title: Informatics as tool for quality improvement: rapid implementation of guidance for the management of chronic kidney disease in England as an exemplar.
abstract: OBJECTIVE
  Chronic kidney disease (CKD) is an important cause of excess cardiovascular mortality and morbidity; as well as being associated with progression to end stage renal disease. This condition was largely unheard of in English primary care prior to the introduction of pay-for-performance targets for management in 2006. A realist review of how informatics has been a mechanism for national implementation of guidance for the improved management of CKD.
  
  
  METHODS
  Realist review of context, the English National Health Service with a drive to implement explicit national quality standards; mechanism, the informatics infrastructure and its alignment with policy objectives; and outcomes are describe at the micro-data and messaging, meso-patient care and quality improvement initiatives, and marco-national policy levels.
  
  
  RESULTS
  At the micro-level computerised medical records can be used to reliably identify people with CKD; though differences in creatinine assays, fluctuation in renal function, and errors in diabetes coding were less well understood. At the meso-level more aggressive management of blood pressure (BP) in individual patients appears to slow or reverse decline in renal function; technology can support case finding and quality improvement at the general practice level. At the macro-level informaticians can help ensure that leverage from informatics is incorporated in policy, and ecological investigations inform if there is any association with improved health outcomes.
  
  
  CONCLUSIONS
  In the right policy context informatics appears to be an enabler of rapid quality improvement. However, a causal relationship or generalisability of these findings has not been demonstrated.
authors.affiliation: Department of Health Care Management and Policy, University of Surrey, Guildford, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: de Lusignan
keywords: Computerized Medical Records Systems; Diabetes Mellitus; Health Policy; Kidney Function Tests; Medical Informatics; Quality of Health Care; Renal Insufficiency