician (journal) LaboratoriotutkimuksetLaboratoriotutkimukset 6631 Laboratory investigations NäytönastekatsauksetNäytönastekatsaukset 3596 Evidence summaries Evidence summaries 3087 Matkailijan terveysopas Matkailijan terveysopas 89 Travelers’ health guide Rokottajan käsikirjaRokottajan käsikirja 84 Vaccinators’ hand book FinOHTAFinOHTA 132 KelaKela 131 Social Insurance Institution’s guidelines PuolustusvoimatPuolustusvoimat 52 Defense forces Lääkärin etiikkaLääkärin etiikka 99 Physician’s ethics Äänet Äänet 77 Sounds Laskurit ja lomakkeetLaskurit ja lomakkeet 26 Calculators and forms InfoInfo 30 Information All guidelines are available in one search engine to 98 % of Finnish physicians as a part of Physician’s Database with documents

Use of EBMG, Current Care and related databases in the Terveysportti Health Portal Number of guideline documents opened 10 million/year Total number of documents opened >20 million/year 1.6 guidelines opened per every working-aged physician every day