Uses of a national decision support system

based on computer-readable guidelines and

structured data from electronic patient records

Ilkka Kunnamo, MD The Finnish Medical Society Duodecim

ilkka.kunnamo@duodecim.fi

WONCA, Florence 2006

Actions taken in Finland• A comprehensive set of guidelines made

available in a national health portal– Every Finnish physician read averagely 1.5

guidelines from the Internet each day in 2005

Actions taken in Finland• A comprehensive set of guidelines made

available in a national health portal– Every Finnish physician read on the average 1.5

guidelines from the Internet each day in 2005

• All patient records in a central archive by 2010– Access by patient’s permission for professionals– Direct access for patients themselves– Essential data coded in XML (HL7 CDA R2 format)

Actions taken in Finland• A comprehensive set of guidelines made available

in a national health portal– Every Finnish physician read on the average 1.5

guidelines from the Internet each day in 2005

• All patient records in a central archive by 2010– Access by patient’s permission for professionals

• Direct access for patients themselves– Essential data coded in XML (HL7 CDA R2 format)

• A national decision support database and web service based on best evidence– EBM Guidelines and its evidence summaries linked to

Cochrane reviews– National guidelines

Structured (coded) information in the EPR (key data set)• Diagnoses and problems (list)• Medication (list)

– Allergies and adverse reactions

• Results of investigations– Blood pressure, laboratory, x-ray

• Surgery, procedures• Structured treatment plan

– includes targets for treatment

Decision support database

• Descriptions of the functionality of the decision support

• Evidence summaries (from EBM Guidelines)

• Scripts written in programming language

Evidence summarieshave links to Cochranereviews

Smith John 020248-139Y 55.1 y

12.10.2002 HbA1c 9.4 7.5

01.12.2001 LDL-chol 2.9 3.0

12.10.2002 BP 136/88 140/90

Insulin H Protaphan 32 yks. ilt. Metformin 500 mg 2 x 2Aspirin 100 mg 1 x 1Simvastatin 20 mg 1 x 1Enalapril 20 mg 1 x 1Amlodipin 5 mg 1 x 1

Medication 25.03.2003

Smoking YesCertificate for drug remuneration20.04.2003

Determine S-K and S-Creatinine(enalapril started 20.10.2002)

Treatment of type 2 diabetesLifestyle counseling in type 2 diabetesInsulin treatment of type 2 diabetesSmoking cessationCare pathway/type 2 diabetes, Central Finland

Search

RRRR

12.10.2001 fB-Gluc 9.8 4-6

21.01.2003 Karstula I. Kunnamo01.11.2002 KSKS J. Saltevo

R

New

Lab Diagnoses Care plan Forms

The colour indicates national treatment target (guideline)

Reminders

Guidelines

Dataentry

CV risk 14 %

Type 2 diabetes

High BP

Rheumatoid arthritis

Osteoporosis

10/2003

08/2004

05/2003

Search Dg

20.8.2004/I KunnamoSwelling in right knee for 2 weeks. Considerablehydrops. No other joints active. 25 ml of fluid wasaspirated, and steroid injected.BP in home measurements 145 – 158/92-98. Notsuccessful in reducing weight. Willing to startantihypertensive medication. Drug orders:Enalapril (Renitec) 20 mg x 1 (new)Methyl prednisolone (Solomet) 40 mg i.a.

• Diagnosis and treatment of rheumatoid arthritis

• Care pathway for type 2 diabetes in C-Finland

• Osteoporosis (patient information leaflet)

R

Reminders andguidelines are shownautomatically withinthe electronic patientrecord

Smith John 020248-139Y 55.1 y DM II 5/1991

12.10.2002 HbA1c 9.4 7.5

01.12.2001 LDL-chol 2.9 3.0

12.10.2002 BP 136/88 140/90

Medication 25.03.2003

01.12.2001 Smoking YesCertificate for drug remuneration20.04.2003

Determine S-K and S-Creatinine(enalapril started 20.10.2002)

Treatment of type 2 diabetesLifestyle counseling in type 2 diabetesInsulin treatment of type 2 diabetesSmoking cessationCare pathway/type 2 diabetes, Central Finland

Search

RRRR

12.10.2001 fB-Gluc 9.8 4-6

21.01.2003 BMI 32.2 102 kg 95 kg21.01.2003 Karstula I. Kunnamo01.11.2002 KSKS J. Saltevo

R

New

Lab Diagnoses Care plan Forms

01.12.2001 CV risk 14 %

Insulin H Protaphan 32 yks. ilt. Metformin 500 mg 2 x 2Aspirin 100 mg 1 x 1Simvastatin 20 mg 1 x 1Enalapril 20 mg 1 x 1Amlodipin 5 mg 1 x 1

Data to be shown are selected by thedecision support system

Alanen

Kemppi

Lieko

Vinkeä

Aku

Kimmo

Tuomo

Vappu

Results of virtual health check (performed by computer as a batch run)

All decision support scripts are executed,and resulting reminders are listed forall patients.

Virtual health check

Alanen

Kemppi

Lieko

Vinkeä

Aku

Kimmo

Tuomo

Vappu

Results of virtual health check (performed by computer as a batch run)

Virtual health check

A new task for the GP

Calculators

• Cardiovascular risk– SCORE, Framingham, UKPDS

• Glomerular filtration rate

• Peak flow rate and diagnostic criteria for asthma

Interactive forms

• Structured referral forms• Physician’s certificates• Forms to assist history-taking• Questionnaires to be filled by patients

– AUDIT questionnaire for alcohol use

The forms will extract part of the data directly from the EPR

Computer-generated letter Dear Mrs. Smith,

The laboratory tests taken on June 1st were as follows: Haemoglobin was 134, which is excellent. The kidney test (creatinine 86) and the liver test (ALT 32) were normal. You can continue your medication. The next tests are due in October. The laboratory referral is attached.

Faithfully yours,

Dr. Jones

Multicentre studies in primary care- Web-based data recording form is activated if patient meets inclusion criteria- Informed consent form is printed for the patient- Part of the data are transferred automatically from the records- An interactive form facilitates data entry- Data are stored in a web server for analysis

APR-tallennustyökaluSuggested: A national web tool forSuggested: A national web tool for recording data for clinical researchrecording data for clinical research

Users’ expectations (focus group interviews)

• ”This is what I expect from the electronic patient record”

• Should improve quality and make routines (”paperwork”) quicker

• Not too many reminders!– Both patient-specific and doctor-specific

lists for ”banned” reminders

Conclusions

• A comprehensive database of decision support functions can benefit the clinician and his patient in a variety of ways.

• Many decision support functions are very simple

For more information:

www.kaypahoito.fi/decisionsupport/decisionsupport.htm

KNOWLEDGEGuidelinesGraded evidenceDatabases: drugs, laboratory, genomeImages and videos for training skillsEthical summariesPatient information

Patient dataGenome map

Database of ”all”previous patients

Probablybeneficialtherapy

Simulation

Individualizedprediction ofthe effectsof treatment

Patient’s valuesand choices

Selection oftreatment

Selection of treatment in the future

Decisionsupport

Doctor’s interpre-tation andexperience

Patient’s user interface• Coded data is translated into lay language by means

of a metathesaurus

• The terms are linked to definitions and explanations, ”The Patient’s Handbook”, and local sources of patient information

DiagnosesLactose intolerance (poor absorption of )

What is lactose intoleranceDiet advice

Laboratory resultsHaemoglobin 124 Normal range What does Hb tellCholesterol 5.9 Normal rangeLDL cholesterol 3.8 Normal range Lipid measurements(”evil cholesterol”)Cardiovascular risk (10 yrs) 3.2 % How can I reduce my risk?

Treatment plan