What can we offer the members? Visions for EQuiP Duodecim projects Ilkka Kunnamo, MD, PhD, Chief Editor Disclosure: I am a salaried employee of Duodecim Medical Publications Ltd., the company that develops and and licenses the EBMeDS decision support service.
The Finnish Medical Society Duodecim • Scientific society founded in 1881 > 90% of the Finnish 20 000 physicians as members Clinical Practice Guidelines • • Continuous Medical Education Duodecim Medical Publications Ltd. • 100% owned by the Finnish Medical Society • Electronic publishing since 1989 – 6 million euro electronic publishing turnover – 26 full time, about 20 part time + 2000 contributors • eLearning platform • National health portals for both professionals and citizens in Finland
History of Duodecim’s eHealth resources Idea of EBM Guidelines emerged 1987 Pilot electronic version on floppy disks 1989 CD-ROM (and book) 1991 Health Internet portal for professionals 2000 Mobile guidelines for smart phones 2001 Health internet portal for citizens 2007 Computerized clinical decision support 2008 rules (EBMeDS) Electronic Health Coaching for citizens 2010 Translations of EBM Guidelines in English, German, Russian, Estonian, Hungarian, Slovenian, Dutch, French, Turkish, Armenian
Health Portal for Professionals
Health Portal for Professionals Use by resource in one year 2012/13 Resource Articles opened (in millions) 39.4 Portal (all resources) • Drug formulary 16.9 • EBM Guidelines (1548 topics) 5.9 • ICD-10 3.5 • Images and videos 2.3 • Information for patients 1.3 • Finnish language medical journals 1.3 • Medical news 0.9 • National guidelines (Current Care) 0.7 + Current Care from open web pages 1.7
The most frequently opened documents (professionals) in one year 2012/13 • GFR calculator 89 964 • Urinary tract infections 74 732 • PEF calculator 46 212 • Fungal infections of skin and nails 44 562 • Medical check for driving license 42 247 • Lyme borreliosis 40 594 • Hypothyroidism 38 383 • Beck Depression Inventory 36 189 • Erysipelas 32 951
Physician ´ s Database use in Finland 2000-2012 Close to 13 million documents were opened in 2012 EBMG almost 50 % of all openings 14000000 12000000 10000000 8000000 6000000 4000000 2000000 0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Finland: National Health Library for Citizens Resource Articles opened (in millions)/y • Portal (all resources) 33.1 • Medical handbook (1100 topics) 19.6 • Images 2.5 • Interpretation of laboratory test results 1.3 • Medicines handbook 1.3 • Medical dictionary 0.8 • 100 questions to paediatrician 0.7 • Prevention of disease 0.6 • Healthy sex 0.5 Finland has 5.3 million inhabitants
Essential contents of a successful health portal • Comprehensive collection of concise guidelines • Quickly searchable with one search term • Drug information databases • Images, videos, calculators; supporting material • Patient information
EBMG (Finland) Editorial Team • 7 salaried physician editors • Close to 500 Finnish physician authors experts • Marketing, IT and technical editors
Mobilisation of all potential guideline developers • Almost 2000 physicians (out of a total of 19 000) involved in guideline and health portal development in Finland – National and regional guidelines are published on the same portal and linked to each other
NICE accreditation Evidence-based medicine methodology
Evidence statement on patient- important outcomes Reasons for downgrading Recommendation Reason for weak recommendation (value statement) Link to Cochrane review
Adaptation and updating of EBM Guidelines in Austria since 2005
Adaptation and updating of EBM Guidelines in Belgium since 2012
Classification of differences • Unexplained – Lack of knowledge on reviewers side – Local habits with no background – Different recommendations – following weak evidence – Different recommendations – inspite of strong evidence • Explained – Different recommendations following differences in system or resources Susanne Rabady, OEGAM Susanne Rabady, OEGAM
Clinical decision support as a service integrated with electronic health records etc Recommendations in the form of CDS rules trigger reminders automatically if patient data suggest that there is potential for improvement
Open library of rules
Demo of the EBMeDS decision support service All rules and functions can be tested in an online testing environment
Personalized care: Demo of the EBMeDS decision support service
Interactive algorithms are automatically populated by patient data (diagnoses, medications, lab test results) from the EHR The patient’s path and the best choice is shown
In a virtual health check all CDS rules are executed in a population of patients, and resulting reminders are listed.
Two purposes for the virtual health check • Clinical : find people who need interventions and contact them – Persons identified • Analytic : create statistics on quality of care and about the target group for clinical interventions – Anonymous
Examples of reminders triggered in a Virtual Health Check for a population of 16 000 from a set of 100 rules Antihypertensive drug not used in moderately high BP 396 • and high CV risk • ACEI/AT blocker/beta blocker not in use in heart failure 143 • LDL > 2.5 mmol/l in type 2 diabetes 69 • Metformin not in use in type 2 diabetes 61 • No visits for a patient with diabetes during last 13 months 58
Example of decision support and quality reporting for a population of 16 000 (a virtual health check) Ca Cardioselect selective ive beta-blockers ockers for patients nts wi with asthma: hma: No reminder (selective beta-blocker 32 in use) Reminder: Asthma – switch to selective 4 beta-blocker? Guideli eline ne compliance nce = 0.89 (n = 36) 89% of patients with asthma and beta-blocker used the right type of beta-blocker.
Data for quality measurement • Quality indicators must be based on evidence and guidelines • Do not develop quality indicators that cannot use – data routinely recorded for clinical purposes in the EHR or – entered by the patients • Use all structured data you can get • Embed quality measures in clinical decision support rules – Good practice as numerator – Eligible population as denominator, exclusions substracted
Patients recording their own data • Symptom history and monitoring • Family history • Blood pressure, weight, height • Peak expiratory flow • Blood glucose • ECG • Pain intensity • Functioning and checking their • current medication list • diagnosis list
CCD EHR 1 Engine 1 Content set 1 VMR EHR 2 Content set 2 Engine 2 Converter EHR 3 Engine 3 Content set 3 EBMeDS Web service interface Several CDS EHRs are allowed to engines from send data in several different providers formats analyze the data Converter Response integrator EHRs receive The users decide which rules they feedback want to implement in one single format The future Access control User User of CDS? preferences DB
Collaboration network of Duodecim • EQuiP www.equip.ch The Cochrane Collaboration www.cochrane.org • • Guidelines International Network (G-I-N) www.g-i-n.net • The GRADE Working Group www.gradeworkinggroup.org DECIDE Collaboration www.decide-collaboration.eu • • PRIMA-eDS www.prima-eds.eu • Magic www.magicproject.org EBMPracticeNet (Belgium) www.ebmpracticenet.be • • Austrian Society of General Practice/Verlagshaus der Ärzte www.ebm-guidelines.at • McMaster University (McMaster Plus) http://hiru.mcmaster.ca/hiru/HIRU_McMaster_PLUS_Proje cts.aspx • United States Clinical Decision Support Consortium Electronic health record vendors •
The Cochrane Collaboration • Primary Care Field http://www.cochraneprimarycare.org/ – Chaired by Floris Van de Laar – PEARLS: Cochrane reviews relevant for primary care – Repository of prediction tools and calculators • EPOC group (Effective Practice and Organization of Care) http://epoc.cochrane.org – Chaired by Jeremy Grimshaw (Canada) – www.rxforchange.ca • CochraneTech http://tech.cochrane.org/ – Lead by Chris Mavergames – Linked Data connecting knowledge sources and tools at the point of care
WONCA Informatics Working Party • Ilkka Kunnamo was elected chair of WIWP in 2013 • Coordination of activities with EQuiP – Organizing workshops together – Linking website contents • Development of policy statement for WONCA on how – IT should support the core tasks of the GP – GPs should utilize IT – WONCA could promote the implementation of effective IT in general practice • Collaboration with WONCA classification committee
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