What can be globalized or shared nationally and internationally

by collaboration• Development and success of electronic

guidelines in Finland• Experiences from translation and adaptation• What can we learn from the U.S.• Role for G-I-N?

Ilkka KunnamoThe Finnish Medical Society Duodecim

History of EBM Guidelines• Idea emerged 1987• Pilot electronic version on floppy disks 1989• CD-ROM 1991• Book 1992• Estonian translation 1995• English translation 2000• Internet 2000• Mobile 2001• Russian translation 2001• Hungarian translation 2005• German translation 2005• Slovenian translation? 2007• French translation?• Dutch translation?

Guidelines in Finland in 2007• EBM Guidelines (Primary care) 1219• Current Care national guidelines 76

• Local guidelines 631– Linked to EBM Guidelines and

national guidelines• Evidence summaries 6683

– Linked Cochrane reviews 1500• Pictures 2062

All guidelines are available in one search engine to 98 % of Finnish physicians as a part of a comprehensive health portal with 50 000 documents

Evidence chain:Guideline – Evidence Summary – Cochrane review

GRADE PICO statement

Use of EBMG, Current Care and related databases in the Finnish Health Portal

0

2000000

4000000

6000000

8000000

10000000

12000000

2000 2001 2002 2003 2004 2005 2006 2007

Numberof guidelinedocumentsopened10 million/year

Total numberof documentsopened >20 million/year

Use of EBMG, Current Care and related databases in the Finnish Health Portal

0

2000000

4000000

6000000

8000000

10000000

12000000

2000 2001 2002 2003 2004 2005 2006 2007

Numberof guidelinedocumentsopened10 million/year

Total numberof documentsopened >20 million/year

1.6 guidelines openedper every working-agedphysician every day

This image wasviewed 11908 timesin 2006

Who make guidelines in Finland• EBM Guidelines

– 6 salaried physician editors, 15 total salaried staff– more than 400 authors, coordinators and referees

• National Current Care guidelines– 15 total staff– 700 members of guideline authoring groups

• Local guidelines– Several hundreds of authors

10 % of Finnish physicians

Success factors in Finland• Comprehensive (high probability of finding

guidance) and well indexed for searching• Concise (readable in one minute)• Produced by trusted peers (scientific society of all

physicians) and backed by GRADEd evidence summaries

• Available within a comprehensive health portal as well as in book, CD and mobile format

• Local protocols and care pathways based on the guidelines and linked to them

• User feedback and log files used for improvement• Development and licenses paid by health care

organizations• Citizens’ health portal based on the same

evidence

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)

Need for adaptation to AustriaGuidelines for referral (when, why, to whom; possibilities and limitations of general practices)Availability of nurses, other paramedics, day clinicsTransport modalities (distances, availability of helicopters, centralization of advanced care)Differences in legislation (drug substitution, psychiatric illnesses)Existing national guidelines and practices

Susanne Rabady

EBM Guidelines Austrian team: 18 primary care physicians from all over the countrySusanne RabadyManfred MaierErwin RebhandlFranz BurghuberBernhard PanhoferReinhold GlehrGustav KamenskiHarald BergerErwin KepplingerPia StützWolfgang Hockl

Peter PichlerThomas HorvatitsWolfgang HocklBernhard FürthauerBarbara DegnIngrid PichlerRenate Hoffmann –Dorninger

The Austrian Societyfor General Practice

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 EBMGuidelines

Kamil Saitkoulov

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

Ten most popular EBM guidelines by logfilesFinnish English GermanUrinary tract infections Complications of tooth

extractionVaccinations

Wrist and hand trauma Ankle fractures Borreliosis

Pneumonia Dermatomycoses Use of antibiotics

Borreliosis Leg oedema Diabetes: definition

Erysipelas Stress fracture Tonsillitis in children

Dermatomycoses Differential diagnosis of chest pain

Sore throat and tonsillitis

Hypothyroidism Henoch-Schönlein purpura

Otitis media in children

Vaginitis Heart failure Herpes zoster

Diarrhoea A child with fever Low back pain

Sore throat and tonsillitis

Cardiac murmurs in children

Heart failureBalanitis in children

Key factors for success of international sharing and adaptation• Publishing in the users’ native language by a

respected publisher• Review, editing and adaptation by a dedicated

local team of trusted colleagues• Collaboration with the original publisher on a

continuous basis• Regular updating that is sufficiently financed• Several publishing formats (book, electronic,

mobile)

Guidelines for resource-poor settings?

• Effective alternatives for best but expensive interventions for resource-poor areas should be included in guidelines.– Banding for bleeding oesophageal varices is

the most effective intervention.

– Sclerotherapy is cheaper and more feasible in resource-poor settings.

Fried M, Farthing M, Krabshuis J, Quigley E et al. Globalguidelines: is gastroenterology leading the way? Lancet2006;368:2041-2042.

What can we share and learn from the U.S.• National Guideline Clearinghouse

• All guidelines summarized into same format

• Syntheses (comparisons of guidelines from different sources)

• Drug alerts (”black box warnings”)

• National Quality Measures Clearinghouse – unique resource

Using the same systemof querying and filtering for both [quality] measurementand reminders has important benefits

July 2007

Incentives for using and implementing guidelines shouldoriginate from the professionals themselves• Everyone wants to be a good doctor

(dentist, nurse, physiotherapist..)

• Everyone wants to make his/her work easier

Empowerment before monitoring• First provide tools for improving

performance

• Then implement quality measurement– as a tool for maintaining control over one’s

own work

Empowerment before monitoring• First provide tools for improving

performance– “Make the right thing the easy thing”

• Then implement quality measurement– as a tool for maintaining control over one’s

own work

Carolyn Clancy

Pay forperformanceintroduced

Campbell S et al. Quality of primarycare in England with the introductionof pay for performance. N Engl J Med2007;357:181-190

Virtual health check forall patients

DecisionSupportEngine

Electronic Health Record

Database

Decision Support

Doctor´s work station

PatientData

Decision Support Component

EBM Scripts

Guideline Links

Local Scripts

Contraindications

Drug interactions

Patient DataInteractive forms

Structured Messages

Decision Support

Drug indications

Decision Support Architecturewww.kaypahoito.fi/decisionsupport/decisionsupport.htm

Knowledge in computer-readable formis probably more easily translated, shareableand divided into modules than full guidelines

KNOWLEDGEGuidelinesGraded evidenceDatabases: drugs,laboratory, genome

Images and videos fortraining of skills

Cost-effectivenessEthical summariesPatient information

Patient dataGenome map

Database of ”all”previous patients

Probablybeneficialtherapy

Simulation

Individualizedprediction ofthe effectsof treatment

Patient’s valuesand choices

Selection oftreatment

”The BIG picture”

Decisionsupport

Doctor’s interpre-tation andexperience

Resourcelimits

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

Tasks for G-I-N• Promote research on guideline

implementation and sharing• Search for alternative interventions for

resource-poor areas to be included in existing guidelines

• Promote the sharing of evidence summaries and other support material for guidelines

Susanne Susanne RabadyRabady Kamil SaitkoulovKamil Saitkoulov

Thank youThank you!!

Welcome Welcome to Finlandto Finland

GG--II--N 2008N 2008

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