Opportunities in the cloud or pie in the sky? Current status and future perspectives of telemedicine in nephrology

Abstract

The use of telehealth to support, enhance or substitute traditional methods of delivering healthcare is becoming increasingly common in many specialties, such as stroke care, radiology and oncology. There is reason to believe that this approach remains underutilized within nephrology, which is somewhat surprising given the fact that nephrologists have always driven technological change in developing dialysis technology. Despite the obvious benefits that telehealth may provide, robust evidence remains lacking and many of the studies are anecdotal, limited to small numbers or without conclusive proof of benefit. More worryingly, quite a few studies report unexpected obstacles, pitfalls or patient dissatisfaction. However, with increasing global threats such as climate change and infectious disease, a change in approach to delivery of healthcare is needed. The current pandemic with coronavirus disease 2019 (COVID-19) has prompted the renal community to embrace telehealth to an unprecedented extent and at speed. In that sense the pandemic has already served as a disruptor, changed clinical practice and shown immense transformative potential. Here, we provide an update on current evidence and use of telehealth within various areas of nephrology globally, including the fields of dialysis, inpatient care, virtual consultation and patient empowerment. We also provide a brief primer on the use of artificial intelligence in this context and speculate about future implications. We also highlight legal aspects and pitfalls and discuss the 'digital divide' as a key concept that healthcare providers need to be mindful of when providing telemedicine-based approaches. Finally, we briefly discuss the immediate use of telenephrology at the onset of the COVID-19 pandemic. We hope to provide clinical nephrologists with an overview of what is currently available, as well as a glimpse into what may be expected in the future.

Keywords: CKD; ESRD; dialysis; quality of life; systematic review; technology; telemedicine; virtual consultation.

FIGURE 1

Taxonomy of telemedicine [1].

FIGURE 2

Telemedicine in HHD: nurse providing instructions and observing patient setting up dialysis at home (patient consent provided).

FIGURE 3

‘Virtual ward round’ for a fictitious inpatient at Furness General Hospital, Barrow-in-Furness, UK. The clinician at the renal centre reviews all patient data and writes an entry directly into the EHR. Panel A: Fluid balance and ward round documentation by parent team locally. Panel B: Virtual nephrology consultation documented remotely. Not shown are medication, vital signs, and laboratory/imaging results, which are also accessible during the remote consultation. The distance between the renal centre and the satellite hospital is 64 miles (103 km) or 90 min by car; the satellite hospital has face-to-face inpatient care once a week in conjunction with an outpatient clinic there. With kind permission from Melanie Waszkiel and Dr Colin Brown, University Hospitals of Morecambe Bay NHS Foundation Trust, Kendal, UK.

FIGURE 4

Schematic illustrating range of patient portals and mobile applications available, with examples of potential uses underneath.

FIGURE 5

RenalPatientView™—screenshot with laboratory results (fictitious patient) from [86] (open access licence).

FIGURE 6

Smartphone technology to remotely monitor urine dipstick results [120] to diagnose urinary tract infection or monitor proteinuria. healthy.io, Tel Aviv, Israel, with permission. The kit comprises a beaker, a solitary urine dipstick and a colour chart. Patients also receive the link to an app via text message that takes them through the process and uses the smartphone camera to assess the dipstick result. The result is uploaded to a secure web platform and the requesting clinician is notified [120].

FIGURE 7

(A) Wearable haemodialysis device. Courtesy of Dr Victor Gura, Cedars Sinai Medical Center of Medicine at UCLA, Beverley Hills, USA. (B) Automated Wearable Artificial Kidney (AWAK) device for PD. Courtesy of Dr Marjorie Foo, Senior Consultant/Head. Director of SGH-Peritoneal Dialysis Program, Department of Renal Medicine, Singapore General Hospital.