What can we offer the members? Visions for EQuiP Duodecim projects - - PowerPoint PPT Presentation

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 Duodecim Medical Publications Ltd.

• Scientific society founded in 1881

> 90% of the Finnish 20 000 physicians as members

• Clinical Practice Guidelines
• Continuous Medical Education
• 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) Portal (all resources) 39.4

• 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

2000000 4000000 6000000 8000000 10000000 12000000 14000000 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

Evidence-based medicine methodology NICE accreditation

Evidence statement

• n patient-

important

• utcomes

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

Susanne Rabady, OEGAM

• 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

Clinical decision support as a service integrated with electronic health records

Recommendations in the form of CDS rules trigger reminders automatically if patient data suggest that there is potential for improvement

etc

Open library of rules

All rules and functions can be tested in an online testing environment

Demo of the EBMeDS decision support service

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

• ckers 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 and checking their

• Symptom history and monitoring
• Family history
• Blood pressure, weight, height
• Peak expiratory flow
• Blood glucose
• ECG
• Pain intensity
• Functioning
• current medication list
• diagnosis list

EHR 1 EHR 2 EHR 3 User DB Engine 1 Engine 2 Engine 3

Response integrator

User preferences EHRs receive feedback in one single format Web service interface Access control

CCD VMR EBMeDS

Converter Converter EHRs are allowed to send data in several formats Several CDS engines from different providers analyze the data The users decide which rules they want to implement Content set 1 Content set 2 Content set 3

The future

• f CDS?

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
• n 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

Guidelines International Network (G-I-N)

• Implementation Working Group

– Chaired by Anna Gagliardi (Canada) – Database of guideline implementation tools – White paper planned on the use clinical decision support for guideline implementation

• Multimorbidity working group (just founded)

– Chaired by Ilkka Kunnamo (Finland) and Cynthia Boyd (U.S.A) – Networking of clinicians and researchers interested in multimorbidity – How to develop guidelines for people with multiple morbidities

GItool Directory (giranet.org)

GRADE and DECIDE

• The GRADE Working Group

www.gradeworkinggroup.org

– How to grade the quality of evidence and the strength of recommendations – How to derive recommendations based on evidence, cost-effectiveness, and patients’ values and preferences

• DECIDE www.decidecollaboration.eu

– How to communicate evidence and recommendations to clinicians, decision-makers, and citizens

The big picture

Focus areas of EQuiP and Duodecim

• 1. (Global) network organization and information

strategy

• 2. European/global collaboration.
• 3. Teaching quality improvement and patient safety
• 4. Patient safety
• 5. Patient empowerment (PECC-WE)
• 6. Professional Health
• 7. Equity, quality and safety
• 8. Accreditation
• 9. Informatics, quality and safety

10.Quality indicators and guidelines 11.Research in quality and safety 12.Practice management

Thank you!

ilkka.kunnamo@duodecim.fi www.ebmeds.org