Telenephrology: current perspectives and future directions

Telenephrology: current perspectives and future directions

mini review www.kidney-international.org Telenephrology: current perspectives and future directions Rajeev Rohatgi1,2, Michael J. Ross3 and Sandawan...

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mini review

www.kidney-international.org

Telenephrology: current perspectives and future directions Rajeev Rohatgi1,2, Michael J. Ross3 and Sandawana W. Majoni4,5,6 1 Northport VAMC, Northport, New York, USA; 2Stony Brook School of Medicine, Stony Brook, New York, USA; 3Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA; 4Royal Darwin Hospital, Darwin, Northern Territory, Australia; 5Flinders University Northern Territory Medical Program, Royal Darwin Hospital, Darwin, Northern Territory, Australia; and 6Menzies School of Health Research, Royal Darwin Hospital, Darwin, Northern Territory, Australia

There is increasing interest in telemedicine among physicians and patients; however, the evidence regarding the quality of care delivered by telemedicine, and telenephrology in particular, compared with in-person care is limited. In this review, different electronic modalities used to deliver nephrology care are reviewed and critiqued, with a focused analysis from the Australian and United States perspectives. Both countries are geographically expansive with significant rural populations where access to nephrology care is limited. However, their health care systems are organized differently. The Australian health care system is a mostly nonprofit, single-payer system, whereas the United States system is more fractured with a greater proportion of patients covered by for-profit private insurance or no insurance coverage. Videoconferencing is widely used in Australia to manage kidney disease including chronic kidney disease, dialysis, pediatric nephrology, and post-kidney transplantation care. In contrast, the United States telenephrology experience is limited, with most reports originating from the Veterans Health Administration, a single-payer system providing care for nearly 9 million veterans, w3 million of whom reside in rural communities. Preliminary reports from the Veterans Health Administration suggest that that delivery of nephrology care via videoconferencing results in clinical outcomes that are at least equivalent to in-person care and improved patient adherence to scheduled appointments. Nevertheless, large, adequately controlled studies are needed to identify patient populations that are most likely to benefit from telenephrology and to determine the optimal systems for the delivery of telenephrology care. Kidney International (2017) j.kint.2017.06.032

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http://dx.doi.org/10.1016/

KEYWORDS: chronic kidney disease; hemodialysis; telehealth Published by Elsevier, Inc., on behalf of the International Society of Nephrology.

Correspondence: Rajeev Rohatgi, Renal Section, Northport VAMC, Building 200, Room A4-55, 79 Middleville Road, Northport, New York 11768, USA. E-mail: [email protected] Received 31 March 2017; revised 31 March 2017; accepted 22 June 2017 Kidney International (2017) -, -–-

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elemedicine, as defined by the World Health Organization, is “the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities.”1 More specifically, telenephrology uses these technologies to care for patients with kidney disease. The broad definition encompasses Web-based applications, videoconferencing, and remote monitoring devices that collect physiological data such as blood pressure (BP). The varying modalities of telehealth communication are designed to reduce spatial, geographic, and temporal distance between patients and physicians with the stated goal of improving access to care and health outcomes. The technologies used in the performance of telemedicine/ telenephrology can depend on several factors including the local technologic resources, equipment costs, local laws and regulations, and goals of the program. That being said, no studies have rigorously evaluated the role of these technologies to achieve the aims of improved access and health outcomes. In this review, we evaluate the effect of these technologies on renal health. First, we review how Web-based and remote monitoring systems have been implemented to improve access to and quality of renal care. We then evaluate the role that videoconferencing plays in the delivery of nephrology care in Australia and the United States, 2 countries with divergent health care systems, where nephrologists struggle to deliver care to geographically disparate populations. Finally, we review the barriers that prevent greater adoption of telenephrology into practice and potential solutions. Web-based telemedicine programs

Web-based programs provide a means to educate and communicate with patients with chronic kidney disease (CKD) outside of the traditional institutional setting. In the United States, Hispanic patients with CKD are less likely to receive kidney transplants than non-Hispanic whites. This discrepancy has been attributed, in part, to lower levels of health care literacy regarding transplant options. To address this inequity, Gordon et al.2 developed a Spanish language 1

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Website to educate Hispanic patients with CKD about kidney transplant options, focusing on the relevant risks, benefits, and alternatives necessary for patients to make informed decisions. Pretest and posttest surveys were administered to evaluate the impact of the intervention on transplant-related knowledge. Ninety-six percent of eligible subjects participated. The Website increased same-day knowledge by 17.1%, and knowledge scores remained 11.7% above the pretest level after 3 weeks. Moreover, 95% of participants stated that they would recommend the website to others, implying that culturally sensitive Web sites engage and educate patients.2 Web-based nephrology consultation has also been piloted and evaluated. Primary care providers (PCPs) referred patients to a hospital-based nephrology practice in the Netherlands via a Web-based consult, which abstracted clinical and laboratory data from the electronic medical record (EMR) and forwarded the consult question and information to the nephrologist.3 The consultant could respond in 1 of 3 ways: (i) provide answers to simple questions, (ii) ask the PCP to gather more clinical data and then reconsult, or (iii) request the patient to be evaluated in person. For program evaluation, the time devoted to initiating and responding to the consult was collected. The nephrologist devoted <10 minutes for each consult, and the average response time per consult was 1.6 days (95% confidence interval 1.2–1.9 days). For each consult requested, PCPs were asked whether they would have referred to nephrology in the absence of the Web-based nephrology consult. Of the 122 consults placed, PCPs identified 43 (35.3%) consults that would have directly been referred to nephrology for an in-person evaluation in the absence of the Web-based system.3 However, after Web-based consultation, the nephrologist determined only 7 of these 43 (16.3%) consults required referral for in-person specialty evaluation. Importantly, of the remaining 79 (64.7%) Web-based consults for which PCPs did not consider in-person nephrology evaluation necessary, 10 were judged by nephrologists to require in-person evaluation.3 Thus, electronic consultation can increase access to subspecialists, in this case, the nephrologists, who can identify patients who are most likely to benefit from their assessment. Other investigations combined remote home monitoring with Web-based systems to improve BP management. In a prospective observational study, 66 kidney transplant recipients were recruited to have their BP monitored at home. Patients were instructed to measure their BP at designated times and frequency.4 The BPs were transmitted into the Good Health Gateway platform. A clinical pharmacist reviewed the BPs and medications and then suggested an antihypertensive intervention, which was reviewed by a physician. Systolic and diastolic BPs were reduced by 6 mm Hg and 3 mm Hg, respectively, after 30 days, and the effect persisted up to 180 days of follow-up.4 In a prospective study of patients with CKD (N ¼ 43), home BP monitoring with clinical support was compared with usual in-person care.5 Home monitoring and usual care significantly reduced systolic BP by 13 mm Hg and 8.5 mm Hg (P < 0.05 2

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compared with the initial systolic BP), respectively, suggesting that the home BP monitoring intervention was at least as effective as usual in-person care. In India, remote monitoring via Web and text message communication was implemented in urban and rural peritoneal dialysis (PD) patients.6 Patients were trained to log on to the Website, enter physiological data, schedule home and clinic visits, and upload photographs of PD fluid and the exit site. Text-messaging permitted swift access to PD experts. Technique failure rates and the risk of peritonitis did not differ between urban and rural patients; however, 5-year patient survival was greater in rural than urban PD patients,6 which was notable because previous studies reported lower rates of survival of rural PD patients than their urban counterparts.6–8 These small studies suggest that Web-enabled telenephrology is acceptable to many patients with CKD and may result in clinical outcomes that are similar to traditional in-person care. However, these studies were of inadequate size, and most were not randomized and lacked appropriate controls, thereby preventing clear conclusions regarding the efficacy of telenephrology. Well-designed and adequately powered prospective studies are therefore needed to determine the optimal modalities/interventions and patient populations most likely to benefit from Web-based telemedicine. The Australian experience with videoconferencing-based telenephrology

The history of telemedicine in Australia dates back to the 1870s when the telegraph was used due to long distances between health care facilities and rural and remote areas of Australia.9 However, it was only in the mid-1990s that published literature appeared on the use of telemedicine in health care delivery in Australia.10 Although there has been a rapid increase in publications on the role of telemedicine in other specialties, there remains a paucity of published data on telenephrology in Australia. Telenephrology is particularly invaluable in Northern Australia (The Northern Territory, Northern Queensland, and Northern Western Australia) where distances between major health care centers and communities are vast and the rates of CKD are among the highest in the world, particularly among the indigenous population. In the late 1990s to the mid-2000s, teleconferencing was primarily used in the Northern Territory for care coordination between specialty services and the remote and rural clinic staff.11 In 1994, a study by Mitchell et al.12 analyzed the clinical application of a telemedicine network that linked renal units at the Queen Elizabeth Hospital to 3 satellite dialysis centers in South Australia. In 21/2 years of operation, there were >6000 instances in which the telemedicine equipment was used to conduct clinical care. Interviews were conducted with 18 medical, nursing, and allied health staff and dialysis patients, which revealed that the full range of staff, including surgeons, nephrologists, nurses, and allied health staff, were able to use the technology successfully. This study was the first Kidney International (2017) -, -–-

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evidence in Australia that demonstrated telenephrology enables staff to support a wide range of clinical services including routine outpatient consultations, evaluation of infections, and determination of whether patients required surgery. It also illustrated that clinical services from disparate areas could deliver complex care to patients who are geographically isolated from these specialists.12 Mitchell et al.13 carried out a longitudinal survey from May 1994 to June 1995 to evaluate the user attitudes toward the introduction of telemedicine to South Australian dialysis units. The staff was mostly positive about telemedicine and thought that it was reliable and simple to operate. However, they also reported that telemedicine in an open ward setting did not provide adequate patient privacy. They indicated that telemedicine was potentially useful in Australian dialysis units but highlighted the importance of planning and cooperation to develop an appropriate environment within which to promote acceptance of telemedicine. The first case of home-based telenephrology in Australia was reported by Mitchell et al.14 in 2000. Videoconferencing equipment, operating on a telephone network, provided realtime telemedicine supervision of home dialysis sessions as well as on-demand requests by the patient. Telemedicine reduced the need for in-person hospital visits, which, in turn, reduced the anxiety that the patient who dreaded visiting hospitals experienced. Although this was a single case report, it provided an example of how home-based telemedicine can provide effective clinical care for geographically distant home dialysis patients. Trnka et al.15 performed a retrospective audit to review their experience with pediatric videoconferencing-based telenephrology in Queensland, Australia. Over a 10-year period (2004–2013), these investigators, using telenephrology, completed 318 pediatric consultations for 168 patients (56.5% male) with a median age of 8 years old (range, 3 weeks to 24 years old) with a variety of pediatric nephrology conditions including congenital anomalies of the kidney and genitourinary tract, nephrotic syndrome, kidney transplant, and urinary tract infection. Telenephrology provided improved access to pediatric nephrology services for patients and their families and educational opportunities for the regional medical teams. In addition, telenephrology provided a cost savings of wAU$31,837 in 2013, which amounted to a savings of wAU$505 per consultation. Thus, this study provided evidence of telenephrology as a cost effective and viable option for effective patient assessment and follow-up.15 The support from the Royal Australasian College of Physicians and Australian Government for telehealth training has enhanced our capacity to train our trainees in telenephrology as we appointed our first trainee in telehealth in 2014.16 It has provided opportunities for nephrology trainees in the Northern Territory Renal services training programs to experience specialty outreach and telenephrology in addition to the conventional models of care. The college also runs workshops and has training programs for telehealth. Kidney International (2017) -, -–-

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Bramstedt et al.17 presented a study assessing telemedicine as an ethics teaching tool for medical students in the nephrology curriculum. They found that telemedicine can be an effective and feasible method with which to deliver an ethics curriculum with a patient-centered approach. Additionally, the cross-cultural experience exposed students to additional contextual features of medicine. The current structure of integrated services in our renal program is a mixture of telenephrology (primarily videoconferencing between clinic staff and patients with or without their families or caregivers at a remote or rural clinic), a streamlined specialty outreach program (regular specialist visits to remote communities by need), and face-to-face hospital appointments in selected cases. The expanded use of videoconferencing-based telenephrology has recently been facilitated by the improvement in Internet connections to remote areas and the inclusion of telehealth among Australian Medicare-funded health care services.18 The availability of telenephrology has also obviated the need for renal transplant patients to live in major regional towns in the Northern Territory as it is now possible to review them with remote clinic staff. Although there has not been an analysis of outcomes for those returning to the communities after renal transplantation, unpublished evidence from our service suggests that the outcomes have improved since adopting telenephrology. We now have expanded the telenephrology services from multidisciplinary integrated care of patients with CKD to those on renal replacement therapy including dialysis and transplantation. There is a need for investigations to assess the impact of telenephrology on clinical outcomes, patient satisfaction, and cost-effectiveness of care in patients receiving dialysis or after renal transplantation. The US experience with videoconferencing-based telenephrology

The US health care system is fragmented compared with the nationalized health care systems of most other developed countries. The private, multipayer health insurance system dictates what services will be reimbursed, and treatment decisions are frequently influenced by cost.19 The regulatory environment is also obstructive. Physician licensing is regulated at the state level without reciprocity. Individual EMRs do not interface with one another, and privacy regulations limit the efficient exchange of patient information. Thus, few studies on videoconferencing-based telenephrology have been conducted in the United States. In contrast, the Veterans Health Administration (VHA) is a government-funded, single-payer system that uses a single EMR nationwide. Moreover, the VHA serves 8.9 million veterans annually (http://www.va.gov/health/aboutVHA.asp) with w36% of enrollees residing in rural communities. Because of the demographics and infrastructure, the VHA has been at the forefront of telehealth in the United States. Several telehealth modalities have been piloted within the VHA; however, we focus on 2 types of videoconferencing 3

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modalities: (i) Extension of Community Healthcare Outcomes (ECHO) and (ii) Clinical Video Telehealth (CVT). The Veterans Affairs (VA) adapted a model of care pioneered by Sanjeev Arora, MD, named ECHO. In this telemedicine model, PCPs confer with hepatologists via videoconferencing on the care of hepatitis C virus–infected patients.20 These teleconferences permit co-management of patients and education of PCPs to improve their ability to manage future hepatitis C virus patients. The Specialty Care Access Network-ECHO is the VA’s implementation of the physician-to-physician videoconferencing platform to deliver specialty care.21 In 2012, the VA funded a pilot Kidney Specialty Care Access Network-ECHO program at the Seattle VA to perform such services to community-based outpatient clinics. In addition, the Kidney Specialty Care Access Network-ECHO program included a didactic patient-focused curriculum on 16 core renal topics for the PCPs.21 The program has recently expanded to the inpatient medical service at the Spokane VA Medical Center (VAMC) where the Seattle VAMC supports inpatient Kidney Specialty Care Access Network-ECHO consultation and lecture series on acute kidney injury.21 Rigorous evaluation of these kidney programs will be needed to determine whether patient outcomes are, at a minimum, similar to standard in-person care. CVT permits face-to-face physician-patient encounters while the patient is located at a distance site. As with many innovations, the program at the James J. Peters VAMC (JJPVAMC) in the Bronx, New York, was born out of necessity. JJPVAMC is the renal referral center for the Hudson Valley VAMC (HVVAMC) located 60 miles north of the Bronx. More than 50% of nephrology clinic appointments of HVVAMC patients referred to JJPVAMC were cancelled or “no-showed.” We suspected that distance was an important factor contributing to poor adherence to scheduled

Physician office

Encrypted high-speed line Health record

Equipment Monitor EMR Headphone

appointments. To address this problem, in 2011, we initiated our CVT telenephrology program, which entailed identifying a clinic room at HVVAMC where an I8500 Mobile Telemedicine Station (Global Med, Scottsdale, AZ) was housed and connected via a Health Insurance Portability and Accountability Act (HIPAA)–compliant high-speed Internet line to a Telemedicine station at the JJPVAMC. HIPAA’s privacy rule (i) requires appropriate safeguards be implemented to guard patients’ protected health information, (ii) formulates conditions on how protected health information can be used and disclosed without prior authorization, and (iii) provides patient rights over their protected health information.22 In practical terms, for videoconferencing, this means that the (i) high-speed Internet line is encrypted; (ii) video transmissions are not stored, unless specifically requested by the provider, to reduce privacy risks; (iii) basic security measures are in place such as authentication and person-user access controls; and (iv) finally, the Internet provider must sign a business associate agreement.22,23 A business associate is a person or organization that provides a service to a covered entity (i.e., provider). The business associate agreement is a contract that states the business associate will also follow the privacy rules of HIPAA.22,23 For example, Skype and Facetime, popular commercial platforms for face-to-face communication, are not encrypted and, therefore, are not HIPAA compliant and are not eligible for use in a business associate agreement for CVT. Our CVT system also includes peripherals such as stethoscope (at HVVAMC), head phone (at JJPVAMC), and high-resolution mobile digital camera (at HVVAMC). A health technician, trained in telenephrology, is located on the patient side to measure vital signs and assist the physician and/or patient (Figure 1). The physician, credentialed at JJPVAMC and HVVAMC, documents the clinic visits in both EMRs. All telenephrology patients are initially seen in-person

Examination room

Equipment Monitor EMR Stethoscope Digital camera Ultrasound

Figure 1 | Basic setup of a telenephrology program. Two sites need to be established: (i) the physician office and (ii) the patient examination room. For example, our physician office was located at the James J. Peters Veterans Affairs Medical Center (VAMC) in the Bronx, whereas the patient examination room was located at the Hudson Valley VAMC in Castle Point, NY. The physician was credentialed at both VAMCs with access to the EMRs at both VAMCs and was, thus, able to document nephrology visits in each EMR. A videoconference monitor is kept in the physician’s office, and a second monitor with the peripherals (i.e., stethoscope, digital camera, ultrasound, etc.) is kept at a designated patient examination room. A high-speed Health Insurance Portability and Accountability Act–compliant line connecting the 2 monitors is needed to generate seamless communication. On the patient side, a health technician welcomes the patient into the room, orients the patient to the monitor, measures the vital signs, assists the physician by manipulating the peripherals as needed to collect physical examination findings, and, finally, reinforces the plan as outlined by the physician. EMR, electronic medical record. 4

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at the JJPVAMC, but then referred by the nephrologist to the telenephrology program. In 3 years we cared for >100 patients with CKD located in the Hudson Valley region using CVT. Approximately 30% of telenephrology clinic appointments were cancelled or “noshows” compared with >50% observed in patients traveling from HVVAMC region to JJPVAMC for in-person visits, resulting in nearly a 55% reduction in cancelled and “no show” visits with CVT telenephrology. The distance traveled by HVVAMC patients was reduced by 50% because they drove to their local clinic.24 We speculate that accessibility and familiarity enhanced visit compliance. Ishani et al.25 investigated whether a telenephrologyenabled home case-management approach could improve clinical outcomes in patients with CKD versus usual care. The telenephrology group was trained to use the bidirectional monitor and the peripheral equipment, like a BP cuff. The multidisciplinary team included a nephrologist, psychologist, social worker, telehealth technician, and dietitian. In contrast, the usual care cohort was not given any prespecified, studyrelated care, and whether patients were followed by a nephrologist was left to the discretion of the primary care provider. After 1 year of follow-up, no differences were detected in the primary endpoints of death, hospitalizations, emergency department visits, or admission to a skilled nursing facility between the groups; however, a subgroup analysis of rural patients showed a trend toward fewer primary endpoints in the telenephrology group than usual care group.25 We believe that VHA, with its existing telemedicine infrastructure support, large and diverse patient populations spread across wide geographic regions, uniform EMR, and single-payer system, is the ideal environment in which to perform future prospective trials on the efficacy and cost-effectiveness of telenephrology. Future directions: adoption and adaptation of telenephrology

The Institute of Medicine report on health care outlines 6 broad areas to improve the quality and effectiveness of health care.26 One is to develop “patient centered” care that is tailored to patient preferences and needs, while another is focused on “equitable” care that does not vary by ethnicity, sex, socioeconomic status, or geographic location.26 Telehealth is a “patient-centered” modality that delivers personalized, on-demand care to patients regardless of geographic location. Nephrology care delivered by telehealth leads to clinical outcomes that, at worst, are unlikely to differ from usual care, as evidenced by the currently available literature. However, the rapid adoption of telenephrology in the United States is limited by several factors. First, reimbursement by Medicare and private health insurance is minimal for these services because no randomized controlled studies have been performed that demonstrate improved clinical outcomes and/or reduced costs.27 Third-party payers are concerned that overuse of electronic services will drive up costs without delivering better clinical outcomes. Therefore, a randomized Kidney International (2017) -, -–-

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controlled trial that, at a minimum, demonstrates equal clinical outcomes at a lower cost (e.g., fewer hospitalizations, emergency department visits) will be required to gain acceptance.27 In a select population with limited access to nephrology care, telenephrology may be able to deliver superior care because of enhanced adherence to clinical visits, as suggested in the Bronx VAMC-Hudson Valley telenephrology program. Satisfaction with the patient-physician relationship is at risk because of the impersonal nature videoconferencing.27 However, a mixture of occasional in-person visits with more frequent telenephrology appointments can build strong connections between patient and physician.27 In the BronxHudson Valley VAMC telenephrology program, all patients were required to have a least 1 face-to-face visit with a nephrologist at the Bronx VAMC to determine appropriateness for telenephrology. But, moreover, these in-person visits set the tone of the patient-nephrologist relationship. In a small sample of patient questionnaires, the response to the telenephrology program was overwhelmingly positive, which may be due to the convenience and strong patient-physician relationships. State medical licensure, credentialing, and medical/legal liability are all issues that need to be addressed to create a seamless system.27 An example of a regulatory hurdle to deliver home-based videoconferencing is that Medicare does not permit the originating site, also known as the patient location, to be the patient’s home or dialysis facility. However, pilot projects, supported by the Center for Medicare and Medicaid Innovation, are underway to test whether homebased videoconferencing can influence outcomes in peritoneal dialysis patients.28 The Tele-Med Act of 2015 permits state-licensed Medicare providers to deliver services to Medicare beneficiaries in any state.27 Similarly, credentialing in several hospital/clinic settings is an onerous task. Thus, to streamline this process, credentialing can be performed at the hub site, whereas the remote site can simply review and approve the hub site’s recommendation.27 To curtail the medicolegal liability, patients sign a consent form regarding the limitations of telenephrology as well as to inform them of alternatives. With the advent of Skype-like technologies, the costs of teleconferencing are decreasing rapidly; however, there are still technical and medicolegal barriers for further adoption.27 Broadband access is not universally available throughout the United States, with rural America and the economically disadvantaged commonly affected. To reach these communities, universal access to broadband and outreach to these communities with technical support will be necessary. In addition, privacy regulations of HIPAA, as outlined earlier, at least in the United States, make medical videoconferencing challenging. Most importantly, acceptance into the larger private insurance–based health system will not occur until a well-designed clinical trial demonstrates significant benefits in health outcomes and/or definitive evidence of cost-effectiveness. 5

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Future investigations should focus on the rural and geographically isolated populations because CVT telenephrology is likely to disproportionately benefit these patients over traditional care.29,30 It is critical to identify optimal patient populations and delivery systems to ensure the most appropriate implementation of telenephrology to the larger health care space. DISCLOSURE

All the authors declared no competing interests. REFERENCES 1. World Health Organization. Telemedicine: Opportunities and Developments in Member States. 2010:1–92. 2. Gordon EJ, Reddy E, Gil S, et al. Culturally competent transplant program improves Hispanics’ knowledge and attitudes about live kidney donation and transplant. Prog Transplant. 2014;24:56–68. 3. Scherpbier-de Haan ND, van Gelder VA, Van Weel C, et al. Initial implementation of a web-based consultation process for patients with chronic kidney disease. Ann Fam Med. 2013;11:151–156. 4. Aberger EW, Migliozzi D, Follick MJ, et al. Enhancing patient engagement and blood pressure management for renal transplant recipients via home electronic monitoring and web-enabled collaborative care. Telemed J E Health. 2014;20:850–854. 5. Rifkin DE, Abdelmalek JA, Miracle CM, et al. Linking clinic and home: a randomized, controlled clinical effectiveness trial of real-time, wireless blood pressure monitoring for older patients with kidney disease and hypertension. Blood Press Monit. 2013;18:8–15. 6. Nayak KS, Ronco C, Karopadi AN, Rosner MH. Telemedicine and remote monitoring: supporting the patient on peritoneal dialysis. Perit Dial Int. 2016;36:362–366. 7. Tonelli M, Hemmelgarn B, Culleton B, et al. Mortality of Canadians treated by peritoneal dialysis in remote locations. Kidney Int. 2007;72: 1023–1928. 8. Zhang W, Gong Z, Peng X, et al. Clinical characteristics and outcomes of rural patients with ESRD in Guangxi, China: one dialysis center experience. Int Urol Nephrol. 2010;42:195–204. 9. Eikelboom RH. The telegraph and the beginnings of telemedicine in Australia. Studies Health Technol Informatics. 2012;182:67–72. 10. Alexander M. Telemedicine in Australia. 1: The health-care system and the development of telemedicine. J Telemed Telecare. 1995;1:187–195. 11. Majoni W. Telemedicine is crucial for improving access to specialist renal care and management of renal disease in remote/rural locations. Intern Med J. 2011;41:11. 12. Mitchell JG, Disney AP. Clinical applications of renal telemedicine. J Telemed Telecare. 1997;3:158–162. 13. Mitchell BR, Mitchell JG, Disney AP. User adoption issues in renal telemedicine. J Telemed Telecare. 1996;2:81–86.

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14. Mitchell JG, Disney AP, Roberts M. Renal telemedicine to the home. J Telemed Telecare. 2000;6:59–62. 15. Trnka P, White MM, Renton WD, et al. A retrospective review of telehealth services for children referred to a paediatric nephrologist. BMC Nephrol. 2015;16:125. 16. Bradford NK, Caffery LJ, Smith AC. Telehealth services in rural and remote Australia: a systematic review of models of care and factors influencing success and sustainability. Rural Remote Health. 2016;16: 4268. 17. Bramstedt KA, Prang M, Dave S, et al. Telemedicine as an ethics teaching tool for medical students within the nephrology curriculum. Prog Transplant. 2014;24:294–297. 18. Australian Department of Human Services. Medicare Benefits Scheme and Telehealth. Available at: https://www.humanservices.gov.au/healthprofessionals/services/medicare/mbs-and-telehealth/. Accessed April 9, 2016. 19. Sarpel U, Vladeck BC, Divino CM, Klotman PE. Fact and fiction: debunking myths in the US healthcare system. Ann Surg. 2008;247:563–569. 20. Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med. 2011;364:2199–2207. 21. Crowley ST, Belcher J, Choudhury D, et al. Targeting Access to Kidney Care Via Telehealth: the VA Experience. Adv Chronic Kidney Dis. 2017;24: 22–30. 22. Kangus E. What is HIPAA-compliant videoconferencing? Available at: https://chironhealth.com/blog/hipaa-compliant-video-conferencingfaqs/. Accessed May 31, 2017. 23. Smith A. HIPAA Compliant Video Conferencing – FAQs. Available at: https://chironhealth.com/blog/hipaa-compliant-video-conferencingfaqs/. Accessed May 31, 2017. 24. Rohatgi R, Tan JK, Mehrotra A, et al. Telenephrology for the remote management of chronic kidney disease (CKD): a retrospective cohort study. Abstract presented at: American Society of Nephrology Annual Scientific Meeting; November 3–8, 2015; San Diego, CA. PO-714. 25. Ishani A, Christopher J, Palmer D, et al. Telehealth by an interprofessional team in patients with CKD: a randomized controlled trial. Am J Kidney Dis. 2016;68:41–49. 26. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press Institute of Medicine; 2001. 27. Dorsey ER, Topol EJ. State of telehealth. N Engl J Med. 2016;375:1400. 28. Magnus M, Sikka N, Cherian T, Lew SQ. Satisfaction and improvements in peritoneal dialysis outcomes associated with telehealth. Appl Clin Inform. 2017;8:214–225. 29. Rucker D, Hemmelgarn BR, Lin M, et al. Quality of care and mortality are worse in chronic kidney disease patients living in remote areas. Kidney Int. 2011;79:210–217. 30. Bello AK, Hemmelgarn B, Lin M, et al. Impact of remote location on quality care delivery and relationships to adverse health outcomes in patients with diabetes and chronic kidney disease. Nephrol Dial Transplant. 2012;27:3849–3855.

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