Uses of a national decision support system based on computerreadable guidelines and structured data

1
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_at_duodecim.fi
• WONCA, Florence 2006

2
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

3
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 patients permission for professionals
• Direct access for patients themselves
• Essential data coded in XML (HL7 CDA R2 format)

4
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 patients 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

5
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

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Decision support database

• Descriptions of the functionality of the decision
  support
• Evidence summaries (from EBM Guidelines)
• Scripts written in programming language

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Evidence summaries have links to Cochrane reviews
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Smith John
020248-139Y
55.1 y
Type 2 diabetes High BP Rheumatoid
arthritis Osteoporosis
12.10.2002
HbA1c
9.4
7.5
Medication
25.03.2003
New
10/2003
Insulin H Protaphan 32 yks. ilt.
Metformin 500 mg 2 x
2 Aspirin 100 mg 1 x
1 Simvastatin 20 mg 1 x 1 Enalapril
20 mg 1 x 1 Amlodipin 5 mg
1 x 1
i
R
12.10.2001
fB-Gluc
9.8
4-6
08/2004
i
R
i
R
05/2003
01.12.2001
LDL-chol
2.9
3.0
i
R
R
i
12.10.2002
BP
136/88
140/90
R
i
Search Dg
21.01.2003 Karstula I. Kunnamo 01.11.2002
KSKS J. Saltevo
20.8.2004/I Kunnamo Swelling in right knee for 2
weeks. Considerable hydrops. No other joints
active. 25 ml of fluid was aspirated, and steroid
injected. BP in home measurements 145
158/92-98. Not successful in reducing weight.
Willing to start antihypertensive medication.
Drug orders Enalapril (Renitec) 20 mg x 1
(new) Methyl prednisolone (Solomet) 40 mg i.a.
Smoking
Yes
Certificate for drug remuneration 20.04.2003
Reminders
Data entry
CV risk
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Reminders and guidelines are shown automatically
within the electronic patient record
Determine S-K and S-Creatinine (enalapril started
20.10.2002)
Treatment of type 2 diabetes Lifestyle
counseling in type 2 diabetes Insulin treatment
of type 2 diabetes Smoking cessation Care
pathway/type 2 diabetes, Central Finland
Search
Diagnosis and treatment of rheumatoid
arthritis Care pathway for type 2 diabetes in
C-Finland Osteoporosis (patient information
leaflet)
The colour indicates national treatment target
(guideline)
Guidelines
Lab Diagnoses Care plan Forms
10
Smith John
020248-139Y
55.1 y
DM II
5/1991
12.10.2002
HbA1c
9.4
7.5
Medication
25.03.2003
New
Insulin H Protaphan 32 yks. ilt.
Metformin 500 mg 2 x
2 Aspirin 100 mg 1 x
1 Simvastatin 20 mg 1 x 1 Enalapril
20 mg 1 x 1 Amlodipin 5 mg
1 x 1
i
R
12.10.2001
fB-Gluc
9.8
4-6
i
R
i
R
01.12.2001
LDL-chol
2.9
3.0
i
R
R
i
12.10.2002
BP
136/88
140/90
21.01.2003 Karstula I. Kunnamo 01.11.2002
KSKS J. Saltevo
21.01.2003
BMI
32.2
102 kg
95 kg
01.12.2001
Smoking
Yes
Certificate for drug remuneration 20.04.2003
01.12.2001
CV risk
14
Determine S-K and S-Creatinine (enalapril started
20.10.2002)
Data to be shown are selected by the decision
support system
Treatment of type 2 diabetes Lifestyle
counseling in type 2 diabetes Insulin treatment
of type 2 diabetes Smoking cessation Care
pathway/type 2 diabetes, Central Finland
Search
Lab Diagnoses Care plan Forms
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Virtual health check
Results of virtual health check (performed by
computer as a batch run)
Alanen
Aku
Kemppi
Kimmo
Lieko
Vappu
All decision support scripts are executed, and
resulting reminders are listed for all patients.
Vinkeä
Tuomo
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Virtual health check
Results of virtual health check (performed by
computer as a batch run)
A new task for the GP
Alanen
Aku
Kemppi
Kimmo
Lieko
Vappu
Vinkeä
Tuomo
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Calculators

• Cardiovascular risk
• SCORE, Framingham, UKPDS
• Glomerular filtration rate
• Peak flow rate and diagnostic criteria for asthma

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Interactive forms

• Structured referral forms
• Physicians 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

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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

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APR-tallennustyökalu
Suggested A national web tool for recording
data for clinical research

• 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

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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

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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

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For more information www.kaypahoito.fi/decisionsu
pport/decisionsupport.htm
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Selection of treatment in the future
Patient data Genome map
KNOWLEDGE Guidelines Graded evidence Databases
drugs, laboratory, genome Images and videos
for training skills Ethical summaries Patient
information
Probably beneficial therapy
Decision support
Patients values and choices
Doctors interpre- tation and experience
Simulation
Selection of treatment
Individualized prediction of the effects of
treatment
Database of all previous patients
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Patients user interface

• Coded data is translated into lay language by
  means of a metathesaurus
• The terms are linked to definitions and
  explanations, The Patients Handbook, and local
  sources of patient information

Diagnoses Lactose intolerance (poor absorption of
) What is lactose intolerance Diet
advice Laboratory results Haemoglobin
124 Normal range What does Hb
tell Cholesterol 5.9 Normal range LDL
cholesterol 3.8 Normal
range Lipid measurements (evil
cholesterol) Cardiovascular risk (10 yrs) 3.2
How can I reduce my risk? Treatment plan