Ilkka Kunnamo, MD The Finnish Medical Society Duodecim ilkka.kunnamo@duodecim.fi

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@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 patient’s 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 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

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

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

7. Evidence summaries have links to Cochrane reviews

9. 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 08/2004 4-6 i R 05/2003 i R 01.12.2001 LDL-chol 2.9 3.0 i R i R 12.10.2002 BP 136/88 140/90 i R 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 CV risk 14 % Data entry 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 i R 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

11. 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

12. 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

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

16. 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

17. 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

18. Suggested: A national web tool for recording data for clinical research APR-tallennustyökalu • 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

19. 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

20. 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

21. For more information: www.kaypahoito.fi/decisionsupport/decisionsupport.htm

22. 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 Patient’s values and choices Doctor’s interpre- tation and experience Simulation Selection of treatment Individualized prediction of the effects of treatment Database of ”all” previous patients

23. 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 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 rangeLipid measurements (”evil cholesterol”) Cardiovascular risk (10 yrs) 3.2 % How can I reduce my risk? Treatment plan