Clinical Decision Support Tools in the Electronic Medical Record
Mackenzie R. Alexiuk, Heba Elgubtan, Navdeep Tangri
Abstract
The integration of clinical decision support (CDS) tools into electronic medical record (EMR) systems has become common. Although there are many benefits for both patients and providers from successful integration, barriers exist that prevent consistent and effective use of these tools. Such barriers include tool alert fatigue, lack of interoperability between tools and medical record systems, and poor acceptance of tools by care providers. However, successful integration of CDS tools into EMR systems have been reported; examples of these include the Statin Choice Decision Aid, and the Kidney Failure Risk Equation (KFRE). This article reviews the history of EMR systems and its integration with CDS tools, the barriers preventing successful integration, and the benefits reported from successful integration. This article also provides suggestions and strategies for improving successful integration, making these tools easier to use and more effective for care providers. The integration of clinical decision support (CDS) tools into electronic medical record (EMR) systems has become common. Although there are many benefits for both patients and providers from successful integration, barriers exist that prevent consistent and effective use of these tools. Such barriers include tool alert fatigue, lack of interoperability between tools and medical record systems, and poor acceptance of tools by care providers. However, successful integration of CDS tools into EMR systems have been reported; examples of these include the Statin Choice Decision Aid, and the Kidney Failure Risk Equation (KFRE). This article reviews the history of EMR systems and its integration with CDS tools, the barriers preventing successful integration, and the benefits reported from successful integration. This article also provides suggestions and strategies for improving successful integration, making these tools easier to use and more effective for care providers. EMR-integrated CDS tools have widely proliferated in the past 20 years by leveraging EMRs to provide evidence-based guidance and enhance clinical decision-making. EMR-integrated CDS tools refer to computer-based functionalities that are seamlessly integrated within EMR platforms.1Khalifa M. Clinical decision support: strategies for success.Procedia Comput Sci. 2014; 37: 422-427https://doi.org/10.1016/J.PROCS.2014.08.063Crossref Google Scholar This is accomplished by utilizing patient-specific EMR data in a computerized knowledge base, which provides evidence-based recommendations to the clinician to guide their decision.1Khalifa M. Clinical decision support: strategies for success.Procedia Comput Sci. 2014; 37: 422-427https://doi.org/10.1016/J.PROCS.2014.08.063Crossref Google Scholar These tools have been primarily designed to be used at the point of care, specifically for the clinician to integrate their knowledge with the output of recommendations from algorithms and knowledge-based engines.2Gartee R. History of electronic health records.Electronic Health Records 2nd ed. 2012; : 576Google Scholar,3Davis S. Roudsari A. Raworth R. et al.Shared decision-making using personal health record technology: a scoping review at the crossroads.J Am Med Inform Assoc. 2017; 24: 857-866https://doi.org/10.1093/JAMIA/OCW172Crossref PubMed Scopus (0) Google Scholar The purpose of this review is to identify examples of EMR-integrated CDS tools such as the Statin Choice Decision Aid and KFRE, and provide evidence and guidance on the implementation of future tools in cardiovascular (CV) and kidney disease. Our goal is to highlight the potential benefits of these tools, their role in improving patient outcomes, and the barriers that need to be addressed for successful integration into clinical workflows. The origins of EMRs can be traced back to the development of early computer systems and information technology.4Evans R.S. Electronic health records: then, now, and in the future.Yearb Med Inform. 2016; Suppl 1: S48-S61https://doi.org/10.15265/IYS-2016-s006Crossref PubMed Scopus (382) Google Scholar In the 1960s, researchers and hospitals began experimenting with computerized databases as a method of storing patient information.5Gillum R.F. From papyrus to the electronic tablet: A brief history of the clinical medical record with lessons for the digital age.Am J Med. 2013; 126: 853-857https://doi.org/10.1016/j.amjmed.2013.03.024Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar Notably in 1967, Dr. Lawrence L. Weed, a physician at the University of Vermont developed the Problem-Oriented Medical Information System,5Gillum R.F. From papyrus to the electronic tablet: A brief history of the clinical medical record with lessons for the digital age.Am J Med. 2013; 126: 853-857https://doi.org/10.1016/j.amjmed.2013.03.024Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar,6Soumis C. A brief history of the EMR. Extractsystems.https://www.extractsystems.com/healthydata-blog/2016/9/30/a-brief-history-of-the-emrDate: Published 2016Date accessed: August 11, 2023Google Scholar which was one of the first computer-based medical record systems designed to electronically catalog patient data.5Gillum R.F. From papyrus to the electronic tablet: A brief history of the clinical medical record with lessons for the digital age.Am J Med. 2013; 126: 853-857https://doi.org/10.1016/j.amjmed.2013.03.024Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar The first EMR system was developed in 1972 by the Regenstreif Institute in the United States.4Evans R.S. Electronic health records: then, now, and in the future.Yearb Med Inform. 2016; Suppl 1: S48-S61https://doi.org/10.15265/IYS-2016-s006Crossref PubMed Scopus (382) Google Scholar,6Soumis C. A brief history of the EMR. Extractsystems.https://www.extractsystems.com/healthydata-blog/2016/9/30/a-brief-history-of-the-emrDate: Published 2016Date accessed: August 11, 2023Google Scholar However, the adoption of this EMR system was limited due to the prohibitive cost of implementation and the lack of adequate technological infrastructure across health institutions at the time.5Gillum R.F. From papyrus to the electronic tablet: A brief history of the clinical medical record with lessons for the digital age.Am J Med. 2013; 126: 853-857https://doi.org/10.1016/j.amjmed.2013.03.024Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar,6Soumis C. A brief history of the EMR. Extractsystems.https://www.extractsystems.com/healthydata-blog/2016/9/30/a-brief-history-of-the-emrDate: Published 2016Date accessed: August 11, 2023Google Scholar The rising popularity of computers and technological advancements throughout the 1980s and 1990s established the foundation for widespread adoption of EMRs into hospitals.2Gartee R. History of electronic health records.Electronic Health Records 2nd ed. 2012; : 576Google Scholar,4Evans R.S. Electronic health records: then, now, and in the future.Yearb Med Inform. 2016; Suppl 1: S48-S61https://doi.org/10.15265/IYS-2016-s006Crossref PubMed Scopus (382) Google Scholar However, it was not until the 2000s when an organization such as Health Level Seven International emphasized the importance of EMR use for standardization and interoperability.7Sweet L.E. Moulaison H.L. Electronic health records data and metadata: challenges for big data in the United States.Big Data. 2013; 1: 245-251https://doi.org/10.1089/big.2013.0023Crossref PubMed Scopus (19) Google Scholar Moreover, several global organizations established standardized protocols for medical terminology and data exchange, which paved the way for a more efficient integration of EMRs into health care systems throughout the past decade.7Sweet L.E. Moulaison H.L. Electronic health records data and metadata: challenges for big data in the United States.Big Data. 2013; 1: 245-251https://doi.org/10.1089/big.2013.0023Crossref PubMed Scopus (19) Google Scholar During the initial stages, EMRs were primarily used for physician note-taking and billing processes.4Evans R.S. Electronic health records: then, now, and in the future.Yearb Med Inform. 2016; Suppl 1: S48-S61https://doi.org/10.15265/IYS-2016-s006Crossref PubMed Scopus (382) Google Scholar EMRs transformed the process of collecting patient information as it began to transition away from paper-based formats.4Evans R.S. Electronic health records: then, now, and in the future.Yearb Med Inform. 2016; Suppl 1: S48-S61https://doi.org/10.15265/IYS-2016-s006Crossref PubMed Scopus (382) Google Scholar Digital EMRs provided physicians with platforms equipped with structured templates and standardized data fields, that facilitated more continuity and organization when documenting patient information.2Gartee R. History of electronic health records.Electronic Health Records 2nd ed. 2012; : 576Google Scholar,4Evans R.S. Electronic health records: then, now, and in the future.Yearb Med Inform. 2016; Suppl 1: S48-S61https://doi.org/10.15265/IYS-2016-s006Crossref PubMed Scopus (382) Google Scholar,7Sweet L.E. Moulaison H.L. Electronic health records data and metadata: challenges for big data in the United States.Big Data. 2013; 1: 245-251https://doi.org/10.1089/big.2013.0023Crossref PubMed Scopus (19) Google Scholar Billing procedures subsequently evolved into more streamlined processes, allowing health care providers to generate electronic claims using data directly from the patient’s EMR.4Evans R.S. Electronic health records: then, now, and in the future.Yearb Med Inform. 2016; Suppl 1: S48-S61https://doi.org/10.15265/IYS-2016-s006Crossref PubMed Scopus (382) Google Scholar There are instances when health technology companies have effectively used EMRs for the purpose of clinical research.8Kaiser Permanente Research bank.https://researchbank.kaiserpermanente.org/our-research/for-researchers/Date accessed: August 16, 2023Google Scholar,9Flatiron healthhttps://flatiron.com/resources/tag/publicationsDate accessed: August 16, 2023Google Scholar These companies utilize their EMR platforms to gather patient data, including aspects such as demographic information, treatment plans, clinical outcomes, and genomic profiles from health care providers.9Flatiron healthhttps://flatiron.com/resources/tag/publicationsDate accessed: August 16, 2023Google Scholar One notable advantage of this EMR-based approach is its ability to bridge the gap between clinical trials and real-world practice.9Flatiron healthhttps://flatiron.com/resources/tag/publicationsDate accessed: August 16, 2023Google Scholar EMR-based research has the capacity to facilitate large-scale retrospective studies and the development of machine learning algorithms to explore disease trends and assess the effectiveness of novel therapies and current treatment plans.9Flatiron healthhttps://flatiron.com/resources/tag/publicationsDate accessed: August 16, 2023Google Scholar Furthermore, research using EMRs can be leveraged in CDS and evaluating healthhttps://flatiron.com/resources/tag/publicationsDate accessed: August 16, 2023Google Scholar their the potential for CDS using EMR systems to be EMRs a of patient data that is not for efficient EMR-integrated CDS tools a of functionalities that in clinical decision-making and enhance patient R.S. Electronic health records: then, now, and in the future.Yearb Med Inform. 2016; Suppl 1: S48-S61https://doi.org/10.15265/IYS-2016-s006Crossref PubMed Scopus (382) Google et of clinical decision support and strategies for Med. PubMed Scopus Google Scholar These tools provide with support guide treatment recommendations on evidence-based and disease R.S. Electronic health records: then, now, and in the future.Yearb Med Inform. 2016; Suppl 1: S48-S61https://doi.org/10.15265/IYS-2016-s006Crossref PubMed Scopus (382) Google Scholar The benefits of these tools include patient to evidence-based and medical et of clinical decision support and strategies for Med. PubMed Scopus Google Scholar of the potential benefits that CDS tools can provide CDS tools have been integrated into et of clinical decision support and strategies for Med. PubMed Scopus Google Scholar There are several an EMR-integrated CDS tool not be et of clinical decision support and strategies for Med. PubMed Scopus Google decision support systems J Med Inform. PubMed Scopus Google C. et and to the use of clinical decision support systems in a Med. PubMed Scopus (0) Google Scholar These can include the of of patients and and the effectiveness of a tool of CDS tool et of clinical decision support and strategies for Med. PubMed Scopus Google decision support systems J Med Inform. PubMed Scopus Google et and to and using clinical decision support systems for a review and PubMed Scopus Google Scholar However, that with EMR-integrated CDS tools are the barriers to successful Research has that a of by EMR-integrated CDS tools are et of clinical decision support and strategies for Med. PubMed Scopus Google M. of clinical decision support systems by alert strategies and Health Inform. 2016; PubMed Scopus Google M. The of clinical decision support systems in clinical a Inform PubMed Scopus Google A. R.S. et to using clinical decision support in in health systems Am Med Inform Assoc. PubMed Google Scholar Furthermore, that a with a lack of in the as in et of clinical decision support and strategies for Med. PubMed Scopus Google M. of clinical decision support systems by alert strategies and Health Inform. 2016; PubMed Scopus Google M. The of clinical decision support systems in clinical a Inform PubMed Scopus Google L. L. et and to the of computerized clinical decision support systems in for a Sci. 2014; PubMed Google Scholar In the of the in of the in a et of clinical decision support and strategies for Med. PubMed Scopus Google M. The of clinical decision support systems in clinical a Inform PubMed Scopus Google L. L. et and to the of computerized clinical decision support systems in for a Sci. 2014; PubMed Google Scholar with can in alert M. of clinical decision support systems by alert strategies and Health Inform. 2016; PubMed Scopus Google Scholar One that be into the on their a is a which can be by on a not and a which can be on a S. of a clinical decision support system on clinical and 2013; PubMed Scopus (0) Google Scholar In can on the and their when of et of clinical decision support and strategies for Med. PubMed Scopus Google M. of clinical decision support systems by alert strategies and Health Inform. 2016; PubMed Scopus Google M. The of clinical decision support systems in clinical a Inform PubMed Scopus Google A. R.S. et to using clinical decision support in in health systems Am Med Inform Assoc. PubMed Google S. of a clinical decision support system on clinical and 2013; PubMed Scopus (0) Google Scholar an alert not be in of the be used to enhance the effectiveness of the et of clinical decision support and strategies for Med. PubMed Scopus Google S. of a clinical decision support system on clinical and 2013; PubMed Scopus (0) Google Scholar The effectiveness of EMR-integrated CDS tools the of the evidence used to et and to and using clinical decision support systems for a review and PubMed Scopus Google et decision support systems for the of evidence-based Am Med Inform Assoc. PubMed Scopus Google Scholar A evidence for EMR-integrated CDS tools is a in health care et of clinical decision support and strategies for Med. PubMed Scopus Google et decision support systems for the of evidence-based Am Med Inform Assoc. PubMed Scopus Google Scholar recommendations from which to clinical et decision support systems for the of evidence-based Am Med Inform Assoc. PubMed Scopus Google The of clinical in the medical PubMed Scopus Google Scholar the evidence CDS tools is of it can in for patient et decision support systems for the of evidence-based Am Med Inform Assoc. PubMed Scopus Google Scholar Furthermore, the evidence it can the of the CDS output to patient in the of care for et decision support systems for the of evidence-based Am Med Inform Assoc. PubMed Scopus Google The of clinical in the medical PubMed Scopus Google Scholar EMR-integrated CDS tools on data to their et decision support systems for the of evidence-based Am Med Inform Assoc. PubMed Scopus Google Scholar the of data can the of decision et decision support systems for the of evidence-based Am Med Inform Assoc. PubMed Scopus Google Scholar A CDS tool be designed for use at the point of it be for the tool to be in et decision support systems for the of evidence-based Am Med Inform Assoc. PubMed Scopus Google Scholar The lack of interoperability of EMR-integrated CDS tools is a that their ability to integrate into health care et of clinical decision support and strategies for Med. PubMed Scopus Google S. Electronic health record and Health PubMed Scopus Google and to a clinical decision support system in a a using the J Med Inform. Scopus Google M. and barriers to clinical decision support (CDS) and implementation in the for Research and CDS for Research accessed: August 11, 2023Google Scholar is as the ability of systems to and utilize data in an efficient and effective et of clinical decision support and strategies for Med. PubMed Scopus Google Scholar In the of EMR-integrated CDS tools, interoperability the of patient data between EMR systems and the CDS S. Electronic health record and Health PubMed Scopus Google M. and barriers to clinical decision support (CDS) and implementation in the for Research and CDS for Research accessed: August 11, 2023Google clinical decision support tools into care for and patient Published accessed: August 11, 2023Google Scholar a can use the CDS tool in an effective to recommendations and on the EMR data of the S. Electronic health record and Health PubMed Scopus Google Scholar One of the barriers to interoperability is the of standardized data EMR et of clinical decision support and strategies for Med. PubMed Scopus Google et and to and using clinical decision support systems for a review and PubMed Scopus Google C. et a for electronic health record at an medical Scopus Google Scholar Health care organizations utilize a EMR system that with its data and S. Electronic health record and Health PubMed Scopus Google C. et a for electronic health record at an medical Scopus Google clinical using clinical decision support a review of trials to identify to PubMed Google Scholar the in the data it for CDS tools to integrate seamlessly across the et and to and using clinical decision support systems for a review and PubMed Scopus Google clinical decision support tools into care for and patient Published accessed: August 11, 2023Google Scholar This is data are to be to the EMR system to output decision et of clinical decision support and strategies for Med. PubMed Scopus Google Scholar The lack of standardized EMR systems a to interoperability it the ability of the clinician to the patient data from the EMR system to into the CDS and that can to information in the clinical decision-making S. Electronic health record and Health PubMed Scopus Google Scholar The of EMR-integrated CDS tools on their of integration into clinical workflows. integration to the of CDS tools into clinical and that the tools are of into the of health care A. R.S. et to using clinical decision support in in health systems Am Med Inform Assoc. PubMed Google S. et for effective clinical decision support: making the of evidence-based a Am Med Inform Assoc. PubMed Scopus (0) Google Scholar Health care are in the integration of CDS their is to the efficient A. R.S. et to using clinical decision support in in health systems Am Med Inform Assoc. PubMed Google et clinical decision support into for Research and Published accessed: August 11, 2023Google S. et and in using a Clinical Decision for for a Med. PubMed Google Scholar are to their streamlined when care to their A. R.S. et to using clinical decision support in in health systems Am Med Inform Assoc. PubMed Google et clinical decision support into for Research and Published accessed: August 11, 2023Google Scholar the CDS tools that the of care, be an to the C. et and to the use of clinical decision support systems in a Med. PubMed Scopus (0) Google et clinical decision support into for Research and Published accessed: August 11, 2023Google Scholar This can in limited with the CDS tools, which their potential A. R.S. et to using clinical decision support in in health systems Am Med Inform Assoc. PubMed Google M. and barriers to clinical decision support (CDS) and implementation in the for Research and CDS for Research accessed: August 11, 2023Google et clinical decision support into for Research and Published accessed: August 11, 2023Google Scholar The lack of the to also to the of et of clinical decision support and strategies for Med. PubMed Scopus Google M. and barriers to clinical decision support (CDS) and implementation in the for Research and CDS for Research accessed: August 11, 2023Google Scholar be to to CDS tools their established CDS tools are as a to their decision-making M. and barriers to clinical decision support (CDS) and implementation in the for Research and CDS for Research accessed: August 11, 2023Google Scholar and are to these widespread acceptance of EMR-integrated CDS tools within et of clinical decision support and strategies for Med. PubMed Scopus Google Scholar have become one of many therapies for the of and the of et for the of for the of cardiovascular disease in the J 2016; Full Text Full Text PDF PubMed Scopus Google Scholar that patients with use to M. M. a from the development of a decision Med. PubMed Scopus (0) Google Scholar However, to treatment of patient M. M. a from the development of a decision Med. PubMed Scopus (0) Google et patients with treatment Med. PubMed Scopus Google et decision of the PubMed Scopus Google S. et approach to support for decision making for PubMed Scopus Google M. M. et in the use of the decision and decision in Med Inform 2017; PubMed Google Scholar The Statin Choice Decision Aid, developed by researchers at the in is an EMR-integrated CDS tool that is designed to health care providers in patients with M. M. a from the development of a decision Med. PubMed Scopus (0) Google et patients with treatment Med. PubMed Scopus Google The Choice decision in a PubMed Scopus (0) Google Statin decision accessed: August 11, 2023Google Scholar utilizing patient-specific data from the this decision by using one of the for Statin decision accessed: August 11, 2023Google Scholar such as and to the patient’s Statin decision accessed: August 11, 2023Google Scholar the decision the into for patients with a of is for patients with an between and and for patients with an et patients with treatment Med. PubMed Scopus Google The Choice decision in a PubMed Scopus (0) Google Statin decision accessed: August 11, 2023Google Scholar the to integrate the decision into EMR systems, it can using patient data, patients with and a of benefits for M. M. a from the development of a decision Med. PubMed Scopus (0) Google et patients with treatment Med. PubMed Scopus Google et decision of the PubMed Scopus Google The Choice decision in a PubMed Scopus (0) Google Scholar The integration of the Statin Choice Decision Aid within EMR systems is a notable of this CDS tool it also for more streamlined of continuity of care and between health care M. M. a from the development of a decision Med. PubMed Scopus (0) Google et patients with treatment Med. PubMed Scopus Google et decision of the PubMed Scopus Google S. et approach to support for decision making for PubMed Scopus Google The Choice decision in a PubMed Scopus (0) Google Scholar There are a of CDS tools that have been integrated into EMR systems, including for kidney disease et for a clinical decision support for the of with kidney J Am PubMed Scopus Google of in the and of kidney to kidney disease and kidney PubMed Scopus Google R. et of for disease on electronic health record big Google Scholar kidney M. M. et and initial implementation of electronic clinical decision for and of kidney Med Inform PubMed Google Scholar and of clinical decision support to care and of kidney disease Am Med. 2016; PubMed Scopus Google Scholar tools also including the Decision Aid for and the R. et of for disease on electronic health record big Google Scholar The KFRE, developed in is one such tool which the of kidney which kidney in and years in patients with et for of kidney disease to kidney PubMed Scopus (0) Google Kidney Failure Risk kidney accessed: August 11, 2023Google Scholar In its the and an also which of and et for of kidney disease to kidney PubMed Scopus (0) Google Kidney Failure Risk kidney accessed: August 11, 2023Google Scholar The within the with the of in are and in an EMR et kidney using electronic medical PubMed Scopus Google M. et of the kidney in J Kidney 2017; PubMed Scopus Google S. S. et kidney and care a Med. Full Text Full Text PDF PubMed Scopus Google Scholar of the of the and of the in the KFRE, it has been into EMR systems to support both clinical and research on CDS tool et for a clinical decision support for the of with kidney J Am PubMed Scopus Google et kidney using electronic medical PubMed Scopus Google M. et of the kidney in J Kidney 2017; PubMed Scopus Google et for using the kidney J Kidney 2017; Scopus Google Risk for kidney disease are and for 2017; PubMed Scopus (0) Google A. et of and in the care J Kidney Full Text Full Text PDF PubMed Scopus Google of kidney disease care a J Kidney PubMed Scopus Google the gap of to PubMed Scopus Google et of the kidney in a United Full Text Full Text PDF Scopus Google et of of for of kidney a 2016; PubMed Scopus (0) Google A. et of the kidney to clinical care of patients with kidney a PubMed Google A. et care for patients with kidney disease in the for a J Kidney PubMed Scopus Google et patients at the of kidney care a PubMed Scopus (0) Google et of the kidney for kidney disease in PubMed Google et Kidney Failure Risk Equation for of disease in an and clinical Med. PubMed Google et of an patient decision for kidney treatment PubMed Google Scholar its integration with EMR systems, can be improving the of patients at of kidney and improving et kidney using electronic medical PubMed Scopus Google M. et of the kidney in J Kidney 2017; PubMed Scopus Google S. S. et kidney and care a Med. Full Text Full Text PDF PubMed Scopus Google Risk for kidney disease are and for 2017; PubMed Scopus (0) Google the gap of to PubMed Scopus Google et of the kidney in a United Full Text Full Text PDF Scopus Google A. et of the kidney to clinical care of patients with kidney a PubMed Google et patients at the of kidney care a PubMed Scopus (0) Google et of an patient decision for kidney treatment PubMed Google A. et of using on of patients with kidney disease from care to care in the United Full Text Full Text PDF PubMed Scopus Google Scholar et kidney using electronic medical PubMed Scopus Google S. S. et kidney and care a Med. Full Text Full Text PDF PubMed Scopus Google Scholar have that into a CDS tool to providers to which is not the of and patient the is the widely used in and in clinical M. et of the kidney in J Kidney 2017; PubMed Scopus Google A. et of and in the care J Kidney Full Text Full Text PDF PubMed Scopus Google et of the kidney in a United Full Text Full Text PDF Scopus Google A. et of the kidney to clinical care of patients with kidney a PubMed Google A. et care for patients with kidney disease in the for a J Kidney PubMed Scopus Google et patients at the of kidney care a PubMed Scopus (0) Google et of the kidney for kidney disease in PubMed Google et Kidney Failure Risk Equation for of disease in an and clinical Med. PubMed Google et of the kidney in a PubMed Google et of the kidney in an PubMed Scopus Google L. A. et kidney kidney in an PubMed Google A of the kidney in kidney disease to disease with of and clinical PubMed Google C. A. et disease and of the kidney in a Kidney a PubMed Google Scholar However, patients with and at of kidney disease care and disease their care et for a clinical decision support for the of with kidney J Am PubMed Scopus Google of clinical decision support to care and of kidney disease Am Med. 2016; PubMed Scopus Google et for of kidney disease to kidney PubMed Scopus (0) Google M. et of the kidney in J Kidney 2017; PubMed Scopus Google A. et of and in the care J Kidney Full Text Full Text PDF PubMed Scopus Google et of the kidney in a United Full Text Full Text PDF Scopus Google A. et of the kidney to clinical care of patients with kidney a PubMed Google A. et care for patients with kidney disease in the for a J Kidney PubMed Scopus Google et Kidney Failure Risk Equation for of disease in an and clinical Med. PubMed Google et of kidney disease in PubMed Google tools and lessons from a decision support in Med. Full Text Full Text PDF Scopus Google Scholar these patients with treatment of their limited of its treatment and poor clinical et of clinical decision support and strategies for Med.