Updating Renal Connect

Updating Renal Connect

RenalConnect is an open-source, web-based, and freely-available (via GitHub) clinical management tool we developed in the Fraser Health renal program in order to assist with management of PD peritonitis, as well as tracking and managing patients being followed by our “transition nurses”, ie those who are new starts to hemodialysis or at high risk of needing to start dialysis imminently.

We have phased-out usage of RenalConnect for PD peritonitis as the features have been rolled into PROMIS.  While we used RenalConnect for managing peritonitis as part of our quality improvement strategy, we noted a significant impact on our program and presented these findings at the American Society of Nephrology meeting in 2012.

Our transition nurses have been using RenalConnect to track and manage their caseloads.

We are strong believers that when we track data as part of our clinical care (rather than simply have clerks or analysts enter data retrospectively or prospectively), the data records and reports generated are more accurate and useful.  Simple put, our fantastic clinicians will likely enter data really accurately as it impacts the person they are caring for.

As a result of being “power users” of the software, our transition nurses were able to provide insightful feedback.  We took this feedback and brought it back to our software developer, Dr. Dimas Yusuf, now a senior resident in Internal Medicine.

We were able to add some nice upgrades (and bug fixes) to the web application.

Some highlights:

  • Often, reporting out mean results can be significantly impacted by just a couple outliers.  We added median results in our reports to give a more complete picture of our outcomes.
    • In the example in the image below, while mean interval from starting HD to meeting a transition nurse if 17.2 days (red arrow), the median is actually 7 days (blue arrow).  This is due to a handful of outliers which skew the mean.2015-06-19_08-56-17
  • When we report out mean and median results, sometimes the results just don’t look like they make sense.  This can happen if there has been an error in data entry.  We’ve added the ability to “Inspect data”.  This feature allows one to drill down on all the data points (by clicking “Inspect data”, blue arrow) that make up any given metric and see if any of the values may be erroneous.  Inaccurate data points can then be quickly fixed (by clicking “manage start”, red arrow).
    2015-06-19_09-04-35

2015-06-19_09-06-46

  • We added 2 new reports to assist with quality improvement in PD:  Time from PD referral to PD catheter insertion and Time from PD referral to PD start.2015-06-19_09-10-39

In general, patients on hemodialysis who are waiting to start PD are on dialysis using a central line.   We know that observational data suggests the any benefit of PD over HD in the short term is likely driven by central venous catheter usage1.  In addition, hemodialysis is much more costly that peritoneal dialysis2. Of course, people wanting to switch to PD from HD likely want it to happen sooner rather than later.  So it serves the triple aim of healthcare to move people onto peritoneal dialysis as quickly as possible.  This new reporting metric will allow our program to understand how we’re performing and try to tighten up our processes of care.

  • We added support for French and Spanish so it is more useful to other members of the global nephrology community.  Over time, we’d love to see contributors add support for more languages.
  • We added support for patients who may not yet have started dialysis (but were still being followed by our transition nurses), and for those who recovered after starting dialysis.
  • We fixed a ton of bugs, many of which were quite annoying.

Of note, all members of the Fraser Health renal team who need access, can login here http://renalconnect.com.

Login to RenalConnect

 

Any members of the FHA Renal team who need access, can do so by requesting it directly from the medical director.

 

We’ve made sure that RenalConnect remains a freely accessible tool that can be downloaded, installed, and implemented by anyone who wishes to use it around the world.  Our hope is that an open-source community will develop around this software and we’ll see it improve over time. Of note, the software developer has kindly agreed to offer a hosted and supported solution that allows medical teams to use the software without having to worry about setting up and maintaining their own installation.

 

 

References

 
Perl J1, Wald R, McFarlane P, Bargman JM, Vonesh E, Na Y, Jassal SV, Moist L. Hemodialysis vascular access modifies the association between dialysis modality and survival. J Am Soc Nephrol. 2011 Jun;22(6):1113-21. PMID: 21511830.
 
Chui BK1, Manns B, Pannu N, Dong J, Wiebe N, Jindal K, Klarenbach SW. Health care costs of peritoneal dialysis technique failure and dialysis modality switching. Am J Kidney Dis. 2013 Jan;61(1):104-11. PMID: 22901772.
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Fraser Health Renal | Success Story in an Infographic

Fraser Health renal has a lot to be proud of.  Here are a few items that I could display really simply using an infographic.   I used a low cost, easy to use service call infogr.am. A picture is worth a thousand words so I’ll stop typing now.

 

FHA Renal Success Stories | Create infographics
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Secure sharing of patient information

Secure sharing of patient information

We live in an era of ubiquitous computing using mobile devices, where we can get instant updates on social events from our family and friends on Facebook, instantly share  photographs that capture important moments in our lives on Instagram and even do our day-to-day banking whenever and wherever we have a free moment.

Yet in healthcare, we have struggled to advance past handwritten notes, desktop-based medical record applications and faxed messages.

Healthcare professionals are now at a crossroads.

We know what can be achieved using the latest in mobile and secure communications, yet struggle to adapt our professional lives given the security and privacy requirements when sharing patient information.

As a result, our patients may be impacted by missed opportunities for their care team to communicate through digital channels, or have the security of their personal health information potentially threatened by well-meaning health care providers who use insecure means such as email and text messages.

I’m going to share a few examples of what I’ve been exploring in my own practice, and compare/contrast what’s happening vs how we could do things differently with concrete, real-world examples.

Inter-provider messaging/communication

Status quo

In Fraser Health, when a member of the health care team needs to contact a physician, we generally send a page, or perhaps call a cellphone.

While a reliable means of communication, there is no mechanism to identify the priority of a message and it can interfere with existing workflow and patient care.  Most physicians can remember examples of  being paged to get a laxative order for a patient with mild constipation while in the middle of managing a critically ill patient.  While the incoming message may be important, it may not be urgent enough to interrupt the current activity.

There’s likely a reason while the millennial generation has larger abandoned voice and moved to text.  It’s far more efficient, adapts to a fast paced lifestyle and allows one to prioritize easily.  Seems to be an excellent match for healthcare.

Reports from US institutions suggest that HCPs are frequently using insecure technologies to send digital messages.  There is every reason to believe this is also happening in Canada.

Opportunity

In the Fraser Health renal program, we been trialling a secure messaging platform provided by Medinet (the same folks who get lab results securely/digitally into physicians medical records).

2015-05-31_21-55-56

How does it work?

It’s basically like email, but more secure.

For those who are unaware, we can’t send email that contains personal health information, as email gets transmitted around the world through the open internet.  If you wouldn’t write something on the back of a postcard, it shouldn’t go in email.  So email is not safe for the personal health information of our patients as it’s too easy for someone to intercept and isn’t compliant with privacy legislation.

Secure messaging ensure that the content of a message cannot be accessed by anyone but the intended recipient while in transit or stored on a server.

If anyone did see the content of a message, it would look something like this (as it has been encrypted):

mQGiBEe68W8RBACVuFuv4d+roDSCdRO1SuO8dQwds4VTjVOqgVKQtq6+8Fe95RY8
BAf1IyLj4bxvWPhr0wZdVwTosD/sFoPtdCyhVcF932nP0GLHsTEeVwSz9mid22HI
O4Kmwj2kE+I+C9QdzAg0zaWQnVaF9UC7pIdMR6tEnADI8nkVDdZ+zb2ziwCg6Yqu
tk3KAzKRT1SNUzTE/n9y2PED/1tIWiXfGBGzseX0W/e1G+MjuolWOXv4BXeiFGmn
8wnHsQ4Z4Tzk+ag0k+6pZZXjcL6Le486wpZ9MAe6LM31XDpQDVtyCL8t63nvQpB8
TUimbseBZMb3TytCubNLGFe5FnNLGDciElcD09d2xC6Xv6zE2jj4GtBW1bXqYWtl

Our partners in IT and privacy spent more than 1 year vetting the Medinet secure messaging solution and we’ve now been piloting it in our Royal City Kidney Care Centre.

By using this technology, the Kidney Care team can easily communicate with the physician as needed to address important but non-urgent issues, despite challenges of distance and competing priorities (such as on call emergencies).

With the pilot successful thus far, I’m really looking forward to this technology rolling out to more members of our renal program.

Physician submissions to Medical Services Plan (MSP)

Status quo

Physician are frequently paid via a fee for service model rather than being salaried or employed by the health authority.  This requires that the physician record the following information for patient encounters: patient name, personal health number, date of birth, date/time of contact, service provided and diagnosis.  This information must then be submitted electronically to the Medical Services Plan (MSP) and physicians often using billing agents to achieve this.  How the patient health information gets from the bedside to MSP is essentially up to each individual physician, but given the sensitive nature of the information, it should be protected in keeping with privacy requirements.

The challenge is that there are no existing secure methods to extract, record and transmit this information from the hospital to a physician’s office or billing agent, and existing physician practices are not well described.

Anectodally, it would seem that many are recording this information on paper and physically transporting it, with the risk of documents being lost or misplaced along the way.  One might also speculate that some may use insecure digital solutions such as email, excel, or dropbox to transmit this information.  Again, these solutions wouldn’t meet the security and privacy requirements needed when storing and transmitting personal health information (PHI).

Opportunity

Ideally, I’d like a solution that allows physicians to capture the information required for billing using a digital device that cannot be accessed by others, and then securely transmits this information to their billing agent.

As it turns out, I’ve discovered a solution which offers this exact service.

Dr-Bill.ca offers a mobile app for iPhone that allows physicians to easily capture required demographic data on patients they see in hospital or clinic.  The information is protected behind a secondary login (known only to the physician) as well as layers of digital security, both on the device and in the servers where the information is housed.

2015-05-31_21-53-13

While the information is moved from the iPhone to Dr Bill’s server, it is encrypted.  This means that even if someone could intercept the data being shared, it is impossible to understand what it says.  This is the same technology that allows one to safely move ones banking information between the bank’s computers and ones laptop or smartphone.

Dr-Bill is already an approved billing service by MSP, and has been required to meet their privacy and security requirements.

This solution has recently been submitted to Fraser Health for evaluation and I look forward to the review, and (hopefully) approval of this solution.

Getting second opinions on visual diagnoses

Status quo

Health care providers frequently find themselves needing second opinions when making a diagnosis.  While some requests for assistance can easily be described in words (eg. How do you generally treat relapsing ANCA vasculitis?), in some cases, there is a distinct advantage to sharing an image. For example, when one is looking at an unusual rash or a difficult to interpret ECG, sharing an image can literally be worth a thousand words.

In the past, HCPs may have often been tempted to grab a photograph using their smartphone and share it insecurely with colleagues using email, SMS or other systems.

Opportunity

A recently launched app called Figure1 allows one to capture images in a secure manner and share them with like-minded colleagues to get more clinical input.  The app takes into account patient permission (with a built-in tool to document patient consent) and the need to make the image private (by deleting any identifying characteristics on a lab report or obscuring any unique identifiers such as a patient tattoo).

2015-05-31_22-08-08

The app also takes advantage of the crowd-sourcing concept.  Rather than just asking an opinion from a single individual you might know, Figure1 offers the advantage of getting insights and input from thousands of colleagues from all over the world.  While the advice should not be used for medical diagnosis directly, it can certainly give more suggestions and ideas than simply flipping through a medical textbook or searching through PubMed.

Summary

With the advent of increasingly seamless and convenient digital communication tools, and a growing number of healthcare providers who have adopted these tools as part of their lifestyle, we shouldn’t be surprised to learn that patient information may increasingly be exchanged through inadequately secure mechanisms.

I’m hoping that healthcare organizations will get ahead of this trend and assess, then implement, secure digital services to protect patient privacy while simultaneously enhancing patient care.

 

 

 

 

 

 

 

 

 

 

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GFR at dialysis initiation

GFR at dialysis initiation

With the release of the latest Management Indicator Report from the BC Provincial Renal Agency, the Fraser Health renal program was able to learn a tremendous amount about our performance.

In a future post, I’ll spend more time discussing other performance indicators.  One indicator that is fascinating to examine today is mean eGFR at dialysis initiation.

2015-05-24_22-12-13

On Feb 4, 2014, the CSN published the guideline “Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis.”

Primary recommendation of this guideline:

For adults (aged > 18 yr) with an estimated glomerular filtration rate (eGFR) of less than 15 mL/min per 1.73 m2, we recommend an “intent-to-defer” over an “intent-to-start-early” approach for the initiation of chronic dialysis. (Strong recommendation; moderate-quality evidence.)

With the intent-to-defer strategy, patients with an eGFR of less than 15 mL/min per 1.73 m2 are monitored closely by a nephrologist, and dialysis is initiated with the first onset of a clinical indication or a decline in the eGFR to 6 mL/min per 1.73 m2or less, whichever of these should occur first.

This guideline was based primarily on the results of the IDEAL study (A randomized, controlled trial of early versus late initiation of dialysis. NEJM 2010 12; 363 (7) :609-19) which showed no advantage to an earlier dialysis start.

Of note, the IDEAL study was published in 2010, while the CSN guideline was published in 2014.

While it generally takes a long time for clinical practice to adjust to new evidence/guidelines, it appears that eGFR at initiation of dialysis didn’t change after publication of IDEAL, but starting in the 2nd quarter of 2014 at around the time the CSN guideline was published, we saw a sustained drop in eGFR at dialysis start.

Previously, mean eGFR at initiation was 11-13 ml/min.  For the last 3 quarters, mean eGFR has ranged from 10-11 ml/min.

It will be interesting to see if this trend continues or is sustained.

An analysis of IDEAL also showed that patients randomized to a lower eGFR at dialysis initiation who intended to start peritoneal dialysis were less likely to actually start on PD that those with a higher eGFR at dialysis initiation (70% vs 80%, p = 0.01).

Given the slight decline in PD incidence/prevalence in FHA during this time period, one must consider whether the trend towards lower GFR at dialysis initiation is contributing.

References

 
Nesrallah GE, Mustafa RA, Clark WF, Bass A, Barnieh L, Hemmelgarn BR, Klarenbach S, Quinn RR, Hiremath S, Ravani P, Sood MM, Moist LM; Canadian Society of Nephrology. Canadian Society of Nephrology 2014 clinical practice guideline for timing the initiation of chronic dialysis. CMAJ. 2014 Feb 4;186(2):112-7. PMID: 24492525.
 
Cooper BA1, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, Harris A, Johnson DW, Kesselhut J, Li JJ, Luxton G, Pilmore A, Tiller DJ, Harris DC, Pollock CA; IDEAL Study. A randomized, controlled trial of early versus late initiation of dialysis. N Engl J Med. 2010 Aug 12;363(7):609-19. PMID: 20581422.
 
Johnson DW1, Wong MG, Cooper BA, Branley P, Bulfone L, Collins JF, Craig JC, Fraenkel MB, Harris A, Kesselhut J, Li JJ, Luxton G, Pilmore A, Tiller DJ, Harris DC, Pollock CA. Effect of timing of dialysis commencement on clinical outcomes of patients with planned initiation of peritoneal dialysis in the IDEAL trial. Perit Dial Int. 2012 Nov-Dec;32(6):595-604. PMID: 23212859.
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Understanding health care funding in BC

Understanding health care funding in BC

Ever wonder where our funding for health care comes from and how budgets are determine? The presentation provided by the Auditor General’s office is a fantastic overview.

http://www.bcauditor.com/files/publications/2013/special/report/Health%20Funding%20Explained%20information%20piece.pdf

Teaser slide:

2013-02-14_14-10-13

 

Of note, Fraser Health has the lowest per capita spending compared to all the other health authorities.  Per Capita Spending at FHA

 

For reference, the total population served in each health authority:

. VIHA 760,000 people

Š . FHA 1.77 million people

Š . VCHA 1 million people

Š . IHA 740,000 people

Š . NHA 280,000 people

 

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New Technologies Presented at Medicine X

New Technologies Presented at Medicine X

I recently had the opportunity to attend Medicine X that ran between September 28 and 30.  Held at Stanford Univeristy, this academic meeting is described at being “a catalyst for new ideas about the future of medicine and emerging technologies.”

Throughout the meeting, I had the opportunity to hear about amazing new technologies and meet incredible thought leaders.  Perhaps most exciting was the chance to meet Sergey Brin (co-founder of Google) and discuss the role Google Glass will play in clinical medicine.

 

Sergey Brin at Medicine X

Sergey Brin at Medicine X

I will highlight a few technologies that I thought could be utilized in our renal program to enhance care or improve efficiencies.

Medigram

The first technology that impressed me was a service called Medigram.  They are trying to replace archaic and functionally deficient pagers and faxes with a mobile and desktop application that allows meaningful communication that moves patient care forward.

Key features:

  • Eliminate pagers and faxing. Start a team discussion and exchange messages instantly with your colleagues.
  • Share multimedia contact (eg skin lesion, EKG or laceration) with colleagues quickly and easily. All medical images are stored and can be accessed securely.
  • Accessible to the entire health care team.  They have a  native app for iOS or Android platforms and offer access to the service from any computer or tablet device with web access.

Given that members of our program often work at geographically distant sites, we clearly need a better communication tool than pagers.  Maybe Medigram could provide the solution.

Clinicast is an exciting data analysis tool.  Data crunching sounds boring, but our program is currently struggling under the weight of data analysis.  Most of our analysis has to be done manually and can’t easily be applied on patient by patient basis.

Imagine if we had a system that allowed us to crunch our massive database, and tell us on a patient by patient basis which individuals would benefit from additional care or interventions.  Imagine a system that allowed us to determine which PD patients needed a assisted home PD or a respite bed for a while to prevent modality failure.  Or which HD patients needed home care to avoid a hospital admission.  Currently, we use our judgement to decide on allocation of scarce resources.  While the gut feeling of an experienced clinician is extremely valuable, we often fail to be consistent.  Sometimes patients don’t get the additional care they may benefit from and on ocassion, we invest additional resources which likely aren’t critically necesary.

Clinicast is a system which solves these problems using advanced data analytics.

From the company website, “ARTO™ uses machine learning algorithms to create a solution that adapts to each client’s specific needs, delivering individualized recommendations of interventions that are most effective in preventing hospitalization for that client’s patients and care settings.”

I actually had a chance to speak to company co-founder, Jack Challis.  It turns out the company is interested in exploring care optimization for patients with kidney disease.  I’m hoping there will be an opportunity to work with Jack and his team to improve care for our patients with CKD while reducing preventable hospitalization.

Of note, there was a rather critical presentation on the performance of the BC PITO EMR program.  The findings of these researchers certainly meshes with the experience of many nephrologists who have participated in the PITO program.

Overall, the meeting was an exciting but sobering one.  While there are clear opportunities to use technology to improve patient care and efficiency, we need to be sure we implement thoughtfully and with clear deliverables in mind.

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