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Telemedicine has significant potential to extend nephrology consultation to rural and isolated communities. We describe a telenephrology clinic which has delivered ongoing consultative care from a nephrologist based at the National Institutes of Health in Bethesda Maryland to the Zuni Comprehensive Health Center in western New Mexico. Over the past nine years the clinic has conducted 1870 patient visits managing patients using a collaborative approach engaging a nurse case manager, nephrologist, primary clinicians, pharmacists, and community health nurses. A significant proportion of the care provided is directed towards patients with advanced kidney disease (eGFR< 30ml/min/1.73m2). While there are unique aspects to the Indian Health Service and to the Zuni community which is served by this clinic, it does serve as a demonstration that nephrologic consultative care can be delivered effectively and efficiently to rural high risk communities using a collaborative and integrated model of care.
Utilizing telemedicine to provide direct consultation to people with chronic kidney disease (CKD) would seem to be an obvious way to deliver care to patients with decreased access to specialty care, particularly rural underserved populations. Nephrologic consultation often is based largely on laboratory assessment, and the patient interaction is often centered around disease education and explanation of treatment choices. Thus, much of what transpires in an in-person interaction could be conducted through a video interaction. Telehealth has the potential to deliver more cost effective care1 and to improve outcomes2. Regardless of cost-effectiveness3, in many settings the alternative to telemedicine may be no care. Lack of nephrology consultation has been recognized as a barrier to improved outcomes even for patients without a geographic barrier to access4.
Published descriptions of direct consultative care of CKD patients are few and generally describe small numbers of patients with early disease managed over a relatively short period of time. Two reports describe approaches to consultation which do not involve direct video interaction between nephrologist and patient; Scherpbier-deHaan5 developed a system of consultation with family physicians based on review of electronically transmitted data, while Fernandes provided patient evaluation through exchange of digital messages between nephrologist and patient6. Mark et al conducted a retrospective review of care provided to 427 patients through a virtual renal clinic in Northern Ireland7 and calculated savings of £111.6 per visit. However, the focus of the virtual clinic was on patients considered less likely to progress based on eGFR, change in eGFR, and proteinuria. Feasibility and patient satisfaction were assessed at two CKD telemedicine clinics which provided follow-up care through two nurses at remote sites and a nephrologist and nurse practitioner at an Ottowa hospital8. (Initial consults were all done in person.) Patient, nurse and nephrologist satisfaction was high. Seventy seven percent of the patients agreed with the statement “I feel as confident about the doctor’s assessment as I would with an in-person assessment.” Ishani and an interdisciplinary team followed 451 veterans with eGFR< 60 (mean eGFR 37) in the Minneapolis Veterans Affairs (VA) Health Care System and found equivalent outcomes to 150 patients followed in a conventional clinic9. The intervention included a home monitoring device for reporting vital signs as well as virtual video visits at home. A retrospective observational study by Rohatgi followed 238 patients enrolled in a telenephrology program at the Bronx VA Hospital, 121 who lived within ten miles of the Medical Center and 117 who lived an average of 64 miles away10. Providing care through telemedicine improved attendance at appointments for the patients living at distance to the hospital.
Indian Health Service (IHS) is an agency of the Department of Health and Human Services that provides comprehensive health care to American Indians and Alaska Natives (AI/AN) with the mission to raise their health status to the highest possible level11. In 2015 IHS served a population of 2.2 million people from 566 tribes. The 2015 budget appropriation of $4.6 million represented a per capita expenditure of $3099, compared to $8097 per capita for the to US population12. Care is delivered through both federal and tribal facilities including 46 hospitals, 344 health centers, 150 Alaska Village Clinics, and 105 health stations. During fiscal year 2013 (October 2012 through September 2013) this system experienced 70,000 admissions and provided 14 million outpatient visits. In addition, the Community Health Representative Program provides significant support for chronic disease management to patients at home and in the community. Disparities in health status persist among AI/AN people resulting in a life expectancy that is 4.4 years less than the US population resulting from higher death rates due to diabetes, liver disease and unintentional injuries13. Diabetes affects 15.9% of the adult population and prevalence of associated complications among AI/AN is high. However, incidence rates of ESRD among AI/AN people with diabetes have decreased significantly over the past fifteen years in association with widespread implementation of a comprehensive diabetes management effort14 which includes a focus on diabetic kidney disease 15.
IHS has a long history of using health information technology to improve access and quality of care for the rural communities that it serves.16 There is no nationally coordinated telehealth program but extensive programs have developed in several areas, particularly behavioral health, cardiology, ophthalmology, and otorhinolaryngology17.
Zuni Pueblo is a rural community located in western New Mexico 150 miles west of Albuquerque with a population of approximately 10,000 people. In 2010, per capita income was $10,792 (2010–2014).18 The IHS Zuni-Ramah Service Unit includes the Pueblo of Zuni and nearby Navajo Communities with a total service population of approximately 14,000. The Zuni IHS is within a Rural Health Professional Shortage Area. The Zuni Comprehensive Health Center is licensed for 37 beds but is able to maintain 18 beds due to a nursing shortage. The facility includes 22 outpatient exam rooms, a high complexity laboratory, and radiology including ultrasound and CT. Adjacent to the hospital is a privately owned and operated dialysis unit with 31 stations and a census on 15 July 2016 of 132 patients. The IHS medical staff includes 13 physicians and two nurse practitioners. The “user population,” individuals who received care at the Zuni Hospital, included 11,261 individuals during 2012–2015. During fiscal year 2015 the Zuni facility experienced 107,042 outpatient visits and had 330 discharges including 64 newborn discharges. Average length of stay was 4.1 days.
As with other native communities in the United States, Zuni Pueblo has high rates of diabetes and diabetic kidney disease. The Diabetes registry of Zuni Hospital includes approximately 1600 individuals of the total service population of 14000. In 2002 the prevalence of ESRD, adjusted for age and gender, was six times the prevalence for all AI/AN and 21 times higher than the rate for European Americans19. In response to the high burden of kidney disease in Zuni, an IHS nephrologist conducted a weekly interdisciplinary CKD Clinic at the Zuni Hospital from 1989–2006. After this nephrologist relocated to the National Institutes of Health in Bethesda, Maryland, an effort was made to continue providing care for patients via telemedicine. The NIH Center for Information Technology, working with the IHS’s Office of Information Technology, established a telehealth link allowing the nephrologist at the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) to consult with patients beginning in 2007. NIDDK used a Tandberg 6000 video-conference system with an encrypted ISDN videoconference connection (384 kbps, H.320, AES encryption) to a Polycom MGC100 video bridge at the IHS Video Technology Support Center in Sioux Falls, SD. From there, a secure IP-based video connection (384 kbps, H.323, AES encryption) is established to a Polycom VSX 7000 video-conference system at the Zuni Indian Hospital. In 2016, the NIH equipment was upgraded to a Cisco Telepresence EX90 connecting to Zuni over the IP network via H.323/SIP protocol. An exam room at Zuni Hospital was utilized for the clinic. The equipment at the NIH was on a movable cart and used in the nephrologist’s office. One wall of the office was painted blue to serve as a backdrop for the video image.
From 2007 through May 2016, clinics were generally conducted two days each month. Most of the patients came from the immediate community of Zuni pueblo. Additional patients came from the Navajo communities nearby. Yearly clinic visits were about 200 per year with a total 1870 telenephrology patient visits documented during the nine year period. Clinical data on all the patients seen in the telemedicine clinic are not easily retrievable, but review of all patients seen in the first five months of 2016 reflects the level of illness managed through the clinic. From Jan 1 through May 31 2016, there were 95 patient encounters with 64 patients. Thirty-nine (60.9%) of the patients were women. Patients ranged from 18 to 85 years old, mean age 63.1 years. There were ten (10.5%) new evaluations and 85 (89.5%) follow-up visits. Etiology of kidney disease was attributed to diabetes in 51 of the 64 patients (79.6%). eGFR was > 60 ml/1.73m2 for 15 patient visits (15.7%), 45–59 ml/1.73m2 for 11 visits (11.6%), 30–44 ml/1.73m2 for 11 visits (11.6%), 15–29 ml/1.73m2 for 40 visits (42.1%) and <15 ml/1.73m2 for 18 visits (18.9%). Most clinic visits (60%) were for management of CKD in patients with eGFR less than 30 ml/min/1.73m2. During the nine year history of the clinic, 44 patients were referred for initiation of dialysis and two died. Zuni IHS billed third parties for 1026 of the 1746 visits; the amount billed was $193,604 and the amount received from payers was $149,71920.
The clinic is organized and managed by an RN case manager from the Zuni Public Health Nursing Department. Initially, this was the nurse who worked in the onsite clinic conducted between 1989 and 2006. She mentored her replacement, who has managed the clinic since 2009. In addition to the case manager, diabetes educators, dietitians, and primary clinicians are easily available for consultation, during the clinic, if necessary (i.e., curbside consults are available even during a telemedicine clinic). Most clinics include the active participation of a PharmD student in the last year of training on a two-month rotation at Zuni.
Zuni Hospital strives to provide continuity of care for patients by assigning each patient to a primary clinician and a team. Any clinician may refer a patient for a telenephrology consultation based on the patient’s status and the clinician’s comfort in managing the patient. There is no eGFR threshold which must be met or at which a patient must be referred. Referring clinicians are strongly urged to complete a one-page referral developed by the National Kidney Disease Education Program21 and incorporated within the Zuni electronic health record (EHR). The referral form includes basic information on presence of diabetes, eGFR trends, albuminuria, patient knowledge, screening labs and medications. Much of the form is pre-filled by the EHR. New referrals are screened by the nurse manager and screening labs which have not been completed are ordered. If there is a question about the referral the nurse manager will discuss with the referring provider. Follow-up appointments can be scheduled by nephrologist, referring provider, or case manager. Return visits are pre-screened and follow-up labs and imaging studies are ordered and obtained prior to the visit. The nephrologist reviews all labs and other studies which he orders.
On clinic day, patients are screened by outpatient staff and medicine reconciliation is performed by the pharmacy student prior to entering the exam room. The nurse manager is in the room with the patient during the entire visit, allowing her to raise issues that may have become apparent “off-screen” or which require clarification by the nephrologist. The nurse manager also provides translation for those patients who prefer to communicate in Zuni. Visits generally last 15–45 minutes. Following the visit, the nurse manager assures a follow-up appointment is scheduled and may recheck the patient or provide additional education at the patients home or through an appointment in the Public Health Nursing office at Zuni Hospital.
Patients with progressive disease who require vascular or peritoneal access placement are referred to a facility in Gallup, NM, approximately forty miles north of Zuni. Vascular evaluation, access placement, and initiation of dialysis are available from the same group of physicians who manage the Zuni dialysis unit. Patients who are interested in transplant are referred to one of two transplant centers in Albuquerque for evaluation. Timely completion of transplant evaluation is a challenge due to the distance, 150 miles, from the transplant center.
The referring Zuni medical staff, the nurse manager, and the nephrologist have identified key elements to the success of this collaborative approach to delivering specialty consultation by telemedicine:
Although telemedicine provides access to consultation for patients, there are clear limitations:
In addition, challenges to conducting a virtual clinic may require development of specific clinical skills:
While the IHS is a unique organization, its’ approach to many of the challenges of addressing the health needs of rural, medically underserved populations conforms to the widely accepted principles of managing chronic conditions (e.g., Chronic Care Model) and may be widely applicable. The model of telemedicine described in this report is based on an interdisciplinary approach to collaborative care that is not inconsistent with the approach of many integrated health care systems (e.g., Veterans Administration). While this model was implemented as a way to provide care which otherwise was not easily accessible, not as a clinical research trial, it does demonstrate that telemedicine can be a durable approach to deliver nephrology consultation to a high risk rural population, including people with advanced kidney disease, over an extended period of time.
Financial disclosures: None
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Andrew S Narva, National Kidney Disease Education Program, National Institutes of Health.
Gayle Romancito, Zuni Comprehensive Community Health Center, Indian Health Service.
Thomas Faber, Zuni Comprehensive Community Health Center, Indian Health Service.
Michael Steele, Center for Information Technology, National Institutes of Health.
Kenneth Kempner, Center for Information Technology, National Institutes of Health.