The National Preconception Care Clinical Toolkit (“PCC Toolkit”)
Translating the KidneyWise Clinical Toolkit into an Electronic … · Objectives To recognize the...
Transcript of Translating the KidneyWise Clinical Toolkit into an Electronic … · Objectives To recognize the...
Translating the KidneyWise Clinical
Toolkit into an Electronic Medical Record
Decision Support Tool
An Innovative and Practical Strategy for Primary Care Providers
Dr. Allan Grill, CCO-Ontario Renal Network
Stephanie Chin, The eHealth Centre of Excellence
CADTH Symposium Concurrent Session B6, April 16, 2018 1:30pm
Disclosure
No actual or potential conflict of interest in relation
to this topic or presentation.
Faculty/Presenter Disclosure
Faculty: Dr. Allan Grill
I have the following relevant financial relationships to disclose:
• Consultant for: CCO – Ontario Renal Network
Relationships with commercial interests:
• Not Applicable
Objectives
To recognize the CCO-ORN KidneyWise Clinical Toolkit as an innovative resource for chronic disease management at the primary care level
To demonstrate the importance of integrating clinical tools into electronic medical records (EMRs) to improve workflow efficiency, clinical support, and change management
To recognize the value of supporting collaborative innovative projects that focus on enhancing patient-centred, chronic disease management (using eHealthCE as a model)
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About the Ontario Renal Network
• Responsible for overseeing and funding the delivery of chronic kidney disease (CKD) services across Ontario
• A ‘network’ of all the kidney care programs in Ontario
• Early detection and prevention of progression of CKD in the primary care setting is a main priority
• Ontario Renal Plan II is a roadmap that outlines how the Ontario Renal Network (ORN) will try to improve the lives of those living with CKD
Prevalence of CKD
• 10% of North Americans have CKD
• 26 million people
• 25% of North Americans > age 65 have CKD
• Only 3% of CKD patients progress to ESRD
Why Should CKD Be Important to Primary Care?
• ~ 90% of CKD cases are at low risk of progression and can be followed by a Primary Care Provider (e.g. family physician, nurse practitioner)
• Early identification and treatment can prevent/delay End Stage Renal Disease (ESRD)
• Medication reviews can prevent Acute Kidney Injuries (AKI) in LTC
• Comorbid cardiovascular disease risk reduction/management (e.g. DM, CAD/CHF)
• Referral of patients at increased risk of progression to advanced stages of CKD to nephrology
Why Develop a CKD Clinical Tool for Primary Care?
• CKD resources required based on feedback from:
• 2012 Primary Care Provider (PCP) needs assessment
• 340 respondents were interested in improving their CKD knowledge
• Access to reference tools/ decision aids centered on evidence-based clinical practice guidelines was ranked highly
• 2013 environmental scan
• Completed to review clinical toolkits available to PCPs
• As a result, a gap in CKD resources for PCPs became apparent
Why Develop a CKD Clinical Tool for Primary Care?
• Feedback from nephrologists suggests a gap in CKD knowledge
• Suboptimal medication, CKD testing, # of referrals (Manns B et al. Clin J Am Soc Nephrol. 2012
Apr;7(4):565-72)
• Anecdotal evidence
• In response, the ORN KidneyWise Clinical Toolkit was created
KidneyWise Clinical Toolkit
• Clinical Algorithm that helps with identification, detection, and management of patients with CKD and guidance on which patients may benefit from referral to a nephrologist
• Evidence Summary that offers further clinical detail regarding the algorithm content, including references to clinical guidelines that were used in the development of the toolkit
• Outpatient Nephrology Referral Form that provides referral guidance by outlining clinical scenarios that would require consultation with a nephrologist along with the appropriate investigations that should accompany the referral
95%
Key Features of An Effective Tool
Point of care tool EMR compatible
Clinical Algorithm
16
Opportunities for enhancement – address workflow limitations
Paper based toolkit – can only integrate into EMR as a PDF document
Created an interactive KW App, but it’s still a 2nd step outside of EMR;Provider must be motivated to use the tool
Ideal situation: incorporate content in real time with clinical support specific to each patient
The eHealth Centre of Excellence
The Quality Based Improvements in Care Program
How can EMR tools make Chronic Disease Prevention and Management (CDPM) easier?
Using EMR tools provides benefits to both clinicians and patients by:
Supporting standardized care in accordance with best practice guidelines
Helping to document visits in a way that is searchable with the capability to
retrieve and share information with care team members
Providing automated reminders for patient follow-up
Reducing office inefficiencies
The Chronic Kidney Disease (CKD)
Prevention and Management EMR Tool
Our Approach
A joint collaborative effort between the ORN and the eCE
Kidneywise Toolkit resource already available for CKD care
EMR Tool development process
Iterative
Focus on workflow and knowledge translation
Change Management
The CKD EMR Tool – Screening and Identification
20
Clinical Decision Support
The CKD EMR Tool - Detection and Diagnosis
21
Risk Stratification
The CKD EMR Tool - Managing in Primary Care
22
Workflow
Supports
Clinician-User Feedback
“I was surprised to see the large number of patients at moderately
increased risk, who I needed to monitor more carefully… including
withholding drugs which may worsen renal function… This would help
in reducing the risk of further renal decline… I was also able to
identify several high risk individuals who needed a referral to
nephrology… This EMR tool really helped me understand that both
eGFR and urine ACR are needed to diagnose CKD… The tool provides
easy tabs on the lab requisition for the appropriate tests as well as
the ability to generate reminder messages regarding when labs are
due again.”
Dr. Upender Mehan, Family Physician, Centre for Family Medicine
PCP Feedback on Workflow Process
Labs detect abnormal eGFR
or Urine ACR
eGFR<60
Urine ACR>3
Refer to Nephrology
Referral Not Required
Before CKD EMR Tool Adoption: Reactive to Patient Needs for Referral
Manage in a non-systematic way, as per usual care based on individual needs.
May require no action or repeat testing
If eGFR<30 or rapidly declining or Urine ACR>60
If eGFR 30-60or Urine ACR<60
Abnormal eGFR
Hypertension
Diabetes
For patients at risk for CKD:
Insert CKD Form in patient’s
chart
eGFR<30, or decline over the six months or ACR > 60
Patient has CKD
Refer to Nephrologist
eGFR 30-59 and/or ACR 3-60Patient has CKD
Manage in primary care
eGFR ≥ 60 and ACR < 3
Patient does not have CKD
Implement measures to:
• modify CV risk
• slow rate of CKD progression
Minimize further kidney injury, including sick day management sheet
Generate messages and reminders to follow-up and redo tests, based on best practice guidelines applicable to each patient's condition
Age 60-75 with Cardiovascular Disease
After QBIC CKD EMR Tool Adoption: Early Detection and Management of CKD at the Primary Care Level has the Potential to be More Proactive
The CKD EMR Tool - Evaluating Adoption
Since the availability of the tool in Sept 2016, To date:
93 primary care providers have the tool available in
their EMR
17 have received a in-person coaching session on the
tool
A closer look at one of the clinics with the tool (early
analysis)
14/19 of physicians used the tool in their practice
Evaluating Impact: Preliminary Findings
31%
74%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Managed without the CKDEMR tool
Managed using the CKD EMRtool
Proportion of Patients at Risk for CKD with ACR and eGFR test measures
Next Steps
Multiple EMRs
Ongoing enhancements and improvements
Ongoing evaluation
Acknowledgements
Dr. Mohamed Alarakhia - eHealth Centre of Excellence
Jennifer La – eHealth Centre of Excellence
Lirije Hyseni - eHealth Centre of Excellence
Peter Varga – ORN, Grand River Hospital (currently at
Headwaters Health Care Centre )
Danika Walden - eHealth Centre of Excellence
Acknowledgements
Name Title
Dr. Scott Brimble Provincial Medical Lead, Early Detection & Prevention of Progression, ORN
Marnie MacKinnon Director, Integrated Care, ORN
Mysoon Alam Analyst, Project Development, ORN
Tachiwa Murray Senior Specialist, Primary Care Portfolio, ORN
Sharon Gradin Group Manager, Integrated Care, ORN
Thank you/Questions