Population health management at Cleveland clinic

Transcription

1 Population health management at Cleveland clinic Sankar D Navaneethan, MD, MS, MPH Using Health Information Technology to Identify and Manage CKD Populations Oct

2 Objectives Development of an EHR based CKD registry at Cleveland Clinic Health System Transformation of registry data to knowledge Barriers in development and maintenance

3 Cleveland Clinic Health System Cleveland Clinic Main Hospital, 8 Community Hospitals &15 Community-based Health Centers Serves >1.5 million people with 75% of patients coming from the seven counties adjacent to Cleveland, Ohio EHR- EPIC (since 2002): routinely used for scheduling, order entry, documentation of progress notes, result review, medication management and provider-to-provider and provider-patient communication.

4 Cleveland Clinic Health System CKD Registry CLINICAL J. Nally, MD S. Navaneethan, MD S. Jolly, MD J. Simon, MD J. Hyland, CNP BIOSTATISTICS J. Schold, PhD J. Sharp S. Arrigain V. Konig X. Liu E-RESEARCH A. Jain, MD S. Welf, BS Navaneethan SD et al. Clin J Am Soc Nephrol 6: 40 49, 2011

5 Selection of patients Patients with 2 outpatient serum creatinine values n=292,372 Patients with 2 serum creatinine values at least 90 days apart n=255,409 Patients with 2 serum creatinine values <90 days apart (n=36,963)) Patients with egfr >60 (n=202,010) Patients identified using ICD-9 codes only (n=3,877) Patients with 2 egfr <60 >90 days apart n=53,399 Final Cohort n= 57,276 Updated every 3 months and now has >95,000 patients

6 Validation of the reliability of EHR data EHR validation - performed in two stages by two investigators Twenty randomly selected EHR generated charts were reviewed to assess whether the ICD-9 codes related to various kidney diseases and comorbid conditions are appropriate 20 random charts were reviewed to exclude the presence of a specific comorbidity that may have been falsely claimed to be present Navaneethan SD et al. Clin J Am Soc Nephrol 6: 40 49, 2011

7 Our Current Structure USRDS data Social security death index Ohio State death files Cleveland Clinic electronic data warehouse CKD Registry Analytical Files for outcomes research EHRs-based and Identification of participants for other clinical trials Institutional quality improvement projects

8 Transforming registry data into knowledge Research: Data for health outcomes research, resource for young trainees and to help with recruitment for clinical trials Patient care: Empowering patients using MyChartpersonal health record Providers: Feedback based on various quality metrics/ processes of care measures

9 Outcomes research projects Associations of vitamin D, serum testosterone, alkaline phosphatase and bicarbonate with mortality in CKD Associations of metabolic syndrome and ESRD/death in CKD Significance of CKD in pulmonary arterial hypertension Role of Implantable cardioverter defibrillator in CKD Utility of Renal resistive index in CKD Cause-specific deaths in CKD Collaborative projects with DECIDE/CKD-PC groups Navaneethan SD AJKD 2011, Navaneethan SD, NDT 2012, Taliercio JJ AJKD 2013, Navaneethan SD CJASN 2013, Jolly AJN 2014, Toledo C Hypertension 2015, Navaneethan SD JASN 2015, Navaneethan SD KI 2015

10 CKD specific enhanced personal health record (PHR) NIDDK R34 grant to improve outcomes for CKD patients through clinical translational (T2) research 2 x 2 factorial design clinical trial

11 Randomized Controlled Trial- Navigating the Challenges of CKD Inclusion criteria Age years English speaking egfr ml/min Patients residing in North East Ohio with CCF PCP Computer Access Exclusion criteria Mentally incompetent Cancer Terminal illness Patients on dialysis and had renal transplant Developed an electronic health record (EHR)-based enhanced personal health record (PHR) that will use electronic communication to disseminate CKD stage-specific goals of care and CKD education to improve outcomes for CKD Stage 3b/4 patients

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13 Registry aids recruitment efforts Patients who meets the specific inclusion/exclusion criteria for clinical trials and prospective studies are identified CRIC, Navigator study, diabetic nephropathy trials Option to provide the study coordinator with their scheduled visits to their provider Saves resources and coordinator time

14 Challenges Implementation Maintenance EMR based clinical trial

15 Challenges- Implementation Intent of developing an EMR based registry Role of funding and engaged team members Identifying and organizing the team Priorities for team members/competing clinical needs of the health IT team Speaking the same language

16 Challenges- Implementation Data dictionary Definitions/Rules are not available for everything that you might ask for Data collection - What to include and what not to

17 Challenges- Implementation Hospitalization data differences in coding of various hospitals Red blood cell transfusion data- differences in timing of documentation Lack of comprehensive medication details until e-prescription was implemented

18 Challenges- Maintenance Sustenance- support for the team members Legal team to understand the data sharing needs for collaborative research Loss of SSDI data linkage a new opportunity to think outside the box? Structural changes within the health care system eresearch reassigned to Business Intelligence

19 Challenges - Maintenance Registry refinements- revisitng rules e.g., internal medicine physicians-residents change over time Need for validation of any new variable being added to the registry Several procedural data: Renal US, ICD and ECHO data- Need for expertise in natural language processing Quality assurance- Changes at the electronic data warehouse

20 Challenges with EMR based clinical trial Building an enhanced personalized health record within EMR Adding an encounter for patient navigators Focus on MyChart for all across system

21 Summary EHR based registry development - feasible with the assistance of multi-disciplinary team EHR based registries offer assistance for - outcomes research, recruitment for clinical trials and QI projects Efforts are needed to accommodate changes in health care system, institutional policies and multiple other changes that could impact on the sustenance of such institution-based registries

22 Acknowledgements Stacey Jolly, MD Jesse D. Schold, PhD Susana Arrigain Victoria Konig Anil Jain MD John Sharp, Joseph V. Nally, MD And the MyChart and other CKD Registry Team members Funding: NIH/NIDDK R34 DK094112, Rosenberg foundation and Unrestricted educational grant from Amgen to the department of Nephrology and Hypertension, Cleveland Clinic Foundation Outcomes data: Ohio Department of Health & USRDS