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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
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
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
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