Translating the KidneyWise Clinical Toolkit into an Electronic Medical Record Decision Support Tool

Transcription

1 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, :30pm

2 Disclosure No actual or potential conflict of interest in relation to this topic or presentation.

3 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

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7 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)

8 #CADTHSymp

9 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

10 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

11 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

12 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

13 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 Apr;7(4):565-72) Anecdotal evidence In response, the ORN KidneyWise Clinical Toolkit was created

14 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

15 Key Features of An Effective Tool Point of care tool 95% EMR compatible

16 Opportunities for enhancement address workflow limitations Clinical Algorithm Paper based toolkit can only integrate into EMR as a PDF document Created an interactive KW App, but it s still a 2 nd 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 16

17 The ehealth Centre of Excellence The Quality Based Improvements in Care Program

18 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

19 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

20 The CKD EMR Tool Screening and Identification Clinical Decision Support 20

21 The CKD EMR Tool - Detection and Diagnosis Risk Stratification 21

22 The CKD EMR Tool - Managing in Primary Care Workflow Supports 22

23 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

24 PCP Feedback on Workflow Process Before CKD EMR Tool Adoption: Reactive to Patient Needs for Referral Labs detect abnormal egfr or Urine ACR egfr<60 Urine ACR>3 If egfr<30 or rapidly declining or Urine ACR>60 If egfr or Urine ACR<60 Refer to Nephrology Referral Not Required Manage in a non-systematic way, as per usual care based on individual needs. May require no action or repeat testing After QBIC CKD EMR Tool Adoption: Early Detection and Management of CKD at the Primary Care Level has the Potential to be More Proactive For patients at risk for CKD: Hypertension Diabetes Age with Cardiovascular Disease Abnormal egfr 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 and/or ACR 3-60 Patient 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

25 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

26 Evaluating Impact: Preliminary Findings 100% Proportion of Patients at Risk for CKD with ACR and egfr test measures 90% 80% 74% 70% 60% 50% 40% 30% 31% 20% 10% 0% Managed without the CKD EMR tool Managed using the CKD EMR tool

27 Next Steps Multiple EMRs Ongoing enhancements and improvements Ongoing evaluation

28 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

29 Acknowledgements Dr. Scott Brimble Name Marnie MacKinnon Title Provincial Medical Lead, Early Detection & Prevention of Progression, ORN Director, Integrated Care, ORN Mysoon Alam Tachiwa Murray Sharon Gradin Analyst, Project Development, ORN Senior Specialist, Primary Care Portfolio, ORN Group Manager, Integrated Care, ORN

30 Thank you/questions