FHIR Clincal Guidelines (v0.1.0) (STU1 Ballot)

This page is part of the Clinical Guidelines (v0.1.0: STU 1 Ballot 1) based on FHIR R4. The current version which supercedes this version is 1.0.0. For a full list of available versions, see the Directory of published versions

Chronic Disease Management - Chronic Kidney Disease (CKD)

Overview

The system-wide goal of evidence-based guidelines is to improve the patient’s health and well-being by guiding health providers who are taking care of patients with chronic health conditions along the management pathways that are supported by evidence and are thus considered the highest standard of care. This example focuses on Chronic Kidney Disease, however we expect that this implementation guide will be applicable to management of many other chronic health conditions, e.g. diabetes, hypertension, congestive heart failure, etc.

The expected outcome of successful implementation of this guideline is to:

  • Formulate an efficient and effective assessment of the patient’s condition
  • Optimize the use of therapy to reduce disease progression, reduce symptoms of CKD, and enhance patient functionality
  • Minimize preventable complications and morbidity
  • Emphasize the use of personalized, proactive, patient-driven care

This clinical use case example is based on the NIH Chronic Kidney Disease (CKD) Care Plan project.

  • Persona descriptions for patients with CKD and their provider care team members are available from the NIH site:
  • A draft set of data elements and terminology codes are also available for CKD care management, created by the NIH CKD Care Plan Working Group

Chronic Kidney Disease (CKD) Guidelines

The guidelines described in this example follow a recommended clinical workflow for diagnosis and care management. The steps in this workflow will be harmonized with other sources to specify a common pattern recommended for all clinical practice guidelines that follow this implementation guide. The pattern includes these general steps:

  1. Screen At-Risk Populations
  2. Evaluate Urgent/Emergent Conditions
  3. Criteria for Confirmed Diagnosis
  4. Determine Stage of Disease
  5. Strategies to Slow Progression
  6. Criteria for Specialist Consultation

KDIGO International Guideline

The Kidney Disease: Improving Global Outcomes (KDIGO) 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD)

VA/DoD Clinical Practice Guideline for CKD

Management of Chronic Kidney Disease (CKD) in Primary Care (2014)

CKD Guideline Algorithm
CKD guideline algorithm

Guideline Recommendations

The following CKD guideline recommendations are copied verbatim from the VA/DoD guideline and will be used to create an example implementation using FHIR and CQL. The provided examples do not yet cover these recommendations.

Strength Recommendation
Weak For We suggest that periodic evaluation for CKD be considered in patients with the following:
  • Diabetes, hypertension, other end organ disease (e.g., chronic heart failure [CHF]), or a personal or family history of kidney disease
  • Systemic illness (e.g., human immunodeficiency virus [HIV], systemic lupus erythematosus, multiple myeloma)
  • History of acute kidney injury (AKI) (e.g., acute tubular necrosis, urinary tract obstruction, interstitial nephritis)
  • Elderly patients
  • Races and ethnicities associated with increased risk (e.g., African Americans, Hispanics, Native Americans)
Weak For In patients with stage 3 and 4 CKD, we suggest a protein diet of 0.6 to 0.8 g/kg/day as it may slow the decline in glomerular filtration rate (GFR) and progression to end-stage renal disease (ESRD).
Strong For In adult patients with stages 1-4 CKD, we recommend that blood pressure targets should be less than 140/90 mmHg.
Strong For In patients with diabetes, hypertension, and albuminuria, we recommend the use of an ACEI or ARB to slow the progression of CKD, unless there is documentation of intolerance.
Strong For We recommend that all patients with CKD who are not on dialysis and have no known history of coronary artery disease be assessed for 10-year CVD risk using a validated risk calculator for primary prevention. If at risk (as defined in the VA/DoD Management of Dyslipidemia guideline), we recommend use of at least a low dose statin.
Weak For We suggest offering supplemental vitamin D to correct vitamin D deficiency in patients with CKD stages 3 or 4.
Weak Against We suggest not offering phosphate binders to patients with stage 3 and 4 CKD with normal serum phosphorous.

FHIR and CQL Examples

Three examples are included for chronic disease management, all focused on chronic kidney disease (CKD).

Clinical Practice Guideline protocol and recommendations

This example includes a small subset of the VA/DoD guideline and recommendations described above.

Care Plan Order Sets

  • Create a patient-specific care plan with interventions (order sets) determined by guideline recommendations.
    • Delivered as a FHIR CarePlan resource with associated activities, including MedicationRequest, ServiceRequest, and Appointment resources. May include a new or revised FHIR CareTeam resource specifying participants and their roles.
  • CKD Plan

Order sets from CKD practice guidelines are categorized for presentation to clinicians and/or when creating and executing order sets that require different order management processes. The provided examples include the following order set categories:

Decision Support Alerts: CKD Risk Assessment

Example FHIR resources in folder: ‘risk-recommendations’.