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Chronic Kidney Disease (CKD)

ESRD Prevention Program




chronic Kidney disease patient engagement system

Doctors often don't test for chronic kidney disease (CKD) and patients may have no symptoms until they are in crisis. Too often, CKD is neither detected nor treated. It is no wonder kidney disease is becoming one of America's most dangerous and most costly health issues and that public health experts are urging more screening for Americans age 60 and older.

PES confronts the challenge posed by kidney disease in three ways.

Identification: Kidney Disease Identification and Surveillance System

Because as many as 50 percent or more of the CKD patients in primary care are undiagnosed, the Kidney Disease Identification and Surveillance System monitors the key laboratory studies that indicate renal damage.The System provides a population view of both acute and chronic kidney disease for quality improvement, care planning, and correct billing (essential for Medicare Advantage).


  • Automatically identify patients.
  • Create opportunities for personalized communications.
  • Benefit from early stage detection.
  • Avoid or delay onset of ESRD.
  • Improve HCC coding.


management: Kidney Disease Engagement and Outreach System

Kidney disease, especially CKD, is a complex management problem for primary care physicians, yet as many as 10 percent of all adults are afflicted. Referral of so many patients to kidney specialists is just not possible.

The PES Kidney Disease Engagement and Outreach System provides point-of-care decision support to primary care providers for their patients with both acute and chronic kidney disease. Based on international clinical guidelines, the system monitors laboratory results and other medical information on a daily basis and alerts the practice to order tests, modify management, or refer to specialists when appropriate. It also reaches out to patients from their provider to return for testing and care. This system helps PCPs manage all stages of acute and chronic kidney disease from mild damage through referral for renal replacement therapy. It also helps manage many of the common and confusing complications of CKD such as anemia and electrolyte disturbances.

These are examples of communications sent to patients and to providers:

Patient Communications   Provider Communications

Invitation Letter, Alerts, and Reminders

  Flow Sheets, Work Lists, Queries, Population Reports

prevention: delaying End-Stage Renal Disease (ESRD)

End Stage Renal Disease (ESRD) is among the most destructive and expensive problems facing our patients today. With increasing incidence and no cures available, prevention remains the most effective and cost-effective strategy for management. 

According to the American Society of Nephrology, kidney disease can be slowed and the transition to dialysis delayed if it is detected early in its progression. The PES ESRD Prevention Program uses proprietary technology including automated physician-patient engagement, analytics, and decision support tools to identify patients with undiagnosed chronic kidney disease and tools to monitor them in order to prevent or delay the progression to ESRD.

The PES ESRD Prevention Program continuously monitors your population of patients to identify new, early cases and to intervene on established cases to prevent progression. CKD patients are assigned to their PCP and receive all the benefits of the Kidney Disease Engagement and Outreach Program to mitigate the damage done, prevent or delay progression and minimize the personal, financial and societal impacts of renal failure.


  • At the end of 2009, more than 871,000 people were being treated for ESRD.
  • Between 1980 and 2009, the prevalence of ESRD increased nearly 600 percent, from 290 to 1,738 cases per million.
Source: National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC)





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