Optimal Use of the Electronic Medical Record in CKD

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The electronic medical record (EMR) has enabled creation of a CKD registry, a database that contains demographic information, clinical parameters, and outcome measurements of more than 41,000 CKD patients who have received medical care within the Cleveland Clinic Health System since January 2005.

Using EMRs, patients were identified using the following criteria: 1) an estimated glomerular filtration rate (eGFR) below 60mL/min/1.73 m2 (measured in outpatients at least twice in an interval greater than three months), or 2) an ICD-9 Diagnostic Code for kidney disease such as diabetic nephropathy, polycystic kidney disease, glomerulonephritis, and hypertensive nephrosclerosis. This database will be used to identify and enroll patients in clinical research projects.

Data elements within the CKD registry include:

  • Patient demographics
  • BP, height, weight, BMI
  • Comprehensive laboratory testing, including GFR, anemia management, calcium, phosphorus, PTH, vitamin D, lipids, and other measures
  • Medications
  • Comorbid diseases, especially cardiovascular disease and its risk factors.

The registry, which will interface with the U.S. Renal Data System (USRDS) and the Social Security network, is uniquely designed to track the management of CKD over the entire care spectrum, ranging from the primary care environment, traditional nephrologic care, CKD clinic, and renal replacement therapy with either dialysis or transplantation.  

The registry will help address the following issues regarding the scope of CKD and its management:

  • Prevalence of CKD by stage within the Cleveland Clinic health system
  • CKD recognition by physician and the health care team
  • CKD progression with loss of GFR over time. The goal will be to produce a “CKD progression tool” for use by physicians, health care teams, and patients in preparing for future CKD needs such as education, vascular access, or renal replacement therapy including dialysis or renal transplantation.
  • Assess “Processes of Care” by the physician regarding the ordering of appropriate assessment related to hypertension, anemia, hyperlipidemia, parathyroid hormone levels, and other parameters.
  • Assess “Clinical Practice Measures Targets” related to the management of hypertension, anemia, hyperlipidemia, hyperparathyroidism, and other conditions.

We are now embarking on a more ambitious project to explore the role of EMRs in identifying and managing CKD patients throughout our health system. Development of a CKD registry was the initial objective of this comprehensive program.

Other objectives include implementation of clinical decision tools (“Physician Alerts”) within the EMR based on clinical guidelines in CKD management; measuring the utility and impact of the Physician Alerts on quality of care and cost; and determining potential barriers to physician acceptance of Physician Alerts.

Details of the rapid development of the CKD registry using EMRs, as well as preliminary registry findings, will be presented on October 29 at the American Society of Nephrology's Renal Week 2009 in San Diego. The initial success of this project reflects a collaborative effort of the Department of Nephrology, Quantitative Health Sciences team, and the eResearch team in the Information Technology Division.

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