Territory Kidney Care: integrated chronic disease support in the NT

The Northern Territory (NT) is a large and sparsely populated jurisdiction, with almost 250,000 residents. Approximately 30 per cent are First Nations Australians, with many living in remote and very remote areas. There is a heavy burden of chronic kidney disease (CKD) and concomitant conditions, including diabetes and cardiovascular disease. CKD disproportionally affects First Nations Australians, who require dialysis or a kidney transplant at rates up to 30 times higher than their non-Indigenous counterparts.

NT primary care services are delivered by government-managed and Aboriginal community-controlled health services. Clinical information systems are siloed, which inhibits efforts to use comprehensive patient records for health care. Integrated care seeks to deliver ‘the right service, at the right time, in the right place, by the right team’. Providing such care is challenged by distance from necessary services, siloed information systems, a highly mobile population and high staff attrition.

Territory Kidney Care (TKC) was conceived in response to the collective demand of health services and communities for better integration of services. The kidney-care platform and clinical decision-support tool links primary and tertiary healthcare systems and providers across the NT.

TKC represents a collaboration between Menzies School of Health Research, NT Health and the Aboriginal Medical Services Alliance Northern Territory (AMSANT). TKC has been developed with input from clinicians (tertiary and primary health care), programmers, health researchers and policymakers across the Top End and Central Australia.

TKC has successfully integrated electronic health records for over 30,000 patients with established risk factors for CKD from six public hospitals, 56 government-operated primary health clinics and nine Aboriginal community-controlled health services in the NT.

TKC combines chronic disease data from multiple clinical information systems. Through a series of clinical algorithms, TKC interprets, summarises and diagnoses from collated records to facilitate early identification and optimal management of CKD and co-morbid conditions. The clinical algorithms, derived from evidence-based guidelines, are developed dynamically with input from clinician experts. TKC’s ability to immediately analyse and summarise longitudinal clinical and administrative information, to present a real-time clinical summary, facilitates efficient and timely integrated care.

Currently there are over 300 users of TKC including nurses, Aboriginal health practitioners, general practitioners, specialists and allied health professionals.

The concept of TKC has evolved from the development of a clinical registry for people living with CKD, into a clinical decision-support tool and platform to support integrated care. We now plan to use machine learning to better predict progression of CKD. In 2020, TKC was awarded the NT Digital Excellence Award in acknowledgment of its benefit to the community. A recent Medical Research Future Fund grant will extend the system to private general practitioners and include other chronic diseases. A rigorous evaluation of the impact of TKC has commenced this year.

TKC facilitates efficient, safe, holistic and high-quality care. Our vision is to develop a versatile, non-disease-specific, digital tool embedded in day-to-day clinical practice. With the inclusion of other chronic conditions, we will develop a scalable system, with the aim to provide integrated care for people in rural and remote areas across Australia.

Contact for access if you are a healthcare provider in the NT: [email protected]