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For kidney and chronic care programs
See the trend, not just the last result.
For value-based kidney care and chronic disease programs. HSRMed puts home stability next to eGFR and uACR over time, finds patients who are declining fast or missing tests, and helps teams act months earlier.
- Risk map of your population by eGFR and uACR category
- Fast-decline worklist for patients losing kidney function quickly
- Testing gaps: patients with diabetes missing a kidney panel
- Chronic programs: diabetes, hypertension, heart failure and COPD
The challenge
Chronic disease moves slowly, until it does not
Kidney disease is often silent until late. Many patients start dialysis without having seen a kidney specialist in time.
Silent progression
Kidney function can decline for years without symptoms, and lab results are reviewed one at a time.
Missed testing
Many patients with diabetes do not have both eGFR and uACR tested every year, so risk goes unseen.
Value-based contracts
Kidney care and chronic care programs are paid on outcomes, and need population trends, not single visits.
Sample screen
Kidney risk map, trends and worklist
The view a kidney care program uses to decide where to focus each week.
Population by kidney risk
1,220 patients with diabetes or hypertension · eGFR × uACR categories
| eGFR category | A1 <30 mg/g | A2 30–300 | A3 >300 |
|---|---|---|---|
| G1 · 90+ | 210 | 42 | 9 |
| G2 · 60–89 | 318 | 88 | 21 |
| G3a · 45–59 | 164 | 71 | 26 |
| G3b · 30–44 | 82 | 49 | 31 |
| G4 · 15–29 | 28 | 24 | 30 |
| G5 · <15 | 6 | 8 | 13 |
Mary Johnson · 12-month view
Home stability and lab results side by side
| Patient | Stage | eGFR, 12 months | uACR, 12 months | HSI | Last kidney panel | Next step |
|---|---|---|---|---|---|---|
| Mary Johnson | G3a A2 | 58 → 47 −9 | 60 → 162 | 63 | 3 weeks ago | Nephrology referral; review medications |
| Carlos Rivera | G3b A3 | 41 → 35 −6 | 380 → 520 | 59 | 2 months ago | Approaching G4: plan with nephrology |
| Betty Lawson | G2 A2 | 72 → 70 −2 | 45 → 58 | 75 | 14 months ago | Kidney panel overdue |
| Ahmed Hassan | G3a A1 | 52 → 51 −1 | 18 → 20 | 77 | 5 months ago | Stable; routine follow-up |
| Joyce Martin | G4 A3 | 28 → 24 −4 | 610 → 700 | 56 | 1 month ago | Kidney care team: education and planning |
| Peter Novak | G2 A1 | 80 → 80 0 | 12 → 11 | 82 | 16 months ago | Kidney panel overdue (diabetes) |
What HSRMed delivers
Built for kidney and chronic care programs
Population risk map
Every patient placed by eGFR and uACR category, with counts you can click into.
Long-term trends
HSI, eGFR and uACR over months and years in one view, so slow decline becomes visible.
Worklists
Fast decline, approaching stage 4, and testing gaps, refreshed as new labs arrive.
Chronic care programs
The same approach for diabetes, hypertension, heart failure and COPD, with home data between visits.
Lab and EHR integration
Lab results flow in through HL7 FHIR; tasks and referrals go back to the care team.
Contract reporting
Population measures for value-based kidney care and chronic care contracts.
How it works
From population to patient
Connect lab and EHR data
eGFR, uACR and other results are loaded for the program population.
Map the risk
Patients are placed by category and trend; fast decliners and testing gaps are listed.
Add home monitoring
Enrolled patients send daily data, and HSI shows stability between lab draws.
Act and report
Care teams work the lists; leaders track progress against contract measures.
What you can measure
Program measures
Questions
Questions from kidney and chronic care teams
Does HSRMed measure kidney function?
HSRMed displays eGFR and uACR from laboratory results and places them next to home monitoring trends. It does not replace laboratory testing or diagnose kidney disease.
Which categories do you use?
The risk map follows the widely used eGFR (G1 to G5) and albuminuria (A1 to A3) categories, so it matches how kidney teams already think.
Can we use it for other chronic conditions?
Yes. Diabetes, hypertension, heart failure and COPD programs use the same trends, worklists and reporting.
Who uses this view?
Nephrology practices, kidney care organizations, primary care groups and health plans running chronic care programs.
Map your kidney care population
See the risk map and worklists with sample data, then plan a pilot.
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