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From May 2020, Estonian family doctors and nurses have used a clinical decision support system that brings patient-based recommendations to their desktops and makes decisions faster and better. The clinical decision support system is the first tool of its kind in Estonia and the first in the world to be implemented nation-wide. It collects and analyzes human data, such as diagnoses, medications, and tests from the last five years, blood pressure readings, and lifestyle indicators.
The development of this decision support system has taken place in close cooperation with family doctors, the Ministry of Social Affairs, and the Health and Welfare Information Systems Centre.
Every year, the Estonian Ministry of Economic Affairs and Communication organizes a competition for the Estonian public sector’s best digital service. This January, through an intense rivalry between 75 services, the Clinical Decision Support System of the Estonian Health Insurance Fund (EHIF) got the coveted prize: The Best Public Sector Digital Service.
Handing over the prize, Siim Sikkut, Undersecretary of Communications and State Information Systems and Chairman of the Competition Jury, commented: “The winning healthcare decision support solves an important problem. It has a very high technical level and helps reduce the administrative burden for both providers and users. Also, it is user-centric, safe, and has the potential to be a pioneer in the world.”
Deceptively simple and extremely complicated
The tool itself is both deceptively simple and extremely complicated. When a patient visits the GP, the Clinical Decision Support System automatically displays treatment recommendations based on the patient’s former history, analysis, and treatments. The centrally installed software chooses from more than 45 000+ plain text recommendations, organizes them by urgency, and links them to more than 16 different databases required in clinical work for further science-based evidence.
“It works using plain text,” Karin Kõnd, Project Manager at the Department of Innovation of EHIF, explains. “When the GP enters any new information about the patient into his or her computer, such as a complaint, the system automatically displays validated treatment options, such as “this patient has a history of x, consider analysis y or treatment z.” It also draws information about prescription drugs, points to the interaction of different drugs, and suggests dosage.”
First in the world
Although similar tools are in use for a single GP or medical institution in other countries, Estonia is the first one to implement it nationwide.
“In 2015, a World Bank study found that the quality of monitoring of chronic patients offered by Estonian family doctors varies in different parts of the country. Although we have official treatment guidelines available online, because the burden on GPs is high, it is not easy to use these treatment guidelines. This is the problem we were looking to solve,” Ms. Kõnd opens the background of the project.
Nation-wide service is made possible because of the overarching e-Health Information System which stores all health data of every individual in Estonia. Although Estonia uses this central system as early as 2010, the quality of data stored by hundreds of different healthcare institutions in the registry has improved over the years. Now the standardization of information has reached the level that allows automated systems such as the Clinical Decision Support to adequately and purposefully draw attention to a treatment option.
Health data is highly regulated
Still, the development of the Clinical Decision Support System proved to be a challenge. One of the critical obstacles was legal.
“Health-related data is highly regulated. Our current legislation for health data storage is document-based and in cooperation with the Ministry of Social Affairs, we needed to adjust the laws for the service to be able to exchange data before a document is created. So, the first years were actually about the alignment of various institutions and cooperation,” says Ms. Kõnd.
The service was implemented last spring, and although this was probably one of the worst times to implement any new health service because of the onslaught of the pandemic, the GP-s have received it well. First surveys showed that 84% of Estonian general practitioners use the tool regularly. Monitoring and development are ongoing to increase its user-friendliness and gather more feedback from doctors. In addition, new ideas are already simmering.
Looking for precision on a genetic level
“We would like to advance in two directions,” Liis Kruus from EHIF reports. “On one side we want to improve the precision. For example, we would fine-tune suggestions focused on specific patients, such as those with kidney failure or pregnancy and so on. Although the system already incorporates this information, we would like to include specialized studies and databases.”
Besides the incremental improvement of the service, some of the expectations of EHIF might seem even too futuristic.
“Eventually, we would like to base recommendations on the genetic information of the patient,” Ms. Kuus envisions. “Because of the groundbreaking developments at Estonian Gene Repository, this is quite a realistic expectation. The main obstacles are, in fact, again legal. Technologically we are ready.”
Additionally, Ms. Kruus envisions that the Clinical Decision Support System would help to improve interaction with patients. On the simplest level, it would allow GP-s to point to patients, for example, who are over 40 years old and haven’t been to a check-up for 5 years. Analytics like this would allow the GP to keep better contact with their patients.
“Although sometimes it is not even possible to measure the exact economic benefits of such digital services, it is quite obvious that the more we free doctor’s time for communicating with the patient, the better their service will be,” Ms. Kruus concludes.
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