Initial Implementation of a Web-Based Consultation Process for Patients With Chronic Kidney Disease

Nynke D. Scherpbier-de Haan; Vincent A. van Gelder; Chris Van Weel; Gerald M. M. Vervoort; Jack F. M. Wetzels; Wim J. C. de Grauw

doi:10.1370/afm.1494

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E-consultation for Nephrogy and other chronic disease specialties in Bradford UK
John Stoves

Published on: 08 July 2013
Author response: learning effect of telenephrology
Nynke D. Scherpbier-de Haan

Published on: 26 March 2013
Formalising consultant contact
Helen Atherton

Published on: 25 March 2013
Chronic kidney disease management using joined up IT really works!
Hugh C Rayner

Published on: 21 March 2013
Will the provision of advice change future patterns of GP referral?
Simon de Lusignan

Published on: 21 March 2013

Published on: (8 July 2013)
Page navigation anchor for E-consultation for Nephrogy and other chronic disease specialties in Bradford UK
E-consultation for Nephrogy and other chronic disease specialties in Bradford UK
John Stoves, Consultant Nephrologist
Other Contributors:
We read with interest the reported benefits of a nephrology e- consultation service in the Netherlands. As discussed by the authors, these findings are very similar to those of our original evaluation of an e-consultation service in Bradford, UK. There is certainly a growing interest in telenephrology as a means of improving care for patients with chronic kidney disease (Nephrol Dial Transplant 3013 28:972-981). We would...
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We read with interest the reported benefits of a nephrology e- consultation service in the Netherlands. As discussed by the authors, these findings are very similar to those of our original evaluation of an e-consultation service in Bradford, UK. There is certainly a growing interest in telenephrology as a means of improving care for patients with chronic kidney disease (Nephrol Dial Transplant 3013 28:972-981). We would like to comment on certain aspects of the study in the Netherlands and also give a short summary of developments in our own service over the last few years.
1. Exporting and importing data from the primary care electronic patient record
A major benefit of record sharing is that primary care physicians do not need to consider which clinical information is important to the nephrologist, providing the opportunity for a more complete assessment (our data sharing model allows the primary care physician to block sensitive clinical information from view). A 'renal digest' of the primary care record may not include all of the clinical information that would influence the opinion of the specialist, for example the availability of a chronological medication record may readily establish an association between treatment changes and a decline in eGFR. Graphical trends in other data such as blood pressure and urinalysis may also be helpful, and the ability to browse through previous imaging reports and clinical correspondence from the primary care team and other specialties (such as cardiology, diabetes and elderly care) is of great value. The advice given by the nephrologist is recorded directly in the patient's primary care record, avoiding the need for exporting and importing data. A task notification is sent to alert the primary care physician that the record has been updated.
2. Security of information
To clarify, all clinical data and electronic messages between clinicians are contained entirely within the clinical record which satisfies information governance requirements. No information is sent by email and nothing is accessible through web browsers.
3. The e-consultation service in Bradford and Airedale
The number of new clinic appointments for patients with chronic kidney disease has reduced over the last 5 years, and referral patterns for 'early adopter' practices and 'late adopter' practices show an initial reduction in referrals from 'early adopter' practices followed by a similar reduction in referrals from 'late adopter' practices. The e-consultation service has been streamlined to make it easier to request specialist advice, with linkage to e-guidance and a set of Frequently Asked Questions. The service has also been expanded to include other chronic disease medical specialties including diabetes, endocrinology and cardiology. This has produced an exponential curve in total e-consultation activity within the region. Within nephrology, we hace established a Renal Hub in the local primary care record system to improve communication with community teams for patients with more advanced renal disease (particular benefits including better medicines reconciliation and more effective coordination of pathways such as anaemia management, hepatitis B vaccination and conservative care). Finally, centralised changes to the structure of the primary care electronic record system will soon make it possible for all primary care teams to access existing e-consultation services including those that are provided by specialists in other parts of the UK.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (26 March 2013)
Page navigation anchor for Author response: learning effect of telenephrology
Author response: learning effect of telenephrology
Nynke D. Scherpbier-de Haan, General practitioner.
Other Contributors:
Dear colleague de Lusignan,
Thank you for your reaction on our article 'Initial implementation of a web-based consultation process for patients with chronic kidney disease.' Indeed, we agree, a study on the learning effect of telenephrology would be very interesting and important. A rise in knowledge and confidence will probably lead to a more adequate referral pattern. At least as important is the effect of tel...
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Dear colleague de Lusignan,
Thank you for your reaction on our article 'Initial implementation of a web-based consultation process for patients with chronic kidney disease.' Indeed, we agree, a study on the learning effect of telenephrology would be very interesting and important. A rise in knowledge and confidence will probably lead to a more adequate referral pattern. At least as important is the effect of teleconsultation on quality of care. We performed a cluster randomised trial in 47 general practices on the effect of telenephrology on referral rate and quality of care (CONTACT study: Consultation Of Nephrology by Telenephrology Allows optimal Chronic kidney disease Treatment in general practice, Netherlands Trial Register 2368). We hope to publish the results in the coming year. We are glad to hear that the educational intervention in the QICKD study had a positive effect on blood pressure control in CKD patients. We are about to publish results on our SHARING study (Shared care for patients with chronic kidney disease in nephrology and general practice). A shared care model between general practitioner, nurse practitioner and nephrologist led to increased quality of care in primary care CKD patients. The intervention was multifaceted and consisted of educational interventions for general practitioners and nurse practitioners, and delegation of tasks to the nurse practitioner. Consultation of a nephrologist or nephrology nurse was part of the model. We agree with you that teleconsultation may be of value for other specialties as well, and could empower primary care by transferring secondary care knowledge to the primary care setting.
Nynke Scherpbier-de Haan, Vincent van Gelder, Chris van Weel, Gerald Vervoort, Jack Wetzels, Wim de Grauw.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (25 March 2013)
Page navigation anchor for Formalising consultant contact
Formalising consultant contact
Helen Atherton, Research Fellow
This study utilises a web-based system in formalising the contact between primary care and secondary care physicians. As well as demonstrating an effect on clinical outcomes, it shows that it is possible to formalise this contact, pulling information through from the electronic health record and providing an interface for entering/providing information relating to individual patients. The security and clinical safety this...
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This study utilises a web-based system in formalising the contact between primary care and secondary care physicians. As well as demonstrating an effect on clinical outcomes, it shows that it is possible to formalise this contact, pulling information through from the electronic health record and providing an interface for entering/providing information relating to individual patients. The security and clinical safety this offers is superior to the informal email contact that routinely occurs between primary and secondary care physicians when deciding whether to refer a patient on or manage them in primary care.
Systems such as this should be considered for all contact between primary care and secondary care consultants in relation to referral. There is much work to do in testing and trialling such systems, but a real opportunity to utilise ICT in a positive way for primary care. This study represents a promising start.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (21 March 2013)
Page navigation anchor for Chronic kidney disease management using joined up IT really works!
Chronic kidney disease management using joined up IT really works!
Hugh C Rayner, Consultant Nephrologist
It is good to see another example of the benefits of electronically integrated care for patients with CKD. Nephrology Is particularly well suited to this way of working as it is commonly possible to provide useful advice and guidance based upon patient-related data without the patient being present. We have seen a dramatic improvement in the standard of primary care of patients with CKD in the UK over recent years. By focussing o...
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It is good to see another example of the benefits of electronically integrated care for patients with CKD. Nephrology Is particularly well suited to this way of working as it is commonly possible to provide useful advice and guidance based upon patient-related data without the patient being present. We have seen a dramatic improvement in the standard of primary care of patients with CKD in the UK over recent years. By focussing on patients at high risk of ESRD, identifying them from registers and databases that track eGFR and proteinuria, the number patients reaching end-stage has declined in our service since 2005. https://www.dropbox.com/s/imp37fxxpyu2kwj/Number of patients starting kidney replacement therapy per.pdf Thanks to improved integration of primary and secondary care this has been achieved without an increase in specialist nephrology resources. The previous care of every patient starting dialysis should be reviewed, looking for opportunities to prevent loss of kidney function that were missed and for ways that the system of care could be improved.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (21 March 2013)
Page navigation anchor for Will the provision of advice change future patterns of GP referral?
Will the provision of advice change future patterns of GP referral?
Simon de Lusignan, Professor of Primary Care and Clinical Informatics
I enjoyed reading this interesting and well conducted study [1]. It would be interesting to know the extent to which learning took place over time and if this might affect long term referral?
We found as part of a diagnostic analysis prior to commencing the Quality Improvement in Chronic Kidney Disease (QICKD) Trial that practitioners had disparate views about CKD, were not certain it was a disease and that they woul...
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I enjoyed reading this interesting and well conducted study [1]. It would be interesting to know the extent to which learning took place over time and if this might affect long term referral?
We found as part of a diagnostic analysis prior to commencing the Quality Improvement in Chronic Kidney Disease (QICKD) Trial that practitioners had disparate views about CKD, were not certain it was a disease and that they would have difficulty explaining this to patients [2,3]. The latter point appears to remain problematic, with many patients remaining unaware of their diagnosis [4].
We hypothesised that lower levels of knowledge and confidence are associated suboptimal quality of care. Pointers towards this come from demonstrating that practices with lower levels of confidence in managing CKD are associated with suboptimal care (though we can’t be certain, as we are comparing individual clinician reported confidence with performance measured at the practice level); and the QICKD cluster randomised trial will report that an educational intervention results in a modest reduction in systolic BP, and an increase in the proportion reaching BP target in people with CKD with sub-optimally controlled BP [5,6].
If this hypothesis is correct it may be worth exploring over time whether there is a training effect from these specialist-GP consultations and if GP confidence and willingness to manage CKD in primary care improves and the numbers of referral falls? I would be interested to hear the authors’ thoughts as to the gap this process fills, as CKD is a recently recognised condition [7]. Possibly the findings may be more generaliseable to other newly recognised conditions or when management is complex or guidlines changed?
References:
[1] Scherpbier-de Haan ND, van Gelder VA, Van Weel C, Vervoort GM, Wetzels JF, de Grauw WJ. Initial implementation of a web-based consultation process for patients with chronic kidney disease. Ann Fam Med. 2013;11(2):151-6. doi:10.1370/afm.1494.
[2] Crinson I, Gallagher H, Thomas N, de Lusignan S. How ready is general practice to improve quality in chronic kidney disease? A diagnostic analysis. Br J Gen Pract. 2010;60(575):403-9. doi: 10.3399/bjgp10X502100.
[3] de Lusignan S, Gallagher H, Chan T, Thomas N, van Vlymen J, Nation M, Jain N, Tahir A, du Bois E, Crinson I, Hague N, Reid F, Harris K. The QICKD study protocol: a cluster randomised trial to compare quality improvement interventions to lower systolic BP in chronic kidney disease (CKD) in primary care. Implement Sci. 2009 Jul 14;4:39. doi: 10.1186/1748-5908-4-39.
[4] McIntyre NJ, Fluck R, McIntyre C, Taal M. Treatment needs and diagnosis awareness in primary care patients with chronic kidney disease. Br J Gen Pract. 2012;62(597):e227-32. doi: 10.3399/bjgp12X636047.
[5] Tahir MA, Dmitrieva O, de Lusignan S, van Vlymen J, Chan T, Golmohamad R, Harris K, Tomson C, Thomas N, Gallagher H. Confidence and quality in managing CKD compared with other cardiovascular diseases and diabetes mellitus: a linked study of questionnaire and routine primary care data. BMC Fam Pract. 2011 Aug 5;12:83. doi: 10.1186/1471-2296-12-83.
[6] de Lusignan S, Gallagher H, Jones S, Chan T, van Vlymen J, Tahir A, Thomas N, Jain N, Dmitrieva O, Rafi I, McGovern A, Harris K. Audit-based education lowers systolic blood pressure in chronic kidney disease based on quality improvement in CKD (QICKD) trial results. Accepted for Publication Kidney International, 13th January 2013, Ref: KI-06-12-0863.R3
[7] Gomez GB, de Lusignan S, Gallagher H. Chronic kidney disease: a new priority for primary care. Br J Gen Pract. 2006 Dec;56(533):908-10.
Competing interests: Recent funded research for a Cluster Randomised trial in CKD. Current (from 1/4/2013) NIHR funded project looking at anaemia management in CKD.
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Competing Interests: None declared.