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These model cases provide pragmatic examples of various chronic kidney disease (CKD) population health management (PHM) efforts implemented at different institutions. The cases provide detailed information about how the effort was implemented, including barriers and solutions related to privacy, technology, and administration. 

CKD Identification, Phenotyping and Registries

  • Cleveland Clinic: Development of an EHR-based CKD Registry for Use in Clinical Research and Improvement of Patient Outcomes 
    The Cleveland Clinic operates one of the oldest EHR-based registries of chronic kidney disease.  The registry, which was established in 2005, includes demographic information, clinical parameters, and outcome measurements for more than 95,000 patients and supports recruitment of patients for clinical trials, quality improvement efforts, and targeted interventions.  This case study outlines the CKD phenotype definition, validation methods, and governance processes employed.
    Organization Type: Private Health System | Purpose: QI, Research

     

  • Alberta Kidney Disease Network: A Province-wide Central Repository of Laboratory and Administrative Data to Support CKD Research
    The Alberta Kidney Disease Network (AKDN) is a collaborative group of nephrology researchers across Alberta, Canada that has developed a registry of patients with chronic kidney disease.  The purpose of this registry is to identify patients with or at risk of CKD, study the epidemiology of CKD, and analyze interventions and health services.  In contrast to registries sponsored by at a single site or healthcare delivery organization. the AKDN registry combines laboratory and administrative data for all patients in the entire Canadian province of Alberta.
    Organization Type: Public Health System | Purpose: Research, QI

  • Kaiser Permanente Southern California: Managing Chronic Kidney Disease Populations within an Integrated Health Management Organization
    Kaiser Permanente Southern California (KPSC) integrated chronic kidney disease (CKD) care strategies and information into its population care management system, which was designed to offer important information to providers at the point of care. KPSC developed a CKD staging algorithm to identify patients at high risk for progression to end-stage renal disease and track provision of evidence-based care. Additionally, KPSC developed the Creatinine SureNet Program, which uses EHR data to identify individuals with a single abnormal creatinine result and no repeat measurement beyond 90 days. The Creatinine SureNet Program aims to ensure all abnormal creatinine values are addressed by creating a parallel system to support clinical practice without interfering with current practice or placing blame.
    Organization Type: Private Health System | Purpose: QI

CKD Analytics & Data Warehousing

  • Institute for Clinical Evaluation Science, Kidney, Dialysis, and Transplant Program (ICES KDT): A Renal Program Nested in a Larger Population Health Management (PHM) Program 

    ICES is an independent, non-profit organization that was established in 1992 in Toronto, Ontario, Canada. It encompasses a community of research, data, and clinical experts and a secure and accessible array of Ontario's health-related data.  ICES’ mission is research excellence to support policy development, better care, and improved health outcomes.  ICES allows for the study of health interventions, health care utilization, and outcomes among the general population as well as unique subgroups including chronic renal disease.  Central to their mission is a curated warehouse of more than 50 linked databases on health care encounters, demographics, population/ geography, disease-specific registries, and many others that enables long-term, passive follow-up of patient outcomes that would be extremely costly or not possible through a clinical trial or prospective cohort study.  
    Organization Type: Not-for-profit | Purpose: Research, Public Policy

Intervening for Improved Health

  • Mayo Clinic:  Project RED: Quality and Design-Method Approach to Improving ESRD Outcomes 
    In 2011, Mayo’s Division of Nephrology and Hypertension began Project Re-Engineering Dialysis (RED), a quality and design-methods approach to improve end-stage renal diseas (ESRD) patient outcomes by creating high-value, patient-centered care across all settings. Project RED focused on designing and implementing an accountable care system with processes to manage all care required by ESRD patients enrolled in Mayo Clinic's dialysis services network. Overall aims of the program were to improve patient-centered outcomes (functional status, quality of life, survival) by reducing errors, improving transitions of care across settings, and implementing patient-centered care and education/communication. Simultaneously, the program aims to meet external regulatory agencies’ and Mayo’s quality, safety, and service goals.
    Organization Type: Private Health System | Purpose: QI
  • Indian Health Service: A Strategic Plan for Population Health and Analytics 
    IHS implemented the patient-centered medical home (PCMH) model in the 1980s, and tracks outcomes at both the community/population and patient level. Given limited resources, IHS has relied heavily on technology — the RPMS system and the EHR in particular. To guide HIT activities and ensure that key goals and objectives are met, IHS developed a 5-year strategic plan starting in 2004, with 5-year updates. An important aspect of this work has been involving the community— tribal community leaders as well as tribal health boards. IHS is committed to having effective partnerships and collaborations at the community level, using activities such as local listening sessions to help facilitate a two-way flow of information. 
    Organization Type: Public Health System | Purpose: QI


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