Implementing Cochrane evidence via EBM Guidelines and EBMeDS

Ilkka Kunnamo, MD, PhDEditor-in-Chief, EBM Guidelines & EBMeDS

Adjunct Professor of General Practice, University of Helsinki, Finland

Disclosure: I am a salaried employee of Duodecim Medical Publications Ltd., the company that develops and licenses EBM Guidelines and the EBMeDS decision support service.

Cochrane Colloquium, Madrid 2011ilkka.kunnamo@duodecim.fi

The Finnish Medical Society Duodecim

Duodecim Medical Publications Ltd.

• Scientific society founded in 1881

> 90% of the Finnish physicians as members• Clinical Practice Guidelines• Continuous Medical Education• Medical terminology in Finnish language• Awards and grants for young scientists

• 100% owned by the Finnish Medical Society• Electronic publishing since 1989• Publisher of the national health portal for both professionals and

citizens in Finland

History and production of EBM Guidelines

• Idea emerged 1987• Pilot electronic version on floppy disks 1989• CD-ROM 1991• Book 1992• Liaison with the Cochrane Collaboration 2000• Internet 2000• Mobile 2001• Computerized clinical decision support 2008 rules (EBMeDS)

• Translations in English, German, Russian, Estonian, Hungarian, Slovenian, Dutch, French

Demo

Included in Essential Evidence Plus

Objective of EBM Guidelines

• The right information

• by one search term

• within one minute

Use of electronic guideline databases in Finland from the professionals’ portal

0

2000000

4000000

6000000

8000000

10000000

12000000

14000000

2000 2001 2002 2003 2004 2005 2006 2007 2008

Numberof guidelinedocumentsopened>12 million/year

1.7 guidelines openedper every working-agedphysician every day

Using Cochrane evidence in EBM Guidelines

• Evidence summaries are written by salaried physician editors from all Cochrane reviews that are relevant to the topics of EBM Guidelines

• 2765 Cochrane reviews are cited in EBM Guidelines evidence summaries by 9/2011

EBM Guidelines uses a slightly modified GRADE system

Evidence statement on patient-important outcomes

Reasons for downgrading

Recommendation

Reason for weak recommendation (value statement)Link to Cochrane

review

Standard wording for evidence and recommendations

• The evidence summaries use standard wording for evidence and recommendations

• See www.ebm-guidelines.com/dtk/ebm01066

Updating

• Evidence-driven– Continuous scanning of the literature– When new important evidence is published,

evidence summaries and recommendations are updated

• Both scheduled (every 2 – 3 years) and (interim) continuous updates

• The salaried Editorial Team is responsible for initiating the updates

Salaried personnel for guideline development in Finland (excluding nursing and dentistry)

• Physician editors 20– Mostly part-time

• Technical editors 6

• Informaticians 2

• IT professionals 5

• Secretaries 3

• Marketing and training 3

• Log files of on-line use

• User surveys

Monitoring the use of guidelines

Databases accessed in 2010 by health care professionals (Finland)• EBM Guidelines 5 046 070• Images and videos 1 852 327• Patient information 1 264 010• Evidence summaries 226 954• Calculators (e.g. GFR) 225 562

• Journal articles 1 271 714

Supplementary contents and tools that facilitate implementation are valued by users

The most frequently opened documents in 2010• GFR calculator 60728• Urinary tract infections 46470• PEF calculator 31199 • Lyme borreliosis 31012• Fungal infections of skin and nails 29195• Diabetes 28204• Medical requirements for driving license 26818• Erysipelas 26028• Hypothyroidism 25752

The most frequently used search terms in 2010 (translated from Finnish)

• Diabetes 47636• Urinary tract infection 41994• Asthma 38560• Gfr 31429• Pneumonia 27161• Gout 26933• Hypertension 23618• Anaemia 22727• Sinusitis 22479

Ratio of opened guidelines and evidence summaries

• EBM Guidelines Finnish version 93.7

• EBM Guidelines German language version 19.3• Finnish national Current Care Guidelines via 4.0

professionals’ portal• Finnish national Current Care Guidelines via 1.3

Current Care website• EBM Guidelines English language version 1.1

The ratio reflects the context of use: only guidelines are opened during patient encounters; evidence summaries are opened during learning (CME) and preparation of presentations

Answers German-speaking countries vs. Finland

Clinical decision support (CDS)

• Recommendations in the form of CDS rules trigger reminders automatically if patient data suggest that there is potential for improvement.

• Example:

The patient has asthma and is using a non-selective beta-blocker – switch to selective beta-blocker

Knowledgeresources

ElectronicHealthRecord

Sends patient data (XML request message)

Receives decision support (XML response message)Peter Nyberg

EBMeDS

The EBMeDS decision support service can be integrated with any electronic health record via XML messaging (see www.ebmeds.org)

Example of decision support and quality reporting for a population of 16 000(a virtual health check)

• Cardioselective beta-blockers for patients with asthma:

No reminder (selective beta-blocker 32

in use)

Reminder: Asthma – switch to selective 4 beta-blocker?

Guideline compliance = 0.89(n = 36)

89% of patients with asthma and beta-blocker used the right type of beta-blocker.

What can be shared internationally (in addition to full guidelines)

• Evidence summaries• Instructions on how to perform procedures• Images, videos• Patient information• Decision support tools

• Guideline authoring and publishing software