Leveraging Electronic Health Records to Improve Care of Patients with CKD, Other Long-Term Conditions

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While numerous research articles provide valuable insights on the potential of electronic health records (EHRs) to improve patient care, there continues to be a need to identify methods for more effectively designing and using EHRs, especially in the management of patients with chronic conditions. A new feature in the Clinical Journal of the American Society of Nephrology (CJASN) indicates that chronic kidney disease (CKD) may be an ideal model for identifying and evaluating such methods.

“CKD is common and its care is suboptimal, allowing significant room to show improvement as EHRs are optimized, and because CKD is defined by objective data, the disease is an ideal example of a condition that can be easily identified by information commonly found in EHRs,” said co-author Uptal Patel, MD, of the Duke University School of Medicine. “CKD care also requires collaboration between diverse professionals across numerous health care settings, which could be facilitated by EHRs. Furthermore, CKD often heralds increased risk for hospitalizations, cardiovascular events, and all-cause mortality, so EHR-based improvements in CKD management may in turn improve care for these related conditions.”

The potential of EHRs

Under the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act, the US Department of Health and Human Services is spending billions of dollars to promote and expand the adoption of health information technology, with specific incentives designed to accelerate the adoption of EHR systems among providers.

EHRs can help clinicians monitor and care for patients with chronic conditions, increase the continuity of services patients receive, facilitate collaboration among providers, and support patient self-management. EHRs can also provide data for observational studies, help identify potential patients for research, and provide detailed information to national surveillance systems.

Several years ago, the US Centers for Disease Control and Prevention (CDC) noted the need for such a CKD surveillance system to help identify and track various aspects of CKD, and the agency pointed to the importance of having data sources such as EHRs and registries (Saran R et al. Clin J Am Soc Nephrol 2010; 5:152–161).

Early on, clinicians at the Cleveland Clinic developed a CKD registry at their institution and showed that it is reliable and valid in a large open health care system with an integrated EHR (Navaneethan SD et al. Clin J Am Soc Nephrol 2011; 6:40–49). The registry has allowed investigators to conduct an EHR-based clinical trial examining whether empowering patients with personal health records or patient navigators improves CKD care, along with identifying participants for other clinical trials and conducting health services research (Navaneethan SD et al. Clin Nephrol 2013; 79:175–183).

Also, the CDC has been collaborating with the University of California at San Francisco and the University of Michigan to implement a CKD surveillance system to track national trends in the number of cases, risk factors, and care practices that affect CKD prevention and control. In addition, the system is evaluating quality improvement efforts and monitoring kidney disease objectives for Healthy People 2020, which provides 14 objectives related to kidney disease (http://nccd.cdc.gov/CKD/default.aspx).

Optimizing EHRs to improve kidney disease care

Strategies to use existing EHRs to improve CKD and other chronic disease care are often developed in isolation, “which limits impact and forces individual health systems to recreate the wheel,” Patel noted.

He and his colleagues, including lead author Paul Drawz, MD, MHS, MS, of the University of Minnesota, joined forces with the National Kidney Disease Education Program Health Information Technology Working Group to identify strategies for using EHRs to improve care for patients with CKD. In their CJASN article, they outline specific design features and goals for incorporating CKD-related data into EHRs—for example, the experts advocate for documenting CKD-related data (such as laboratory results and information related to risk factors and medical complications) into EHRs using standard code systems and units, and they recommend storing CKD-related data in formats that can be easily accessed by patients and clinicians. EHRs could also be used to develop CKD registries so that clinicians can manage panels of patients and coordinate care with other specialties.

“These strategies are absolutely on target for what’s needed to create the CKD components of the Learning Health System, which is the notion of learning from structured EHR data shared from multiple health systems to identify at-risk populations and infer evidence-based approaches to improving quality and outcomes,” said Brian Dixon, PhD, a faculty member at Indiana University’s Fairbanks School of Public Health, who is not part of the working group but whose research focuses on the use of information systems to improve public health practice and clinical outcomes.

The concept of a continuous Learning Health System was first expressed by the Institute of Medicine and is now being adopted across the country and around the world (http://bit.ly/1cvuHrL). “Structuring data is an important precursor to making data available on CKD to enable surveillance, research, and quality improvement,” Dixon said.” The informatics work needed to improve CKD surveillance and research is not sexy but it is critical to achieving a high performing health system in the US.”

With the implementation of the HITECH act, increasing numbers of hospitals and independent physician practices are implementing EHRs, said Sankar Navaneethan, MD, MPH, who helped establish the Cleveland Clinic’s EHR-based CKD registry.

“In some states, there are ongoing initiatives to inter-link EHRs as this could reduce repetition of expensive investigations and improve communication between health care providers and health systems,” he said. “Long-term studies examining whether such improved communication improves outcomes in kidney disease and other chronic conditions are warranted.”

Because the possibility of improving CKD-related care with EHRs will require collaborations among primary care providers, nephrologists, and experts in public health, outcomes research, and bioinformatics, the National Institute of Diabetes and Digestive and Kidney Diseases will convene stakeholders in CKD health information technology, population health management, and research in the fall of 2015 to begin to identify pragmatic methods for seizing opportunities and overcoming challenges in using EHRs to manage CKD populations.

Study co-authors include Patrick Archdeacon, MD, Clement McDonald, MD, Neil Powe, MD, MPH, MBA, Kimberly Smith, MD, MS, Jenna Norton, MPH, Desmond E. Williams, MD, PhD, and Andrew Narva, MD.

Disclosures: The authors reported no financial disclosures.

The article, entitled “CKD as a Model for Improving Chronic Disease Care through Electronic Health Records,” will appear online at http://cjasn.asnjournals.org/

PE Drawz, et al. CKD as a Model for Improving Chronic Disease Care through Electronic Health Records. Clin J Am Soc Neph CJN.00940115; published ahead of print June 25, 2015, doi:10.2215/CJN.00940115.