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Electronic Consultation as an Alternative to Hospital Referral for Patients with Chronic Kidney Disease

By: Bradford Teaching Hospitals NHS Foundation Trust

convenience, avoidance of unnecessary referrals, increased GP confidence in managing chronic kidney disease in the community, facilitating prompt and informative decisionmaking by the nephrologist, releasing resources in the specialist unit, saving transport and resource costs

40kg CO2e per outpatient visit avoided (Estimated)

Over 90% of the primary care practices in the Bradford and Airedale PCT use a centralised IT system (SystmOne®), allowing detailed electronic health records to be shared by groups of healthcare professionals in various care settings.

The rising prevalence of recognised CKD prompted a multidisciplinary review of local renal service provision and a programme of work to strengthen communication at the interface between primary and secondary care.

Strategy for Change

  • Development of a CKD e-consultation service in SystmOne®, allowing GPs to send electronic referrals and share patient electronic health records with a renal specialist after first obtaining verbal patient consent.
  • Participating GPs attended education events and received paper and electronic guidance about the new service. It was explained that the service should be used to obtain advice for specific queries and to request virtual review of patients with an indication for hospital clinic referral that was ‘borderline’ according to local criteria.
  • GPs use criteria agreed in local guidelines to ‘request advice’ or ‘question the need for hospital clinic review.
  • The renal specialist is able to open the electronic health record and view important clinical details such as patient comorbidities, medication history, lifestyle factors, previous communications from other specialists, reports of previous imaging and a chronological display of selected numerical data (BP, estimated glomerular filtration rate, blood biochemistry and urinalysis).
  • A decision is then made as to whether a patient should be referred to clinic, undergo tests or interventions in the primary care setting, or continue to be monitored and treated by the primary care team.
  • Responses are saved in the patient’s electronic health record and also sent as tasks to alert the referring primary care team.

A single practice pilot of e-consultation indicated potential benefits, with better coordination of patient management and avoidance of clinic referrals. We therefore introduced e-consultation to 17 volunteer implementation practices in July 2007,supported by two nephrologists.

Effects of Change

  • E-consultation was regarded by GPs and patients alike as a convenient service that provided timely and helpful advice and avoided unnecessary referral to the hospital clinic. GPs recognised that e-consultation presented an educational opportunity that increased their confidence in managing CKD in the community. Patients were generally willing to consent to the viewing of their electronic health record by a renal specialist.
  • For the nephrologist, e-consultation permitted a detailed and efficient review of a patient’s primary care electronic health record, facilitating prompt and informed decision-making. Patients in need of renal outpatient clinic assessment were readily identified, and others benefited from the provision of timely advice. Avoidance of unnecessary hospital clinic visits was seen as an effective way of releasing resources in the specialist unit for those patients who need them most, as well as saving on transport and other environmental costs. The NHS Sustainable Development Unit estimates that an outpatient visit generates a carbon footprint of approximately 40 kgCO2e (Carbon Dioxide Equivalent).
  • Between September 2007 and September 2008 11 out of 68 (16%) econsultations were finally referred to clinic, comparedto 376 out of the 398 (94%) paper referrals.


Primary Care Teams have greater responsibility for the management of chronic kidney disease

Bradford and Airedale Teaching Primary Care Trustand the Bradford Institute for Health Research

John Stoves, john.stoves@bradfordhospitals.nhs.uk