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)

Tweet Tweet

• @allan_k_grillMD

• @eHealthCE

• #CADTHSymp

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