The Finnish e-xperience

1. The Finnish e-xperience Ilkka Kunnamo, MD, PhD Editor-in-Chief, EBM Guidelines & EBMeDS Duodecim MedicalPublications Ltd. AdjunctProfessor of General Practice, University of Helsinki Disclosure: I am a salariedemployee of Duodecim MedicalPublications Ltd., the companythatdevelops and licenses EBM Guidelines and the EBMeDSdecisionsupportservice. Leuven June 16, 2011

2. Finland 5.3 millioninhabitants 19 000 doctors

3. The Finnish Medical Society Duodecim • The scientific society of Finnish physicians • Founded 1881 • Continuous Medical Education • Clinical Practice Guidelines • The society owns the publishing company Duodecim Medical Publications Ltd. • The largest medical publisher in Scandinavia • More than 50% of income from electronic publishing (health portals)

4. History of EBM Guidelines and EBMeDS • Electronic version on PC 1989 • CD-ROM 1991 • Book 1992 • Liaisonwith the CochraneCollaboration 2000 • Internet 2000 • Mobile phone 2001 • Translations in English (2000), German, Russian, Estonian, Hungarian, Slovenian, French, Dutch • EBMeDSprojectstarts 2003 • EBMeDS into clinicaluse 2008

5. The 8-year cycle • 1987 Idea of EBM Guidelines • 1995 Use of EBM Guidelines goes up Current Care Guidelines development • 2003 Use of Health Portal goes up EBMeDS development starts • 2011 Use of EBMeDS going up 100th Current Care Guideline published Use of Health Portal for citizens catches up

7. Use of electronic guideline databases in Finland from the professionals’ portal Number of guideline documents opened >12 million/year

8. Professonal’s Health Portal in Finland In 2010 almost 50 million opened articles

9. Citizens’ Health Portal In 2010 more than 30 million opened articles by the general public

10. Mobilisation of all potential guideline developers • Almost 2000 physicians (out of a total of 19 000) involved in guideline development in Finland • National and regional guidelines are published on the same portal and linked to each other

11. Making electronic guidelines usable • Easy to find by typing one search term • Concise format – information found in 1 minute • Supporting contents and tools • Images, videos, calculators, algorithms, patient information • Evidence summaries • Based on best available evidence

12. Example of evidence summary with strength of recommendation • Diagnosis and screening of early localized prostate cancer

13. The most frequently used search terms in 2010 • Diabetes 47636 • Urinary tract infection 41994 • Asthma 38560 • Glomerular filtration rate 31429 • Pneumonia 27161 • Goat 26933 • Hypertension 23618 • Anaemia 22727 • Sinusitis 22479

14. EBM Guidelines databases accessed in 2010 (Finland) • Guidelines 5 046 070 • Images 1 763 031 • Patient information 1 264 010 • Evidence summaries 226 954 • Calculators 225 562 • Videos 89296 • Journal articles 1 271 714

15. Experience of the same guideline set (EBM Guidelines) in 6 languages and 7 countries + the English-speaking world • Finland • Austria • Germany • Switzerland • Russia • Hungary • Estonia • EBM Guidelines in Wiley Interscience • National Guideline Clearinghouse (a sample)

16. Need for adaptation in Austria • Guidelines for referral (when, why, to whom; possibilities and limitations of general practices) • Availability of nurses, other paramedics, day clinics • Transport modalities (distances, availability of helicopters, centralization of advanced care) • Differences in legislation (drug substitution, psychiatric illnesses) • Existing national guidelines and practices Susanne Rabady

17. Lessons from Russia • Strong need for local adaptation of guidelines before implementing them. • Adaptation is probably best done by physicians practicing in the same settings where guidelines will be used, but it is important to invite opinion-leaders. • Co-editions are better than pure translations. • Most guidelines now developed in Russia are based on methodology suggested by EBM Guidelines Kamil Saitkoulov

18. Lessons from Hungary • Local adaptation needed for • drugs (especially dermatology) • sharing of tasks between primary care and specialists • Take much care on adaptation! • Learning opportunity from methodology of electronic publishing, coding methods, guideline electronic representation Mihaly Makara

19. What can be shared (besides full guidelines) • Evidence statements and grading of evidence • Evidence summaries • Instructions for procedures • Images • Patient information • Guideline authoring and publishing software • Decision support tools

20. Answers German-speaking countries vs. Finland (user survey by Webropol) Rabady, Kunnamo Lisbon 2009

21. Comparing Dissemination Rabady, Kunnamo Lisbon 2009

22. Comparing Usage Rabady, Kunnamo Lisbon 2009

23. How to maintain health portals in Finland • The Professionals’ portal is subscribed by all hospitals and primary care health centres • Organizations are willing to pay for reliable knowledge • Professionals need not pay by themselves • Citizens find the contents of the Citizens’ portal mainly via Google • The maintenance of the citizens’ health portal is paid by the ministry of health and by hospital districts • No pharmaceutical industry funding!

24. Firststep: Evidence and guidelinesavailable to professionals and citizens Nextstep: Personalizedmedicine

25. What is EBMeDS? A plug-in decision support service that can be integrated with any electronic health record (EHR) or personal health record (PHR)

26. Clinical decision support: automatic, patient-specific guidance Knowledge is pushed to the user Knowledge resources Electronic Health Record EBMeDS Sends patient data (request message) Receives decision support Peter Nyberg

27. Which patient data are used for decision support? • Problem list (diagnoses) • Medication list • Test results • Measurements (e.g. blood pressure) • Risk factors (e.g. smoking) • Procedures in standardized, coded format

28. The EBMeDS decision support service can be integrated with any electronic health record Demo website for clinical decision support

29. A web-based tool was developed for • Collaborative content management • Linking to international, national and local knowledge sources • Cochrane reviews are the main source • Adapting to different EHR data coding systems and measurement units • E.g. ICD-10, ICD-9CM, ICPC-2, SNOMED CT, ATC, RxNorm, LOINC… • Translation of reminders into the user’s language

31. Interview of 10 users(Finland, U.S.A, Belgium, Netherlands, Australia)

32. Translation time • Translation of ˜500 reminders takes about 45 hours • …while the translation of full EBM Guidelines takes one year.

33. Conclusions • A web-based authoring tool allows multinational and multilingual authoring of clinical decision support from evidence to actionable recommendations and functioning software • Translation of reminders is an easy task compared to translation of full guidelines

34. Interactivewebsite for citizens AlmostonemillionFinns (a fifth of the population) used the website NIMAC 18.4.2010

35. NIMAC 18.4.2010

36. The curve shows how many out of one hundred of your kind will reach the below indicated age Your optimal prediction: 50 out of 100 will reach 85 years Your current prediction: 6 out of 100 will reach 85 years

37. Tools for populationhealth, professionaldevelopment and qualityimprovement

38. In a virtual health check all rules are executed in a population of patients, and resulting reminders are listed.

39. Examples of reminders triggered in a VirtualHealth Check for a population of 16 000 • ACEI/AT blocker/beta blocker not in use in heart failure 143 • No glucose test in patient with cardiovascular disease 142 • Aspirin not in use in patient using nitrates 121 • Thiazide diuretic in patient with renal failure 115 • LDL > 2.5 mmol/l in type 2 diabetes 69 • Metformin not in use in type 2 diabetes 61 • No visits for a diabetic during last 13 months 58 • Folate missing in patient using methotrexate 40 • LDL > 2.5 mmol/l in patient with cardiovascular disease 29 • Heart failure and spironolactone – no recent test results 25 • Abnormal TSH in patient with hypothyroidism 9 • ACEI/AT blocker missing in diabetic with albuminuria 4 • Beta blocker not in use after myocardial infarction 2 • Aspirin not in use in patient with polycythaemia vera 1

40. Example of a virtual health check for a population of 16 000 • Cardioselective beta-blockers for patients with asthma/COPD: No reminder (selective beta-blocker 32 in use) Reminder: Obstructive pulmonary 4 disease - change to selective beta-blocker? Quidelinecompliance = 0.89(n = 36) 89% of patients with COPD and beta-blocker used the right type of beta-blocker.

41. Duodecim willbe the firstnon-UKguidelinedeveloper and EBMeDS the firstclinicaldecisionsupportproduct to obtain NHS EvidenceAccreditation for methodology Link to accreditationreport

42. Duodecim becomes the firstnon-USmember of the ClinicalDecisionSupportConsortium

43. Selection of medical interventions in 2020 Patient data Genome map KNOWLEDGE Guidelines Graded evidence Databases: drugs, laboratory, genome Images and videos for training of skills Cost-effectiveness Ethical summaries Patient information Probably beneficial therapy Decision support Patient’s values and choices Doctor’s interpre- tation and experience Resource limits Simulation Individualized prediction of the effects of treatment Selection of treatment Database of ”all” previous patients

44. Start smallThink bigMove fast

45. Keep it simple Be flexible Collaborate

46. Collaboration Finland/Belgium • Continuous discussions between editorial teams • Feedback from editors and users from both countries compared and acted upon • Development of clinical terminologies and indexing tools • Platform for developing national or local decision support rules • Collaborative development of drug databases • Development of translation tools

47. Dank u wel! Merci beaucoup!