Overview

• Innovators at the Iowa City Veterans Affairs (VA) Health Care System sought to streamline the nephrology consult process and reduce the cost of travel for patients by developing an actively monitored electronic dashboard to trigger the nephrology consultation process.

Organization Name

Iowa City Veterans Affairs Health Care System

Organization Type

• Rural health system
• Veteran's Affairs

Tech Involved

• Electronic medical record
• Telemedicine software

Team Members Involved

• Case Management
• Primary Care Physicians
• Specialists

Workflow Steps

• This telenephrology quality improvement initiative took place at four rural community-based outpatient clinics (CBOC) spread throughout the VA catchment area. The development and implementation of this process occurred between October 2017 and August 2019.
• Using process mapping, innovators first identified six “non-value added” steps after abnormal renal labs are obtained, which trigger a consult request by the primary care physician (PCP) before the face-to-face consultation with the nephrologist occurs. These steps were replaced with a case manager who monitors a telenephrology dashboard that displays lab result data with “must-have” features (i.e., essential kidney labs, kidney function trends, prediction models for development of chronic kidney disease, and colors to distinguish indicators) and “attractive” features (i.e, lab data filtering and sorting, including by date).
• The telenephrology dashboard was first deployed at one rural CBOC. Feedback from the implementation at this CBOC called for refining acute kidney injury parameters, as the parameters were too sensitive and triggered multiple consultations. Innovators also determined that patients who were at highest risk for kidney disease should be prioritized for consultation. After these adjustments were made to the model, the dashboard was deployed at all four CBOCs.
• In order to evaluate the initiative, innovators collected data at these clinics from the three months prior to the initiative’s implementation and compared these data to data from the three months after the initiative was implemented. The primary outcome was the time from PCP consult order to completion of nephrology consult note. Secondary outcomes included the number of telenephrology consults, the amount of patient travel to consults, and the cost of patient travel to consults.

Outcomes

• Overall, the telenephrology dashboard intervention did not decrease the time of consult completion, but it did increase the number of nephrology consults completed, thus contributing to the early detection of kidney disease.
• The primary outcome of the study was the time of consult completion, which was defined as the days between a primary care provider placing a nephrology consult and a nephrologist completing the related consult note. There was no statistically significant change in consult completion time after the implementation of the telenephrology dashboard. 
  • The time of consult completion was 41.6 days in 2017, 28.6 days in 2018 and 48.9 days in 2019. 
• A secondary outcome was travel time and cost for the participants. The dashboard intervention saved each patient a mean of 108 miles (median 100 miles). This equals 47,718 miles saved in total for the 459 participants, which corresponds to a financial saving of $21.60-63.90 per patient.
• Another secondary outcome for this study was the number of telenephrology consultations. Since the implementation of the dashboard in March 2018, the number of telenephrology consults has consistently exceeded the number of in-person consults.
  • From July 2019 onward, it was noted that the majority of nephrology consults  (55.7%) were telemedicine consults. The average number of consults in the last six months of project implementation was 27.3 per month. 

Unique Challenges

• The primary outcome of the study, which was the reduction of the time needed to complete a consult, was not met. One reason why no change was detected was the high variability in time of consult completion among different sites and among different patients. Another reason was that the volume of patients identified for telenephrology consultation was high, and this contributed to longer times for consult completion. 
• The generalizability of the study remains unclear. The research group is currently studying the generalizability of the results by expanding this telenephrology dashboard project to the entire Iowa City VA Healthcare System. 
• The longer-term impact of this intervention on kidney health, especially with regards to progression to end-stage disease, remains unclear. Further studies should be pursued to examine whether this telenephrology intervention positively impacts outcome measures for patients with kidney disease, in addition to process measures. 

Sources

• Swee, M. L., Sanders, M. L., Phisitkul, K., Bailey, G., Thumann, A., Neuzil, N., Kumar, B., O’Shea, A., & Dixon, B. S. (2020). Development and implementation of a Telenephrology dashboard for active surveillance of kidney disease: a quality improvement project. BMC nephrology, 21(1), 424. https://doi.org/10.1186/s12882-020-02077-0