A lack of efficient coordination when caring for kidney disease can result in delayed treatment and missed opportunities for early intervention, highlighting the need for tools that more efficiently evaluate patients with early signs of the disease, explains Melissa L. Swee, MD, MME. A potential solution for this problem is to use telemedicine dashboards that are designed to proactively identify and manage kidney disease—or telenephrology. “With the COVID-19 pandemic still raging, nephrologists and other physicians need to know how they can best incorporate telemedicine into their practices,” says Dr. Swee.

The Iowa City VA Health Care System serves more than 184,000 veterans living in mostly rural areas of Eastern Iowa, Western Illinois, and Northern Missouri. The hospital and specialized clinics—including nephrology—are headquartered in Iowa City, but another 10 community-based outpatient clinics (CBOCs) in Iowa and Illinois also deliver primary care. When specialist services are required, patients are referred to the Iowa City clinics or receive care outside the VA system. This can disrupt coordination of care between primary care practitioners (PCPs) and nephrologists.

Improving Quality

Dr. Swee and colleagues developed a quality improvement initiative to facilitate coordination of care using a telenephrology dashboard. For a study published in BMC Nephrology, they assessed charts of 53,085 veterans at risk for kidney disease in four CBOCs from the Iowa City VA from 2017 to 2019. “Our paper described the methods we used to incorporate telemedicine into our clinics,” Dr. Swee says. “We also actively searched our VA systems to ensure these patients were being followed by specialists for their laboratory results.”

For the study, data on 1,384 veterans at these CBOCs—459 of whom generated telenephrology consults—were analyzed by the telenephrology dashboard. The number of telenephrology and other electronic consultation methods consistently outpaced traditional face-to-face consultations starting in March 2018, when the team began using the dashboard (Figure). “We were able to reliably identify patients early in their disease before it was too late to save their kidneys,” says Dr. Swee. In addition, the study demonstrated that the average patient saved between $21.60 to $63.90 per trip to Iowa City. Furthermore, fewer steps were needed to complete the consult, demonstrating savings of time.

Key Implications

The study provides important implications for PCPs and nephrologists as healthcare systems continue to be compelled to improve value and reduce waste, according to Dr. Swee. “Our analysis shows we can save patients time and money by providing specialist expertise up front, which is especially important for rural veterans,” she says. “We provide a blueprint for how to care for patients who lack access to specialist care. Using the telenephrology dashboard, we can work behind the scenes to uphold kidney health, which in turn can ensure every effort is being made to preserve the kidneys.”

The study group notes that the dashboard is simple, scalable, and flexible for monitoring kidney disease. By using systematic methods to evaluate user needs and desires, the dashboard program can be easily integrated into the clinical environment and workflows. “Although results will vary by location, we’ve provided ample information on the tools we developed so other providers can develop their own telemedicine dashboards,” says Dr. Swee.

A multidisciplinary team representing interests of various stakeholders is essential to ensuring success with a telenephrology dashboard, adds Dr. Swee. “Our project highlights the need for multidisciplinary collaboration between physicians, nurses, schedulers, and patients to make changes in systems that benefit everyone,” she notes. Ideally, stakeholders will go beyond nephrologists and PCPs to include nephrology and primary care case managers to better understand back-office processes for consultations. Projects of this scale require close coordination and proactive planning.

Future Research

The research team is continuing to adapt its telenephrology intervention for wider scale implementation in all 10 CBOCs in the Iowa City VA, but Dr. Swee says longer-term studies are needed. “We implemented the dashboard about 2 years ago, but we’re still collecting data on whether it helps delay kidney disease progression,” she says. “While our short-term results are promising, we look forward to determining if this approach will translate over the long term.”