AMOEBA (ISSN: )

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1 AMOEBA (ISSN: ) Available online at Vol.40, No.05 Page: (September 2015) Nederlandse jeugdbond voor natuurstudie, postbus 9955, s graveland, netherlands, 1243 zs Effect of Electronic Medical Record (EMR) in Diagnosis of Chronic Kidney Disease Babak Mahmud Zadeh 1, Reza Safdari 2, Marjan Ghazi Saeidi 3, Ayub Pezeshki 4, Ali Nikmaram* 5 1 MD and Health IT Expert 2 PhD of Health Information Management, head of paramedical university of Tehran University of Medical Sciences iran 3 PhD of Health Information Management, Manager of Health Information Management of Paramedical University of Tehran University of Medical Sciences iran 4 Professor of Nephrology and assistant professor of ZanjanUniversity of Medical Sciences iran PhD of Health Information Management, Manager of Health Information Management of Paramedical University of Tehran University of Medical Sciences iran 5 ZanjanUniversityofMedicalSciences,Academic Medical Center of Vali Asr, Information Technology Unit iran *Corresponding Author: alinikmaram@chmail.ir ABSTRACT Objective: chronic kidney disease is a silent disease, which can result in cardiovascular diseases and late diagnosis of it can lead to losing kidney and even death.increase in number of patients and high healthcare costs have challenged health community. Basic problems are existed in way of on time diagnosis of the disease, which have increased workload of physiciansseverely. Electronic medical record (EMR) used scientific method to facilitate diagnosis for physicians. Method: the present study is in kind of applied-developmental research. Data collection method is in form of studying books and papers and investigation of similar systems, study of cases of patients and designation of questionnaire. Results:the present study has designed electronic medical record system with taking pattern of similar systems and application of important standards in field of healthcare and exact method of diagnosis of disease based on web and using suitable technologies. Information structure of case would be corrected perfectly and fast access to background of patient would be provided and steps of CKD would be determined in shortest time and this can facilitate, speed and care in diagnosis of physicians. Conclusion: electronic medical record has adequate information structure for determining steps of CKD and can be effective help for physicians. In primary test, the system has improved more than 5% of final diagnosis. Improvement of quality of care, better organization of information, being on time, reduction of medical mistake, immediate access to information of different places, technology of supporting decisions and improvement of working process are some advantages of this system. Key words: chronic kidney disease (CKD), electronic medical record (EMR), Glomerular Filtration Rate (GFR) 144

2 Introduction Chronic kidney disease (CKD) is an important problem of general health (1-3), which can result in unpleasant medical healthcare outputs. Prevalence higher than 17% of the disease around the world, its destructive and progressive and mostly symptomless nature of the disease in its process toward kidney failure and its companionship with deathful cardiovascular diseases and high costs of healthcare and treatment can be factors that can introduce the disease as a global health threat (4). More than 20% of population of the USA suffers from CKD (5), which is along with considerable increase in risk of cardiovascular disease and stroke (6) and many people have reached End Stage of Renal Disease (ESRD) and are under dialysis treatment (7). Renal disease is the ninth cause of mortality in the US (8). In Iran, more than 20% of people; meaning above 14million people, suffer from the silent disease and it is increasing annually to 15-17%(9, 10) and will be doubled during next 8 years (11). Experts believe that statistics of renal patients in the society is a part of iceberg, which its peak is out and wide range of it is under the water. Till 2021, the number would be terrible (12). The study has been conducted in Vali Asr Hospital in Zanjan on discharged patients with final diagnosis of CKD and ESRD for 9-month period in 2013 and its similar time; meaning 9-month period of 2014 indicated 16% increase in CKD and 33% increase in ESRD during two sequential years. Most of the patients refer to the doctor when their disease has been progressed and has become close to the stage of renal failure (13), which should be under dialysis or kidney transplant should be performed that is expensive (14, 15). CKD has 5 stages and patients in the stages of 3-5 are mostly exposed to renal failure and death (16, 17). One of the methods for diagnosing stages of CKD is estimation of Glomerular Filtration Rate (GFR) from serum creatinine in sequential times in form of stability of its reduction to 90 days after last egfr (18), so that it can be placed and estimated in special formula using factors of age, gender, and race and body size. The equation has been developed carefully and is completely valid and is more careful for measuring 24-hour urine cleanup (17, 18). GFR = 186 * (Pcr) * (Age) * (0.742 if Female) * (1.210) Information of case of a patient is a valuable factor, which can be applied for purpose of improvement of healthcare, planning, scheduling and studying (19). According to obtained results, establishment of various Hospital Information System (HIS) in Iran has been just able to make processes of intersectional communications electronic; although the process of documentation of forms of cases of patients are manual and the system has no Electronic Medical Record (EMR). Lack of information in manual records of patients has made many problems for doctors for certain diagnosis and for identification of stage of CKD properly, although patients may refer to the doctors for several times. According to importance of this issueand unsuitable situation of information elements of record of patients and need for using suitable method of diagnosis of CKD, necessity of EMR would be felt more than before. In most developed countries and especially US and based on advice of kidney disease support groups like NKDEP, NIDDK, NKF, K/DOQI, famous method of MDRD is being applied for purpose of diagnosis of kidney disease for purpose of calculating GFR from serum creatinine (17, 18). Unfortunately, in the studied community, the method has not been applied by doctors. Amount of application of doctors of EMR in 2001 in the US has been equal to 17%, in Canada to 14%, in Australia to 25%, in New Zealand to 52% and in the UK to 59% (20). In 5 states of the US, law has forced that diagnosis of CKD should be using GFR and estimation of GFR should be based on level of serum creatinine (22). Studies indicate that EMR can decrease medical mistakes, especially at the time that is along with system of supporting integrated decision (20). 145

3 Methodology The present study is in kind of applied-developmental research. In terms of type of the study, the research is descriptive and in terms of creating the system can be among empirical studies. Data collection method is conducted through study of books and papers, assessing record systems and diagnosis of CKD and study of records of patients of valiasr Hospital. The study has referred to databases including SID, IRANDOC, IRANMEDICS, Science Direct, Sage Pub, Springer, JAMA, ProQuest and Google Scholar and also keywords such as EMR, Electronic medical Record, CKD EMR, Chronic kidney disease, Chronic Renal Disease and Electronic Health Record have been studied. Designation of questionnaires has been conducted using Likert Scale, direct observation, assessment of 12 HIS systems of Iranian Hospitals and several foreign systems of CKD and interview with doctors through other methods. 114 records of CKD have been studied in Vali Asr Hospital of Zanjan, among which 57 cases had complete information and their diagnosis methods and results have been investigated and applied. Results The study on inpatient and outpatient records related to CKD patients on the sample population indicated that there are basic problems with information record of patients, which are resulted from unsuitable structure of forms and defect in information elements of the form and this can result in deficit in saving and recovery of information as it is depicted in table 1. Some information of patients such as weight that is important in diagnosis of kidney disease would not be recorded in most records of patients, especially outpatients; although the doctor measured weight of the patient at the time of visit. Most recorded information has no structured information elements. As HIS has no subsystem of EMR, there would be no place for inserting such information. Table 1: problems of structure of paper forms of inpatient and outpatient records of CKD patients Problem Inpatient records Outpatient records Lack of recording weight and height of patient 100% 100% Lack of certain place for recording reagent doctor 40% 100% Lack of certain place for recording blood type of patient 100% 100% Lack of access to result of tests of previous references 10% 90% Lack of readability of manual records in forms 30% 80% Doctors use special formulations for diagnosis of disease with referring to background of patients. Obtained results from the questionnaires indicate that majority of doctors of studied sample use 24- hour urine cleanup method for estimation of GFR and MDRD method would not be applied as it is indicated in table 2. According to obtained results from studies of doctors of developed countries, especially the US, MDRD method has highest application (17, 18). Rutkowski M et al have depicted in a study that for purpose of determining stages of CKD and measuring GFR from serum creatinine, based on a formula that is confirmed in the agenda, (MDRD) has been applied K/DOQI (18) and successful results have been gained. TakurJi et al have conducted a study under the title of CKD screening and management in the Veterans Health Administration. In this study, they have studied direct effect of EMR under the title of Veterans Health Administration (VHA) with the approach of preventing CKD through diagnosis of CKD before reaching stage of dialysis and dialysis cares using MDRD method (23). The system is the greatest and most developed integrated healthcare system in the US (24). 146

4 Table 2: applied methods of doctors Applied method Percent 24-hour urine collection method 56% Cockraft-Gault equation method 44% MDRD equation method 0 In the studied sample, most of the doctors don't use MDRD method; although they believe that the method is more exact than other methods. The present study indicated that the method has been confirmed by doctors, especially nephrologists (Table 3). Diagnosis method Table 3: exact method confirmed by doctors Percent 24-hour urine collection 33% Cockraft-Gault equation method 11% MDRD equation method 56% In Iran, more than 25 private companies produce and develop HIS (25). Study on 12 systems by the author has indicated that most of them have no department under the title of EMR and recording clinical information and a few numbers, who have worked on electronic medical record, have not been successful for completely implementation of it. Discussion Michael V has conducted a study under the title of disease management programs for CKD patients and indicated that in diagnosis of these patients as the first challenge in a disease management program; only EMR can be useful that has the ability to record identity data and experimental data (22). Mehrabi and Mottaghi have conducted a study under the title of design of electronic medical record for diabetic patient and have found that medical centers have many problems without EMR (26). The author has applied similar systems and has designed CKD-EMR system in platform based on web, which can be in communication with HIS system in addition to management of information of patients. Designing CKD-EMR system has been conducted using MDRD formula and calculations have conducted estimation of GFR and stage determination in shortest time. The system has been implemented in studied hospital and information of records of CKD patients are entered to the system. In regard with putting information of patients in this system, sequential times of hospitalization of patients, especially in regard with creatinine test, were considered. Doctors of the studied community tested the proposed EMR and could observe information of their patients. The information is same information of manual records confirmed by the doctors. The system extracted required information from demographic and clinical section and announced stage of CKD progress in a diagram through considering existing factors in computational formulation of GFR as it is illustrated in figure

5 Figure 1: estimation of GFR and determining stage of CKD by system Designed electronic medical recordhas high care and speed and facility in terms of organizing information process of CKD and has been accepted and welcomed by sample community of doctors. Results of performance appraisal of CKD-EMR system on information of records of 57 patients was compared with the results of diagnosis in manual records of the patientsand care and certainty of the system was confirmed as it is depicted in table 4. Performance Table 4: comparing performance of system with manual records Two recent GFR Progress stage of the disease announced by system Diagnosis of electronic medical system Diagnosis recorded in manual record Number of records Percent of error in manual records Final diagnosis <15 5 ESRD CKD % Advising dialysis by EMR that is not conducted in manual record Patient under dialysis in manual record that is not advised by EMR >15 4 CKD ESRD % <15 5 ESRD % >15 4 CKD % 148

6 Conclusion Electronic medical record for chronic kidney disease (CKD-EMR) with its suitable structure and having suitable information elements can organize information process of the record of patients and can also save clinical information of patients uniformly and help doctor significantly at the time of retrieval of the information, which is not existed in manual records. In addition, the system includes exact and careful scientific diagnosis method for determining stage of the chronic kidney disease and can help doctor for purpose of diagnosis of the disease. Performance and efficiency of electronic medical record compared to manual records is considerable in terms of type of diagnosis, carefulness, speed and facility and easement. Improvement of quality of healthcare provided for the patients, better organization of information, improvement of process, being on time and up to date, correctness and perfection of documentation, easy access to electronic version of the records, decrease in medical mistakes, fast access to information in different places, technology of supporting decision making processes and improvement of working process can be main advantages of the Electronic Medical record for Chronic Kidney Disease. References 1. Schieppati A, Remuzzi G. Chronic renal diseases as a public health problem: epidemiology, social, and economic implications.kidneyint Suppl. 2005; 98:S7-S Schoolwerth AC, Engelgau MM, Hostetter TH, et al. Chronic kidney disease: a public health problem that needs a public health action plan [abstract]. Prev Chronic Dis. 2006; 3:A Levey AS, Coresh J, Balk E, Kausz AT, Levin A, Steffes MW, Hogg RJ, Perrone RD, Lau J, Eknoyan G. National Kidney Foundation: National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med 2003, 139: Kasper D, Braunwald E, Fauci A, Hauser S, Longo D, Jameson J. Harrison s principles of internal medicine. Mc Graw-Hill Professional Coresh J, Selvin E, Stevens LA, Manzi J, Kusek JW, Eggers P, et al. Prevalence of chronic kidney disease in the United States. Jama. 2007;298( :) 6. Baumgarten M, Gehr T. Chronic kidney disease: detection and evaluation. American family physician. 2011;84(10): Collins AJ, Foley RN, Herzog C, Chavers BM, Gilbertson D, Ishani A, et al. Excerpts from the US renal data system 2009annual data report. American journal of kidney diseases: the official journal of the National Kidney Foundation. 2010;55(1 Suppl 1):S1. 8. Miniño AM, Statistics NCfH. Deaths: final data for Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; Author N. No Statistics about Kidney disease in Iran. Etemad Newspaper. 2011;Sect. Medical. 10. Author N. Kidney disease Statistics in Iran is rising. Iran Newspaper. 2013;Sect. Medical. 11. Author N. Statistics of Kidney disease will be Twice [cited 2014:[1 p.]. Available from: Author N. Kidney disease Gallop with the lights off: Iran Newspaper; 2014 [cited 2014]. Available from: Iraj Najafi M, Farhad Islami M, Fatemeh Malekzadeh M, Rasool Salahi M, Mostafa Hosseini P, Monirossadat Hakemi M, et al. Prevalence of Chronic Kidney Disease and its Associated Risk Factors: The First Report from Iran Using Both Microalbumin-uria and Urine Sediment. Archives of Iranian medicine. 2012;15(2): Nourbala M-H, Einollahi B,Kardavani B, Khoddami-Vishte H-R, Assari S, Mahdavi-Mazdeh M, et al., editors. The cost of kidney transplantation in Iran. Transplantation proceedings; 2007: Elsevier. 15. Pourfarziani V, Nourbala MH, Azizabadi Farahani M, Moghani Lankarani M, Assari S.Costs and length of hospitalizations following kidney transplantation. Iran J Kidney Dis. 2009;3(2): Levin A, Stevens PE. Summary of KDIGO 2012 CKD Guideline: behind the scenes, need for guidance, and a framework for moving forward. Kidney international. 2014;85(1): Atabak S, Loni L. Treatment of chronic kidney disease. Tehran: Golbaran Pub; Rutkowski M, Mann W, Derose S, Selevan D, Pascual N, Diesto J, et al. Implementing KDOQI CKD definition and staging guidelines in Southern California Kaiser Permanente. American Journal of Kidney Diseases. 2009;53(3):S86-S

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