July 9, 2009 (Honolulu) – Specialty care physicians can improve the health of high-risk patients by reviewing electronic health records and proactively providing e-consultations and treatment plan recommendations with primary care physicians, according to a Kaiser Permanente paper published online in the British Medical Journal.
The quality improvement project at Kaiser Permanente demonstrated that specialists can take a more active role in managing the health of populations with chronic illness – in this case, kidney disease – by using electronic health records to coordinate care among primary and specialty care providers. In the project, nephrologists (kidney specialists) proactively consulted remotely with primary care doctors to help manage patients at risk for end-stage renal disease.
Using a new system developed by the paper's lead author, Brian J. Lee, MD, and his colleagues at Kaiser Permanente, nephrologists in Hawaii used electronic laboratory results to rank more than 10,000 kidney patients not yet referred to a specialist by their risk for kidney failure. Then, they monitored the patients who were most at risk to make sure they were getting care in line with evidence-based treatment recommendations. After identifying the at-risk patient population, the nephrologists relied on Kaiser Permanente HealthConnect®, an electronic health record system, to evaluate next steps.
The nephrologists used the EHR to review the patient's electronic medical record and to provide an e-consult to the patients' primary care physicians. In many cases, the nephrologists recommended referral for more intensive specialty care. In others, the primary care physician was given the treatment plan necessary to prevent the need for referral. Results of the five-year project showed it increased early intervention for high-risk patients and reduced by two-thirds the number of late specialist referrals – those occurring within four months of the onset of end-stage renal disease.
"The goal with kidney disease is to detect it early enough to make changes that will slow the disease down. If you're more likely to end up with kidney failure, we want to reach you in time to help prepare you for successful dialysis treatment," said Lee, a nephrologist with Kaiser Permanente Hawaii. "Patients who have a chance to consult with a nephrologist well before the onset of kidney failure are less likely to be hospitalized and more likely to survive longer. Our patients are more successful in starting dialysis when they are able to choose the type of dialysis or transplant with their physician, have a dialysis access implanted, start treatment outside of the hospital before becoming very ill, and be educated and psychologically prepared for it."
While the vast majority of chronic kidney disease patients can be successfully managed by primary care doctors, some patients are better off cared for by a nephrologist, particularly those at highest risk of worsening kidney disease. Many people with chronic kidney disease don't even know they have it, and yet it is critical to reach people before their kidney disease progresses too far. The most common risk factors are obesity, diabetes and hypertension – all controllable through healthy lifestyle changes and medication.
"We want to provide the best and most comprehensive care that we can to our patients," said Geoffrey Sewell, MD, president and executive medical director of the Hawaii Permanente Medical Group, whose 410 physicians exclusively provide care for 222,594 Kaiser Permanente members in Hawaii. "Our integrated system of primary and specialty care physicians working together provides complete care - from the prevention of disease to the management of acute and chronic illness. This coordinated care program is made possible by KP HealthConnect, a system that supports the decisions we as physicians make with our patients every day."
"This pilot illustrates the benefits of leveraging technology and the expertise within a multi-specialty group practice," said Lee, the paper's lead author. "In the past, specialists have been limited to helping only those patients who were referred to them. Now that we can use databases to identify disease trends and populations, and electronic health information to provide data on individual patients, our specialists can proactively find and recommend treatments for patients who could really use their help."
Source: Golin/Harris International