Digital Home-Monitoring of Patients after Kidney Transplantation: The MACCS Platform

We established a telemedicine care for patients after kidney transplantation, including a team consisting of experienced medical professionals. If vital signs exceed critical values, or messages indicate that something is happening with the patients, care can be adapted quickly to the needs of the patients. The telemedicine team also supports routine clinical care and improves the communication between patients and physicians in charge.

The development of this platform, which is still ongoing, takes into account the opinion of patients and different medical professionals. In addition, we adhere to the current GDPR. Begin by training the patient.

Show them where to find laboratory values and how they are presented, how to find the text messaging function, and how to send a message, how to start a video consultation, and how to find a medication plan, and confirm medication intake. Demonstrate how to submit vital signs, blood sugar, well-being status, and confirm, or decline medication intake. Train the patient how to take the immunosuppressive drugs correctly, and how to measure heart rate and blood pressure.

Set the patient's current body weight in the telemedicine dashboard by clicking on the Therapeutic Plan button. Fill in weight in kilograms, and click on Confirm Data. Define the therapeutic plan for home measurements with the patient, and fill out the frequency table in TBase.

Discuss with the patients when to contact them to remind them to forward data, and encourage the patients to call in case of medical, or technical problems. On the next day, check whether data have been received, and call patients to explain that the data have arrived, asking about any technical issues they may have faced. Start the day with a structured process in reviewing incoming vital signs in the telemedicine dashboard.

Filter patients according to their critical values, and if necessary, call the patient, or discuss the case with a physician from the telemedicine team. Review well-being data. Call patients if the well-being score is low, or if it decreases by more than two points.

Consult a telemedicine team physician if the reason for the decrease in well-being is critical. Review less critical, but suspicious values, and discuss these cases with a physician. Control incoming medical messages and take action if necessary.

Document all calls and activities in the telemedicine dashboard chart. Identify patients who did not document data in the app as previously agreed. Call the patients and ask about potential technical problems as the reason for missing the data.

If technical data transmission is working, remind the patient to regularly forward data as agreed. Answer incoming calls from patients and local nephrologists. Ask patients at regular intervals about satisfaction with the telemedicine survey and usability of the app.

Document this information, which is forwarded to the development team for evaluation and continuous improvement. Review reports from the nurses on critical values, such as high blood pressure. In severe cases, contact the senior nephrologist of the transplant team, or the physician who saw the patient during the last inpatient stay.

Call the patient, take medical history, and give advice. Follow the patient closely over the next days if a change of medication, or an unclear situation has occurred. During the onboarding process, listen to the telemedicine team and ask questions.

Give signed consent, and download the app with the help of the nurse. After receiving the initial login data from the nurse, change the login data and confirm participation digitally. Enter the new login data into the app, and push Sign In.After the app opens, enter the well-being status, and click on the Send button.

Observe the buzzing sound and the confirmation sign and send the result from app to computer. Measure the blood pressure, enter the data into the app, and push the Send button. Observe the buzzing sound and the green banner pop-up showing vital data sent.

Look at the show history list, and observe the table with all the values and transmission information. Open the communication page, and send a text message to the nurse. Start a video session by clicking the Video button.

Open the lab results page, and look at recent laboratory data. Open the medication page, scroll through the medication plan, and confirm medication intake. Set the alert function for timely medication intake.

After the nurse explains how the medication plan can be forwarded and printed out, log out of the app. At home, open the app and enter the vital signs. Look at laboratory values, medication plan, and confirm medication intake.

Send a text message and perform a video consultation. Enter login data in the registration page, and look at the consent page, where consent was given for data transfer to the local nephrologist, and where consent can be easily withdrawn. In the first five months between February and July 2020, 172 kidney transplant recipients matched the inclusion criteria, and were asked to participate.

Out of 172 participants, seven needed to borrow a smartphone. 33 patients declined for various reasons. In the end, 139 patients were enrolled.

Of these, eight patients withdrew, and 131 patients are still participating in the project. The demographic characteristics of the participants are shown here. In total, 29, 089 entries were transmitted on 8, 954 observation days from 131 active participating KTR, which resulted in 3.4 entries per day per patient.

The MACCS platform fits into a digital infrastructure. It includes data transmission to medical professionals at highly specialized outpatient care centers, patients, and physicians in private practice. We even programmed APIs to safely provide the data into the different EHRs.