Implementing Cochrane evidence via
EBM Guidelines and EBMeDS
Ilkka Kunnamo, MD, PhD
Editor-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 2011
ilkka.kunnamo@duodecim.fi
The Finnish Medical Society Duodecim
• 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
Duodecim Medical Publications Ltd.
• 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
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Idea emerged
Pilot electronic version on floppy disks
CD-ROM
Book
Liaison with the Cochrane Collaboration
Internet
Mobile
Computerized clinical decision support
rules (EBMeDS)
1987
1989
1991
1992
2000
2000
2001
2008
• 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
14000000
12000000
10000000
1.7 guidelines opened
per every working-aged
physician every day
8000000
6000000
4000000
2000000
0
2000 2001 2002 2003 2004 2005 2006 2007 2008
Number
of guideline
documents
opened
>12 million/year
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 patientimportant
outcomes
Reasons for
downgrading
Recommendation
Link to Cochrane
review
Reason for weak
recommendation
(value statement)
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
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Technical editors
Informaticians
IT professionals
Secretaries
Marketing and training
6
2
5
3
3
Monitoring the use of guidelines
• Log files of on-line use
• User surveys
Databases accessed in 2010 by
health care professionals (Finland)
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EBM Guidelines
Images and videos
Patient information
Evidence summaries
Calculators (e.g. GFR)
• Journal articles
5 046 070
1 852 327
1 264 010
226 954
225 562
1 271 714
Supplementary contents and tools that facilitate
implementation are valued by users
The most frequently opened
documents in 2010
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GFR calculator
Urinary tract infections
PEF calculator
Lyme borreliosis
Fungal infections of skin and nails
Diabetes
Medical requirements for driving license
Erysipelas
Hypothyroidism
60728
46470
31199
31012
29195
28204
26818
26028
25752
The most frequently used search
terms in 2010 (translated from Finnish)
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Diabetes
Urinary tract infection
Asthma
Gfr
Pneumonia
Gout
Hypertension
Anaemia
Sinusitis
47636
41994
38560
31429
27161
26933
23618
22727
22479
Ratio of opened guidelines and
evidence summaries
• EBM Guidelines Finnish version
• EBM Guidelines German language version
• Finnish national Current Care Guidelines via
professionals’ portal
• Finnish national Current Care Guidelines via
Current Care website
• EBM Guidelines English language version
93.7
19.3
4.0
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
1.3
1.1
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 nonselective beta-blocker – switch to selective
beta-blocker
The EBMeDS decision support service can be
integrated with any electronic health record via
XML messaging (see www.ebmeds.org)
Electronic
Health
Record
Knowledge
resources
EBMeDS
Sends patient data (XML request message)
Receives decision support (XML response message)
Peter Nyberg
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
in use)
32
Reminder: Asthma – switch to selective
beta-blocker?
4
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)
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Evidence summaries
Instructions on how to perform procedures
Images, videos
Patient information
Decision support tools
• Guideline authoring and publishing
software