VAi2 Projects: VA eKidney Clinic and Renal Video Teletechnology

The U.S. Department of Veterans Affairs (VA) established the VA Center for Innovation (VACI) to identify, fund, and test new health care system proposals. During the second annual innovation initiative (VAi2) competition a total of four VAi2 proposals pertaining to kidney disease were selected. Two of these focused on the implementation of telemedicine in nephrology—creation of a virtual kidney clinic and development of clinical home-based video technology.

VA eKidney Clinic

The team-based approach to chronic kidney disease (CKD) management often involves patient visits to a variety of providers, including the physician or physician extender, renal nurse, renal dietician, renal social worker, and pharmacist. Disease symptoms and treatment options are frequently discussed at various levels specific to the particular provider and topic. However, many patients and their family members seem to misunderstand the gravity of a kidney disease diagnosis because the information can be overwhelming.

Disease and treatment education are consistently the main “ace in the hole” for prolonged chronic disease management. To that end, the VA has taken a lead in providing a virtual kidney clinic website—the eKidney Clinic (http://www.medicalsurgical.va.gov/kidney/program.asp). This website allows the patient to personalize their understanding of kidney failure. A patient with kidney disease can pace his or her understanding, repeat information as necessary, test their disease comprehension, reflect on the disease process, and frame questions for their online providers. The virtual providers also remain impartial when conveying and explaining symptoms that can and do occur. Information about common medications that patients with CKD may need is reviewed by a virtual pharmacist. A visit with a virtual dietician answers questions about high-potassium foods, clarifies why they should be avoided as kidney function worsens, and provides advice on how to help manage foods that can taper a high phosphorus load. Patients can search the virtual learning site for specific terms and unfamiliar jargon used by the medical team. A virtual social worker discusses various choices for renal replacement, including hemodialysis (home, in-center, or nocturnal), peritoneal dialysis, renal transplantation, as well as the option to be managed conservatively with no dialysis.

A chronic progressive and lingering disease is understandably difficult for patients and their caregivers. The eKidney Clinic teaching website gives veterans and other patients with CKD, and their families and caregivers, some support away from the physician’s office or clinic providers. The site is easy to navigate and has many accessibility features, including the ability to enlarge the font size as necessary, listen in on the virtual messages for each room that the patient chooses to enter to learn about the different aspects of CKD and its progression, or read the messages associated with representative pictures discussing the topic at hand for the visual learner or those who are hearing impaired. The website is mindful of the diversity of individuals with CKD and carefully tailors the ethnicities presented to ensure visual integrity and reduce bias in the presentation of the disease process for any particular group of individuals not presented. Overall, this VA initiative is an excellent addition in improving care not only for the veteran patient with CKD but also for all patients suffering from CKD.

Renal video teletechnology

Patients with kidney disease often have a multitude of chronic comorbid conditions that require careful and close management by several different health care providers. Some veterans with CKD live far from VA facilities that provide subspecialty nephrology care, which may impede their access to this important care. Multidisciplinary case management with telemonitoring has been demonstrated to improve outcomes in chronically ill populations without CKD, but it has not been as frequently applied to vulnerable elderly populations with CKD, such as veterans.

The VAi2 renal video teletechnology initiative, led by the Minneapolis VA health care team in collaboration with American TeleCare, focuses on providing advanced care management to veterans with moderate to severe CKD in the Minneapolis or St. Cloud VA Health Care System or an affiliated Community Based Outpatient Clinics. The advanced care management consists of tools, equipment, and education that allow veterans to self-monitor their CKD from home. For example, the telehealth device contains peripherals for patients to monitor their vital signs (blood pressure, weight, and glucose) and enables a patient education session to be done in the patient’s home at their pace. Further, this management plan will connect the highest risk veterans with CKD to a VA care team that has expertise to manage major risk factors (e.g., diabetes and hypertension) as well as other associated comorbid conditions and psychosocial complications. This technology allows video visits with the interprofessional VA-based team (nephrologist, nurse practitioner, nurse, renal dietician, renal social worker, clinical PharmD, and psychologist) and provides educational modules to the veteran at home (on such topics as kidney disease, diet changes, and diabetes). The interprofessional team has helped patients achieve lifestyle goals, assisted with patient education and activation, managed each patient’s chronic conditions (hypertension, diabetes, depression, and others), and helped identify and resolve acute conditions.

To date, 601 veterans have already been enrolled in this advanced care management plan. A clinical trial is being conducted to compare the impact of this technology with usual care for veterans with CKD. In addition to slowing CKD progression, it is anticipated this intervention will reduce emergency room visits and hospitalizations, and thereby reduce health care costs. Preliminary findings from this trial should be available in the near future.

Notes

[1] Devasmita C. Dev, MD, is the Director of Dialysis and Interventional Nephrology at the Salem VA Medical Center in Salem, VA. Areef Ishani, MD, MS, is affiliated with the Minneapolis VA Health Care System and University of Minnesota, in Minneapolis, MN.