Characterizing the Ideal Clinical Office System for Nephrology

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Characterizing the Ideal Clinical Office System for Nephrology

  1. 1. INFORMATION TECHNOLOGY Characterizing the Ideal Clinical Office System for Nephrology Franklin W. Maddux and Dugan W. Maddux Clinical information technology (IT) systems that support nephrology-specific content can facilitate the coordinated, progressive, and comprehensive care of all patients with renal disease including those with each stage of chronic kidney disease (CKD). The ideal clinical IT system should have flexible fea- tures to meet the needs of individualized practice patterns, yet also have tools to enhance continuity, measure performance, and deliver decision support features that assist the nephrologist in providing optimal care for the CKD patient. This article provides insight into the complexities of engaging in the process of technology adoption, including selection, integration, and implementation while emphasizing the utility of using a continuous quality improvement paradigm to identify and achieve positive results from the adoption and integration of a clinical IT system into outpatient clinical practice of nephrology. Q 2008 by the National Kidney Foundation, Inc. Index Words: Health information technology; Nephrology electronic health record; Chronic kidney disease; Electronic health record; Nephrology The Nephrology Professional I n the outpatient setting, health care pro- viders in nephrology are faced with provid- ing care for a large population of chronic Environment Clinical IT systems will be a necessary and inte- kidney disease (CKD) patients with complex gral part of nephrology care given the scope of medical needs. Recent studies support the the CKD population, the complexity of CKD need for coordinated outpatient care between care, and the limited number of nephrologists. primary care providers and nephrologists The Centers for Disease Control has adopted even at the early stages of CKD. Strategies to CKD as a ‘‘public health condition.’’ School- treat CKD patients to delay the progression werth and colleagues1 have documented the 4 of kidney disease and to improve outcomes conditions that must exist for the Centers for at the start of dialysis are known, but they Disease Control to identify a public health con- are being underused. Clinical information dition. These criteria require the disorder to technology (IT) systems that support nephrol- have a large societal burden, an unfair societal ogy-specific content can facilitate the coordi- distribution, known preventive actions that nated, progressive, and comprehensive care could reduce the disease burden, and a lack of of CKD patients. The ideal clinical IT system deployed strategies to affect the societal bur- should have flexible features to meet the needs den.1 In the United States, nearly 20 million of the individual practice and also have tools people have CKD, approximately 11% of the to- to enhance continuity and measure perfor- tal US population.1,2 The cost of care for CKD mance in the care of CKD patients. The pur- exceeds $25 billion dollars annually, and pa- pose of this article is to provide context for tients with predialysis CKD access the health nephrology practices to consider when decid- care system 2.4 times more frequently than the ing to adopt a technology initiative while pro- stage 5 CKD population.1,3 The United States viding insight into the complex features of the Renal Data System projects that by the year implementation of such systems. 2015 there will be 712,290 patients with end- stage renal disease (stage 5 CKD).4 In addition, From the Specialty Care Services Group, Nashville, TN. the relative risk of stage 5 CKD requiring dialy- Address correspondence to Franklin W. Maddux, MD, sis or transplantation therapy disproportion- FACP, Specialty Care Services Group, 3100 West End Avenue, ately affects certain ethnic groups as described Suite 150, Nashville, TN 37203. E-mail: Frank.Maddux@ in Figure 1.5 Clearly, the large number of people specialtycaresg.com Ó 2008 by the National Kidney Foundation, Inc. with CKD represents a large societal burden, 1548-5595/08/1501-0011$34.00/0 and CKD places a disproportionate disease doi:10.1053/j.ackd.2007.10.010 burden on certain population subgroups. 64 Advances in Chronic Kidney Disease, Vol 15, No 1 (January), 2008: pp 64-72
  2. 2. The Ideal Clinical Office System 65 Figure 1. Incident stage 5 CKD patients. Rates adjusted for age and gender (USRDS 2006 Annual Data Report). CKD, chronic kidney disease. Recent data suggest that early interventions health IT systems that will provide tools to and preventive therapies may postpone the help meet these patient care and nephrology need for renal replacement therapy.1,2 Early practice needs. detection of problems such as mineral metab- The scope and scale of the problem of olism abnormalities and anemia associated caring for CKD is large. Every resource that with CKD may improve patient outcomes allows early identification of the CKD patient and delay the start of dialysis.2,3 Early recogni- and early recognition of unique CKD treat- tion of nontraditional risk factors for cardio- ment issues should be mobilized to impact vascular disease may also improve outcomes outcomes for these patients. The large CKD in CKD.6 There is evidence that these CKD is- patient population, the complexity of care at sues are currently underdiagnosed and under- various stages of CKD, and the importance treated such that new strategies to detect and of clinical and laboratory data in this care treat CKD complications may improve patient make CKD an ideal clinical setting for the outcomes.1-3 utilization of the advanced technology of a Most nephrology practices today continue nephrology electronic health record (nEHR). to function as small businesses with an aver- Selecting a clinical system is a process that age size of 6 physicians per practice.7 It is an- can be very difficult for practices. Many of ticipated that the rate of new nephrologists the systems commercially available today entering private practice from fellowships have recognized the barriers to adoption each year will not meet the demand placed within the marketplace and have aimed to on practices to accommodate the care of find ways to assist practices in their decision more CKD patients.8,9 The average nephrolo- making and implementation. Such systems gist currently cares for about 70 stage 5 CKD as Fresenius Medical Care’s CKD Solutions– patients. By the year 2015, it is projected that nEHR (Waltham, MA; www.CKDSolutions- each provider will be responsible for over 100 nEHR.com), Sage Health’s Intergy (Tampa, stage 5 CKD patients. The use of clinical FL; www.sagehealth.com), and Allscripts guidelines for patient care, the use of non- (Chicago, IL; www.allscripts.com) purport to physician providers for routine care, and have specific integrations for nephrology and data reporting to participate in the practice the unique features of nephrology practice. measurement process are all expected to in- The Renal Physicians Association (www. crease as the demands of nephrology practice renalmd.org) has put together in their member evolve. The expanding CKD population, site a series of resources that nephrology prac- the limited number of nephrologists, and an tices can use that will assist in the process of increasing demand for clinical practice finding a system that has features specific to measurement will drive the need to adopt the practice of nephrology and renal care.
  3. 3. 66 Maddux and Maddux The Quality of Care Connection systems by health providers. The first is a fed- eral safe harbor for technology adoption that Health information technology (HIT) is recog- was implemented in October 2006. This safe nized as a means to support practices in im- harbor allows large health organizations that proving the quality of care delivered by the qualify as permitted donors to provide up adoption of best practice standards and the to an 85% subsidy for certain software li- use of disease specific guidelines. The concept censes and tools for smaller health care pro- of a continuous quality improvement model viders.12 This safe harbor program is in for evolving a better, more cost-effective, and effect through 2013 and has rules that will al- stable clinical care environment hinges on low smaller practices to implement advanced the ability to look at information across a pa- IT systems. Each system under this safe har- tient population and measure performance bor must meet certain requirements that in- on standard metrics that are understood by clude standard features of interoperability all parties involved in the health care process. and e-prescribing. Hardware, staff, and stor- HIT systems including electronic health re- age of information are not included in the cords (EHRs), personal health records, and safe harbor, but the intent is to promote clinical decision support systems must be system deployment that has been delayed used to collect this complex clinical infor- because of the high cost of system licenses mation. The American Health Information and implementation. Community Quality Workgroup envisions The second early catalyst to adoption of that performance measurement in health care HIT systems is a program within the Tax Relief is tightly integrated with patient safety and and Health Care Act of 2006, which provides patient care quality.10,11 Timely reporting and a 1.5% bonus payment for those practices organizational level performance analysis will who report clinical data and outcomes under be used to evaluate national quality care the Physician Quality Reporting Initiative.13,14 performance and, ultimately, will drive perfor- This act is the first true federal pay-for- mance expectations through payment.11 De- performance program that is not part of a spite this recognized need, the adoption of IT demonstration project. It is expected that such solutions has been slow because of the high programs will evolve to include not just re- cost of IT systems and the complexity of the porting but also the implementation of both work required to implement such systems. process and outcome performance measure- The AHIC Quality Workgroup documents an ments that ultimately will be tied to the EHR adoption rate among outpatient pro- methods and levels of reimbursement for viders of only 15% to 18%.10,11 Patient-care physician practices for clinical care.14 information, which can only be obtained Other catalytic events include the adoption through health IT solutions, will not only ben- of certain clinical standards for nomenclature efit health care consumers directly but will also that have become an important element in provide valuable population-based data to developing ideal clinical systems. HIT clinical support beneficial health care spending and systems must ensure quality data collection, policy.11 Given the desire to stimulate adoption integration, and output. To ensure quality data of HIT systems, several catalysts have been de- in HIT clinical systems, data standards must veloped to encourage a more rapid acquisition be adopted and used. Such standards include of HIT systems. These catalysts have been spe- the Health Level 7 (HL7), Systematized Nomen- cifically initiated to address the cost barriers to clature of Medicine Clinical Terms, and Logical adoption while recognizing that the functional Observation Identifiers Names and Codes and user barriers are being overcome by (LOINC) standards that identify how systems advances in the systems and technology plat- will interact and interface with each other and forms that deliver these systems. determine certain standard data specifications for clinically relevant elements. The HL7 stan- Catalyzing Health IT Adoption dard is the most widely accepted data format Several catalyst efforts have been initiated standard in health care information systems. to stimulate the adoption of advanced HIT The prevalent use of HL7 standards allows
  4. 4. The Ideal Clinical Office System 67 relatively easy electronic exchange of health efficient workflow and the use of clinical deci- care data between IT systems.15 Systemized sion support systems. The HIT Integration Pyr- Nomenclature of Medicine Clinical Terms is amid (Fig 2) provides a visual depiction of the widely accepted as a standardized set of clinical pathway of activities that a practice may expect terms.16 The LOINC standard is a means by to encounter when implementing an advanced which laboratory data can be shared across HIT clinical system. Although the depiction is various labs and analytic platforms for use in not designed specifically for nephrology, it pro- reporting and data analysis. The LOINC data- vides a means of outlining the work that a prac- base can identify not only laboratory data but tice must undertake if they strongly desire also vital signs, echocardiograms, and other a successful integration of an IT system into clinical data. LOINC is used by many large the practice. commercial laboratories including Quest and When selecting an HIT clinical system, a LabCorp. This is a universal database that can nephrology practice must first identify and facilitate incorporation of this type of laboratory define practice goals and needs for a nephrol- and clinical data directly into an EHR.16 LOINC ogy EHR. The articulation of these goals will is maintained by a nonprofit medical research identify HIT system features that are priori- organization, the Regenstrief Institute.17 ties. Some basic questions to ask about a pro- spective HIT system might include the following: (1) Is there automated data ex- The HIT Integration Pyramid for change? (2) Is there system scalability to an ex- Medical Practices panding practice size? (3) Will there be a need It is important for clinic practices to recognize for in-practice IT expertise and support? and the complexity and commitment to process (4) How does the system fit into the clinical change required to fully implement the features practice environment? An ideal HIT clinical of an advanced HITsystem. Often the final inte- system should offer network infrastructure grated functionality of an advanced HITsystem and use within the usual clinical practice is clearly identified, but the incremental inte- space. It should be available for use in the pa- gration required to achieve this goal is not ap- tient room, at the nursing desk, at the check-in preciated. The implementation of a clinical IT desk, and wherever the care provider is lo- solution must proceed through a series of steps cated. The network infrastructure should sup- that will gradually integrate the IT tools into the port a variety of delivery platforms from fixed workflow of clinical medicine. This integration to portable to handheld devices and should process provides an opportunity for a practice have the ability to interact in real time with to enhance clinical care delivery through more the clinical data from any place that care is Quality Improvement Clinical Care CQI Decision Support Figure 2. The Technology Integration Pyramid for Electronic Data Interchange Medical Practices. (Adapted Implement Electronic Workflow from CKD Solutions–nEHR, A closer look at CKD solu- Establish Electronic Care Environment tions. Available at http:// www.ckdsolutions-nehr. Identify Clinical Workflow Ready for e-Change com/html/closerlook.html. Accessed July 19, 2007). Develop Clinical Network at all Sites of Care Delivery CQI, continuous quality im- Define Practice Goals and Needs for the EHR provement; EHR, electronic health record.
  5. 5. 68 Maddux and Maddux to be delivered. The HIT clinical system non-IT laboratory result review process to de- should be redundant, reliable, and scalable. termine if an IT solution will enhance and im- Within the context of the development of prove this daily workflow process. The clinical a clinical network, the practice must make IT system should offer efficiency and improve- a sentinel decision about whether the system ment in the laboratory review process because will be delivered from within the practice en- it can automatically present a diagnostic test vironment or over the Internet. A Web-based for review; allow review in the context of the system will differ from a locally hosted model patient’s clinical information and previous in a variety of ways including capital invest- laboratory results; document a provider re- ment required, sophistication of the internal sponse; and disseminate this response and practice network security model, redundancy any necessary orders to others including nurs- of data, scalability of systems, and disaster re- ing staff, other providers, and the patient. covery processes. For many practices without The more fully a practice makes a transition extensive networking expertise, the delivery into the electronic environment the more use- of the clinical system through a model of ful the clinical IT tools and data will be. Clin- ‘‘Software as a Service’’ over the Internet is ical information can enter a system in 3 ways: preferred because of the simplicity and lack as discrete data elements, as objects of text, or of additional personnel required to support as an image of physically represented data. An and evolve such a system. IT system will store all clinically relevant data Clinical workflow patterns are unique to in an electronic format through some combi- each practice, but understanding this work- nation these methods. Discrete data that can flow is important in identifying those compo- be stored in a relational database offer the nents that will benefit from the change that an best ability to analyze groups of patients and advanced HIT clinical system can bring to doc- maintain standardization of the nomenclature umentation, decision support, and best prac- of clinical information. This type of data typi- tice integration. To fully engage the clinical cally comes from point-of-care documentation system, a practice must accept that mere in- sources commonly known as templates. Other stallation of a software system is not enough discrete data sources in the world of CKD to ensure that a system will improve produc- care include laboratory, pharmacy, dialysis, tivity; enhance analysis; and make changes and hospital data. that will benefit patient quality of care, pro- The clinical IT solution should allow the ductivity of providers, or efficient functioning documentation of prose or text. Textual data of the practice. allow the documentation of an individual pa- As an initial step to clarify existing work- tient history or care provider assessment with- flow, practices should consider developing out complete reliance on templates or boiler a clinical process library. A clinical process li- plate information. It allows for the ‘‘story’’ of brary analyzes the practice workflow process the patient to be captured and the unique including scheduling, gathering patient intake features of an individual patient/provider information, the patient check-in process, interaction to be documented. The ability of identification of historic clinical events, clinical advanced systems to be flexible enough to encounters with providers, enrollment of capture both normalized, structured discrete patients into appropriate-structured care pro- data and prose-based text data is essential to grams based on their diagnoses and demo- having a system that will evolve as the prac- graphics; patient education tools; and billing tice of nephrology evolves. capture. These are examples of some indepen- Clinical systems should allow data acquisi- dent processes that occur in the clinical tion through the ability to accept an image of environment of a practice that should be en- data that is delivered to the practice in a phys- hanced by the tools of the HIT clinical system. ical representation and must be converted or One example of a clinical workflow process scanned into an electronic document. This that can be greatly impacted by a clinical IT image should have the ability to be routed solution is the review of laboratory informa- through the system and ‘‘tagged’’ with appro- tion. A practice must understand the current priate placeholders that will allow the image
  6. 6. The Ideal Clinical Office System 69 to traverse through the system workflow based on the electronic analysis as defined mechanisms for provider review and docu- by the provider. mentation and, ultimately, be correctly placed Decision support can be implemented in in the appropriate patient electronic record. a number of ways, and it represents another The automated workflow of imaged data feature of IT clinical systems that enhance should include the capacity for the image to existing workflow in a way that cannot be be reviewed and annotated by a care provider. duplicated in the nonelectronic environment. Imaged data cannot be normalized so it does The concept of making the provider a more have more limited reporting and research ca- reliable cognitive clinician when analyzing pacity when compared with discrete data ele- clinical information is 1 goal of the decision ments and even textual clinical information. support tools that an nEHR can bring to the The additional data coming from third practice of CKD care. Decision support in the parties is most efficiently integrated into a sys- patient care setting provides a set of tools tem through the use of an electronic data inter- and communication options for the clinician change (EDI) between the source of the data such that the presentation of a patient with and the clinical system. EDI is a real example a specific condition will trigger a specific set of high-level interoperability between 2 sys- of actions to be considered based on current tems. This level of the HIT Integration Pyramid clinical recommendations. Some examples creates a novel approach to how providers would be the notification that a CKD patient receive new information about their patients at stage 4 should have education about dialysis and what they can do with that information. options and vascular access preparation or It is the first of the levels that provides some- that a patient with stage 3 CKD and anemia thing that cannot be provided in a non- should undergo evaluation for enrollment electronic environment. The acquisition of into an anemia-management program. But information from a related third party in ne- decision support extends beyond reminders phrology is typically a laboratory, hospital, that make the clinician a ‘‘smarter’’ provider or dialysis facility. This information is trans- to include also the ability to analyze practice ported to and from the nEHR in a method patterns. System analysis of provider atten- that does not require any human data entry tion to timely laboratory data review or high- and provides a means for routing the informa- lighting the work in a queue of documents to tion to the appropriate person for review or review and respond to are all part of im- the specific electronic chart for permanent proving the timeliness of care and the ability repositing. EDI’s have become progressively of the provider to prioritize the work to be more common over the past decade, and accomplished. This also represents system- many follow the standard of HL7 for ex- driven decision support, which can impact change of clinical health information. In an productivity of providers and their efficient EDI, the clinical data are received in a highly workflow. structured format through a secure method Decision support is also deeply integrated of transmission. In the most elegant of these into how a practice determines which individ- interfaces, there is error checking between uals will perform specific functions within the systems to ensure that the data sent are the practice. The system can provide coordination data received and the exchange is occurring of medication refills. It can help patients in real time. Other EDI processes are per- access the scheduling or triage personnel. formed in a batch environment on a near These system issues go well beyond the tradi- real-time basis but still clearly enhance the tional concept of an electronic medical record timeliness of the delivery of information and extend into the communication of clinical when compared with traditional printing, fax- information within the practice environment ing, or mailing. The use of an EDI most easily as well as to referring or consulting providers integrates decision support software because that share responsibilities for the patient. it offers the opportunity for clinical systems Clinical care Continuous Quality Improve- to analyze information when it is electroni- ment represents a high-level concept in inte- cally delivered and provide a targeted action grating ideal clinical systems. The concept of
  7. 7. 70 Maddux and Maddux driving improvements in the method and the and extend directly to the patient. The systems delivery of care with continuous observation will be both practice specific and patient spe- of clinical performance and measurement cific but will integrate across all venues of allows providers to recognize that the delivery care for an individual patient. of care is dynamic and will change over time. The ideal clinical system should become a part of the Continuous Quality Improvement pro- Nephrology-Specific Functions cess and help a practice evolve its implemen- Specific functionality for a clinical system in tation of best clinical practices. The IT system nephrology includes a broad series of features must have the capacity to capture normalized that are specific to the management of patients information and report on the conditions of with renal disease. Nephrology as a specialty care for the providers of the practice and their is dominated by the collection and analysis patients. of critical laboratory data that is crucial to Finally, the drive toward pay for perfor- the decision-making process used by pro- mance by CMS and other payers is a recogni- viders caring for the various stages of CKD. tion that the cost of health care remains high Functional elements that have nephrology and the systems for understanding how to specificity include those elements that cap- make providers follow best practice standards ture, document, and communicate the unique is complex. Integrating the functional compo- clinical targets in the care of patient with renal nents identified in the pyramid will allow disease. Figure 3 provides a list of the primary a practice to be in a position to measure, re- elements of a nephrology-specific EHR. port, and adjust the clinical workflow in the Areas of specific note include the tools that practice. This performance and measurement are part of the structured, stage-oriented deliv- process is one of the ultimate objectives driv- ery of CKD care. These decision support tools ing the adoption of HIT in clinical practice. should highlight the conditions understood as Once integrated to this level, the practice can core components of care for the CKD patient. then engage in the ongoing process improve- These core components include the educa- ment methods to persistently streamline and tional aspects of therapy for stage 5 CKD, improve the means by which patients receive vascular access preparation, dialysis options care. Ultimately, the integration of these education, recognition and treatment of ane- methods will cross over practice boundaries mia, bone and mineral management, and Figure 3. Components of nEHR. Adapted from CKD Solutions-nEHR, which is a joint project between Fresenius Medical Care, Waltham, MA, and HIT Services Group, Nashville, TN. nEHR, nephrology electronic health record; EHR, electronic health re- cord; CKD, chronic kidney disease; P4P, pay for per- formance; PM, practice management.
  8. 8. The Ideal Clinical Office System 71 unique nutritional issues in advancing CKD. documentation that dialysis patient oversight Other nEHR features should support the abil- care is being provided under the guidance ity to monitor and optimize care for diabetes, of the monthly capitation payment model for lipid disorders, hypertension, and cardiovas- the nephrology practice. Documentation of cular disease as well as prompt the use of dialysis rounding activities should be main- preventive measures such as hepatitis B, Pneu- tained in the nephrology practice record but movax, and influenza vaccinations. These should contain elements from the dialysis clin- elements represent a set of core clinical im- ical information system such as core dialysis peratives as outlined in the National Kidney laboratories, dialysis prescription, and intra- Foundation Kidney Disease Outcomes Quality dialytic medications. The most advanced sys- Initiative guidelines.18 Each represents an area tems would also have the ability to respond of clinical decision making on the part of the to alerts from the dialysis clinical system and provider during the course of treatment for initiate orders that flow from 1 clinical system a CKD patient. to the other in a secure manner. This level of Ideal clinical IT systems should provide interoperability represents an advanced de- a communication link between the patient, gree of system integration that highlights the all care providers, and ancillary-care services. utility of advanced HIT clinical systems. It should encourage patient compliance with medications, appointments, and educational Contracting and the Business Model efforts. Systems should integrate with other entities that also provide care to the patient The ideal clinical system must support a busi- and coordinate that care with tools that avoid ness model that respects a number of tenets redundant interactions between the patient that benefit the medical practice. Contracting and the local health system. The incorporation for a system should provide a combination of clinical tools to communicate with referring of licensing, implementation, training, mainte- providers may highlight these core elements nance/upgrade path, and a business associate and underscore who has responsibility for arrangement between the practice and soft- particular components of care. Integration ware provider. The contract should delineate with pharmacy systems should give a record service levels that are acceptable to the prac- of an individual’s full prescription history for tice and response times that are realistic for incorporating prescribing from all providers. the vendor. The unique nature of the health care enterprise should ensure that the clinical system and vendor provide adequate security Integration of Systems and controls that meet the standards of the Nephrology care is delivered from multiple Health Insurance Portability and Accountabil- clinical sites including the local hospital, the ity Act.19 Practices should look for methods nephrology clinic, and the dialysis unit. Inte- that encourage the vendor to reasonably pro- gration of these multiple sites of care is critical vide data interchange interfaces with other to realizing the full advantage of a clinical sys- systems at known pricing expectations. Fur- tem. This integration requires that the systems thermore, if the practice were to change to an have a data interchange that shares common alternative system, then the vendor should information elements. An example of an im- be required to provide the practice clinical portant integration of data is the nephrology data in a machine-readable format for the practice oversight of patient care in the dialy- next vendor to incorporate. Although most sis unit. Although, the dialysis facility must systems ultimately will be certified to be able note rounding activities the clinical documen- to meet certain system and functional require- tation and billing of the services occurs from ments, the current certification process under the nephrology practice. The ideal nEHR sys- the guidance of Certification Commission for tem should provide a means of sharing the Healthcare Information Technology is pro- information that must be obtained by the gressing with a slow adoption process, chang- dialysis facility for compliance with the condi- ing rules for certification and a substantial tions of coverage while maintaining adequate expense to software vendors.20
  9. 9. 72 Maddux and Maddux Summary Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Car- Clinical IT systems offer valuable tools in in- diology, and Epidemiology and Prevention. Circula- suring quality care across an outpatient popu- tion 108:2154-2169, 2003 7. 2005 Nephrology Practice Business Benchmarking lation. Such systems are necessary for current Survey. Rockville, MD, Renal Physicians Association quality initiative programs and for the collec- 8. Cooper RA: Weighing the evidence for expanding tion of clinical data that will ultimately sup- physician supply. Ann Intern Med 141:705-714, port the best practice guidelines for CKD 2004 care. Government, industry, and payer re- 9. McMurray S: Workforce issues in chronic kidney dis- sources now have aligned incentives to sup- ease. Presented at American Society of Nephrology 35th Annual Meeting, Philadelphia, PA, November port the outpatient medical community in 1–4, 2002 adopting clinical IT systems. These incentives 10. AHIC Quality Workgroup: Quality Workgroup Exec- for adoption come at a time when outpatient utive Summary of the End State Vision, January 31, clinical IT systems are becoming more flexible, 2007. Available at: http://www.hhs.gov/healthit/ portable, and affordable. It is now an oppor- ahic/materials/qual_vision_execsum.pdf. Accessed tune time because of the pressure in practice April 28, 2007 11. AHIC Quality Workgroup: Quality Workgroup Vision to begin to measure and document the prac- Summary, January 31, 2007. Available at: http:// tices performance for a nephrology clinic to www.hhs.gov/healthit/ahic/materials/qual_vision_ consider adoption of an IT system that will summary.pdf. Accessed April 28, 2007 support quality care for CKD patients in the 12. New Regulations to Facilitate Adoption of Health In- outpatient setting. formation Technology; News Release–United States Department of Health and Human Services. Avail- able at: http://www.hhs.gov/news/press/2006pres/ References 20060801.html. Accessed April 28, 2007 13. Centers for Medicare and Medicaid Services: Physi- 1. Schoolwerth AC, Engelgan MM, Hostetter TH, et al: cian Quality Reporting Initiative Overview. Available Chronic Kidney Disease: A public health problem at: http://www.cms.hhs.gov/pqri. Accessed April that needs a public health action plan. Available at: 27, 2007 http://www.cdc.gov/pcd/issues/2006/apr/05_0105. 14. National Quality Forum: About Us. Available at: htm. Accessed April 28, 2007 2. Levey AS, Coresh J, Balk E, et al: National Kidney http://www.qualityforum.org/. Accessed April 28, Foundation Practice Guidelines for Chronic Kidney 2007 Disease: Evaluation, classification and stratification. 15. Health Level 7 Website. HL7 ANSI-Approved Stan- Ann Intern Med 139:137-147, 2003 dards. Available at: http://www.hl7.org/. Accessed 3. Available at: http://www.nkdep.nih.gov/resources/ April 28, 2007 nkpedPPTPresentation/nkdep_ckd_preseentation_files/ 16. SNOMED CT Website. What is SNOMED CT. Avail- frame.htm. Accessed July 19, 2007 able at: http://www.snomed.org/snomedct/what_is. 4. Gilbertson DT, Liu J, Xue JL, et al: Projecting the num- html. Accessed April 28, 2007 ber of patients with end-stage renal disease in the 17. LOINC Background. Regenstrief Website. Available United States to the year 2015. J Am Soc Nephrol at: http://www.regenstrief.org/medinformatics/ 16:3736-3741, 2005 loinc/background. Accessed April 28, 2007 5. U.S. Renal Data System, USRDS 2006 annual data re- 18. NKF KDOQI: Kidney Dialysis Outcomes and Quality port: Atlas of end-stage renal disease in the United Initiative Clinical Guidelines. Available at: http:// States, Bethesda, MD, National Institutes of Health, www.kidney.org/professionals/KDOQI/guidelines. National Institute of Diabetes and Digestive and Kid- cfm. Accessed April 28, 2007 ney Diseases, 2006. Available at: http://www.usrds. 19. Health Insurance Portability and Accountability Act org/2006/slides/html/02_incid_prev_06_files/frame. of 1996; Federal Register, P.L. 104–191, 1996 htm. Accessed on April 28, 2007 20. Certification Commission of Health Information 6. Sarnak MJ, Levey AS, Schoolwerth AC, et al: Kidney Technology; CCHIT Certified Ambulatory Electronic disease as a risk factor for development of cardiovas- Health Record (EHR) Products. Available at: http:// cular disease: A statement from the American Heart www.cchit.org/certified/. Accessed April 28, 2007

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