CKD Screening and Management in the Veterans Health Administration: The Impact of System Organization and an Innovative Electronic Record
Section snippets
Features of the VHA
The VHA is the largest integrated health care system in the United States, caring for 5.3 million patients in 155 medical centers, 881 clinics, 207 readjustment counseling centers, and 135 nursing homes.8 Until the early 1990s, the system had multiple incentives for inefficiency, including hospital funding based on occupancy and costs. However, starting in 1995, the VHA underwent a wide process of reengineering, changing what had been primarily an inpatient subspecialty-based system into a
Practice Guidelines and Performance Measures
Diabetes is the leading cause of ESRD,2 and as emphasized in the Healthy People 2010 objectives,7 detection of early diabetic nephropathy and intensive management of diabetes are measures that significantly impact the progress and outcome of CKD. The number and percentage of veterans with diabetes has increased markedly from about 561,000 (20%) in 2000 to about 1,300,000 in 2007 (24%), an increase that may be attributed to an increase in the number of veterans who receive VHA care, aging of the
The VHA Electronic Record and Clinical Reminders
Since 1985, the VHA has used a system-wide electronic database system for both administration and clinical care, which by December 2005 contained 779 million clinical documents, more than 1.5 billion orders, and 425 million images. In the late 1990s, a graphical user interface, CPRS, was added to facilitate access to the database, making it possible for clinicians to securely update a patient's medical history, place orders, and review test results and drug prescriptions from personal computers
VHA CKD Guideline and ESRD Management
The VHA and the Department of Defense first published an evidence-based Pre-ESRD Guideline for Primary Care in 2001 to provide a tool for primary care providers to follow and manage patients with CKD and made it available online.21 The current guideline has been extensively updated to include new evidence, the use of eGFR, and management based on the stages of CKD and is targeted to primary care providers, residents, students, and fellows. It also addresses the issue of preparing patients for
Conclusion
It clearly is important to identify patients at high risk of CKD, to conduct regular screening of renal function, preferably using eGFR, and to provide education to all providers about how to prevent or slow the progression of CKD. The VHA experience shows that effective measures to accomplish screening and implement recommended management include the establishment of clinical guidelines and performance measures based thereon, with regular monitoring of and feedback to facilities and individual
Acknowledgements
The opinions expressed by the authors’ do not necessarily reflect the opinions of the Department of Veterans Affairs or the authors’ affiliated institutions.
Support: None.
Financial Disclosure: None.
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Cited by (27)
Development of methods to evaluate nephrological screening and support measures, and lessons learned from the Styrian nephrological screening program “niere.schützen”
2018, Zeitschrift fur Evidenz, Fortbildung und Qualitat im GesundheitswesenEstimating prevalence of CKD stages 3-5 using health system data
2013, American Journal of Kidney DiseasesCitation Excerpt :We used modeling based on NHANES data to assess the degree to which this underestimation occurred by examining the predicted prevalence of CKD in the untested populations of the health care systems. In the context of this study, the observed prevalence of CKD stages 3-5 in the total population was a third lower than the predicted prevalence (Fig 1), even within the VA system with its robust electronic health record and implementation of clinical reminders.15 This highlights the ongoing need to optimize strategies for appropriate testing and identification of persons with CKD in both the general population and high-risk groups.
Use of electronic health records and administrative data for public health surveillance of eye health and vision-related conditions in the United States
2012, American Journal of OphthalmologyCitation Excerpt :In theory, information in the clinical notes of primary care providers and eye care providers that are recorded in the Computerized Patient Record System could be obtained for analysis. Like the Kaiser Permanente EHR system, the VHA EHR system provides physicians with clinical reminders in the form of interactive dialogue boxes that are triggered by certain diagnoses, clinical conditions, patient characteristics, or passages of time.17 These reminders suggest possibly needed actions such as laboratory tests, medication refills, patient education, or referral of patients to specialists.17
Risk Factors and Screening for Chronic Kidney Disease
2010, Advances in Chronic Kidney DiseaseCitation Excerpt :Two illustrative examples, the Veterans Health Administration (VHA) and Southern California Kaiser Permanente, hold promise to address time limited primary care-patient interactions and health care system fragmentation.41,42 The VHA uses perhaps the largest, including over five million patients, most mature and sophisticated EHR, featuring an annual diabetic urinary albumin screen reminder, eGFR reporting with each serum creatinine result, lipid management reminder to target low-density lipoprotein cholesterol less than 100 mg/dL and clinical reminders for blood pressure target less than 130/80 mm Hg for CKD and/or diabetes.41 Preliminary data from a single VHA center suggests clinical decision support is associated with significant improvement in CKD recognition by primary care physicians, but only minimal improvements in blood pressure control.43
Surveillance of Chronic Kidney Disease Around the World: Tracking and Reigning in a Global Problem
2010, Advances in Chronic Kidney DiseaseCitation Excerpt :More recently, a CKD registry has been established within the Cleveland Clinic Health Care System in the state of Ohio.24 Disease management programs can be incorporated into such registries especially if the electronic medical record includes automatic alert systems for practitioners, as has been successfully achieved in the Veterans Affairs health care system's electronic medical record.25 Similar registries are being planned in different health care systems around the country.