Leveraging the Cerner EHR for SEHA’s acute kidney injury project

Dr. Siddiq Anwar, Consultant Physician, Sheikh Shakhbout Medical City (SSMC), Abu Dhabi

“We are thankful to SEHA IT team and for the support of Cerner team for developing the innovative digital tools to improve renal care”

Sheikh Shakhbout Medical City (SSMC) has recently launched an electronic Continuous Renal Replacement Therapy (CRRT) prescription to streamline practices that will help improve filter running times, enhance delivered CRRT doses and reduce inventory costs. “Hospitals” magazine recently interviewed Dr. Siddiq Anwar, Consultant Physician, Sheikh Shakhbout Medical City (SSMC), Abu Dhabi, United Arab Emirates, who said: “We are thankful to the SEHA IT team with the support of the Cerner team, for being involved in planning, building, and testing all the digital tools we have developed over the last four years to improve renal care”.

Acute kidney Injury (AKI) is common in the intensive care unit (ICU), where it is associated with increased mortality; how did this project come to life, and how does it benefit patients?

AKI affects up to 30% of all ICU admissions. In addition to the development of AKI in patients admitted to critical care units, mortality rises up to 50-80% in ICUs. Furthermore, renal-replacement-therapy (RRT)-dependent AKI is associated with a substantial health economic burden. Continuous renal replacement therapy (CRRT) is a predominant form of treatment used in the ICU due to its accurate volume control, steady acid-base and electrolyte correction, and achievement of hemodynamic stability. Optimizing filter life and performance efficiency in CRRT will help improve both health care and financial outcomes associated with this therapy. 

We have recently launched an electronic CRRT prescription in SSMC to streamline practices that will help improve filter running times, enhance delivered CRRT doses and reduce inventory costs. The aim is to eliminate clinically unwarranted waste, unnecessary variation in practices, and any defects in our care of patients with an ultimate goal of having lean health care systems and improved outcomes while keeping patients’ best interests in mind.

How do you think the EHR can offer an integrated high-quality service to hospitalized AKI patients?

In-hospital AKI is now considered a patient safety thermometer and marker of inpatient care. Hence the National Health Service (NHS) in the UK mandates the reporting of in-hospital AKI to the UK Renal Registry. 

Early identification of actual and potential warning stage test results of AKI helps front-line workers make early interventions to prevent further deterioration. 

In addition, the development of clinical decision support tools, like hyperkalemia management order sets, will help a non-expert promptly initiate the initial management, improving patient outcomes.

At a macro level, studying the AKI data from in-hospital AKI longitudinally will help health care organizations tailor their renal services to support areas of need. This includes supporting outlier areas with extra support in terms of education and resources to help improve health care outcomes.

How can this system reduce the mortality rate due to AKI in intensive care?

The goal of digitizing the complete AKI detection and management pipeline is to prevent deterioration patients from requiring intensive care by early identification and institution of interventions. In those patients who are on RRT in the ICU, delivering the prescribed CRRT dose requires a system that allows standardization of practices to improve filter running times and delivered dose. The goal is to optimize and standardize CRRT care to eliminate waste in the process and reduce variability as a means to improve patient safety.

Multiple studies have shown a very strong association between AKI and consequent septic shock and mortality in adults and children. Early detection is key for survival;  how does this system help in early detection?

Renal dysfunction is a significant component in most severity scores used to assess critically-ill patients, like MELD-Na for acute liver injury,  APACHE and SOFA  score for patients in intensive care units . Moreover, in-hospital AKI is increasingly considered as an early marker of the deteriorating patient. 

The assessment of the severity of AKI is based on the rise of creatinine from the patient’s baseline. By building the NHS e-alert algorithm in our version of the Cerner EHR – the first in the Middle East – we aid the early detection of the significant rise of creatinine. This helps the institution of early interventions and the development of dedicated care bundles, which will help improve care. Part of the work that has gone on in our EHR is to develop specific order sets, which help with the diagnosis of common renal problems associated with AKI-like hyponatremia. 

There is also an exciting research project currently underway in Sheikh Shakhbout Medical City (SSMC) to study the population who develop AKI in our hospital in partnership with Khalifa University and Mohammed Bin Zayed University of Artificial Intelligence. The study aims to better understand the unique challenges we have in our region with its unique demographics. In addition, we have secured a research support to develop an AI-based decision support tool, RenAIssance, which aims to help a non-expert with the assessment of water balance and kidney perfusion to prevent kidney injury, using a handheld ultrasound with an embedded AI algorithm.

To what extent can this step minimize the burden of chronic diseases such as kidney diseases? And how?

This region is seeing an exponential rise in patients who develop the end-stage renal disease (ESRD). One of the risk factors for developing ESRD is recurrent AKI episodes. By developing a database of those at risk of frequent AKI, like those with cardio-renal syndromes, extra attention could be given to these patients minimizing the risk of ESRD. This will include developing an integrated workstream with interdisciplinary collaborations to focus on preventing future deteriorations and early interventions.

At a macro level, the UAE Department of Health can also study the trends of AKI and chronic kidney disease (CKD) by leveraging big data stored in the health information exchange – Malaffi (Arabic for ‘my file’) – to develop targeted performance indicators and policies to encourage early detection. In addition to focusing on issues around perioperative AKI and diabetic kidney care management to slow down the burgeoning epidemic of ESRD. 

Through this project and other similar ones, how can Cerner implement the vision and strategy of the UAE government and rulers to use the power of artificial intelligence (AI)?

One of the visionary strategic initiatives enacted by the UAE government is the digitalization of health care records of all residents in the country, which is now connected to Malaffi. The same informed decisions facilitated through Malaffi can also be made at a macro level by a machine learning (ML) algorithm to recognize patterns of deterioration by studying a patient’s data longitudinally and the big data which has now been created right here in UAE to predict those at risk of progression to ESRD.

Developing ML and AI tools trained on representative data reflecting the unique demographics are more likely to be clinically relevant and impactful. 

To this end, there has been a strategic investment by the leadership of UAE to foster the creation of a bio-health cluster around SSMC in Khalifa University, Mohamed bin Zayed University of Artificial Intelligence, and New York University Abu Dhabi, which are attracting the best talents from across the world. 

In addition, the availability of cloud-based computing in EHRs and developing telehealth solutions catering to local cultural sensitivities can help radically transform the care in the UAE. 

How is technology changing kidney care in the UAE?

In the last four years, while spearheading the digitalization of renal care in SEHA, we digitalized the whole AKI management pipeline, most recently the CRRT prescription. 

In doing so, we have created a unique structured big data capability that has been unknown in our area of the world until now. And when you create the digital infrastructure, the highways, and airports of the 21st century, then research investment will come. 

Recently, in partnership with a leading AI medical device company, SSMC has launched the UAE and the region’s first point-of-care ultrasound (POCUS) academy dedicated to the use of ultrasound to assess the hemodynamic circuit, filling a much-needed educational gap in the country and the region. We have also secured a commitment for one more academic project to bringing state-of-art renal training to the Middle East. All this was made possible by digitalizing renal care in SSMC.

The modern EHR is much more than an electronic version of a medical record – it is the engine that drives operations, clinical excellence, and academic growth.

At SSMC, we are thankful to the SEHA IT team with the support of the Cerner team, for being involved in planning, building, and testing all the digital tools we have developed over the last four years to improve renal care.

This digital infrastructure which is now embedded in our EHR  is going to be the foundation for the augmented intelligence platform which aims to enhance medical decision-making and help improve in-hospital AKI outcomes. RenAIssance was selected by the UAE Ministry of Economy in a recently organized Hackathon to help develop solutions that will help tackle global problems with new technologies. 

A health care organization that embraces technology and has a system thinking approach will benefit not just the patients but also foster innovation to support the health care system in the country.

We are thankful to the wise and nurturing leadership at SSMC who are supporting all these projects to add value not just to our organization but also to contribute to the development of the UAE health care sector and help accelerate our vision to make SSMC a destination medical and academic center.

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