Territory Kidney Care: a clinical decision support system to facilitate integrated care for people with CKD in the NT



Territory Kidney Care (TKC) is an innovative clinical information system that uses powerful analytics to assist with the early identification and best-practice management of kidney disease. Menzies developed TKC in partnership with the NT Department of Health, the peak Aboriginal health representative body (AMSANT) and local Aboriginal community-controlled health services. TKC utilises a service orientated architecture that connects to existing health platforms, automatically and securely transferring clinical information of select patients based on agreed criteria. Algorithms applied to the consolidated records stratify patients according to risk and CKD stage, enter patients into surveillance loops and initiate triggers to alert the tertiary clinical support team of actions required. TKC enhances health care through the integration of clinical information systems and the implementation of evidence-based protocols.

Based on published literature TKC is the only system worldwide that can seamlessly consolidate primary and tertiary care information and derive clinically relevant summaries based on dynamic algorithm-based phenotyping. TKC undertook an iterative and incremental design process in partnership with stakeholder health services and clinicians to ensure the system was built ‘fit for purpose’.


Integrated systems of care which focus on prevention and care coordination, can slow the progression of kidney disease and reduce complications of inter-related illnesses such as diabetes and cardiovascular disease.

The TKC clinical support system facilitates integrated care through:

  • Combining clinical information from multiple systems to provide a complete patient picture
  • Improved surveillance and identification of CKD and earlier intervention
  • Appropriate referrals and reduction in remote community travel
  • Supporting GPs adherence to evidence-based care
  • Creating efficiencies in service provision
  • A platform for health services innovation
  • More robust and timely data for:
    • Quality Assurance
    • Service planning
    • Resource advocacy

Chronic Kidney Disease (CKD) is a common and serious health problem in Australia. CKD refers to all kidney conditions where a person has kidney damage and/or reduced kidney function. People with CKD suffer poor health outcomes, reduced life expectancy and reduced quality of life. The burden of CKD is particularly heavy amongst Indigenous Australians and in the NT the rates of kidney disease are the highest in Australia. More than 2 in 5 Aboriginal adults in remote NT communities show evidence of having CKD. Many people do not know they have CKD as up to 90% of kidney function can be lost before symptoms are evident. Additionally, chronic conditions such as diabetes, hypertension and heart disease, although occurring more frequently in Aboriginal people, may not be fully recognised as risk factors for CKD. CKD is an under-diagnosed condition.

Demand for dialysis treatment and the associated expenditure has increased relentlessly over recent decades in the NT and has surpassed all projections. Measures to address the high rates of chronic kidney disease and provide earlier intervention to delay or avoid the need for dialysis are urgently needed.

Territory Kidney Care is an integrated clinical information system that provides a means to facilitate earlier and targeted patient care without increasing the resource burden on staff.

Implications for policy and practice:

In the NT, where the Aboriginal population is highly mobile and often access multiple community and hospital-based services, there are significant challenges to the provision of optimal integrated care. Patients with a high risk of developing chronic kidney disease (CKD) are slipping through “the cracks” in our health system.

The effective integration of disparate health care systems is crucial in the “new normal” post-COVID19 era. The NT experienced very different challenges in the delivery of health care during the pandemic, compared to other jurisdictions. Remote communities were declared biosecurity zones and travel by clinical staff and patients to and from the communities was severely restricted. Virtual health care became a necessity. However effective virtual health care relies on access to complete patient information and clinicians are often required to work with diverse interfaces to obtain the data they need; often this information is incomplete.

TKC, adds an immense contribution to virtual healthcare, telehealth and integrated care and will be core to our ability to sustain effective care for people with complex chronic conditions as we transition to post-COVID models of care. TKC has the potential to transform care delivery and provide consumer-centric, affordable, accessible and high-quality health care.

Our research has found:

Our work with tertiary and primary health services has found that a substantial proportion of people at risk of CKD are not regularly screened and that a number of people with advanced CKD do not have a correct diagnosis and are therefore not receiving evidence-based care.

However there is strong evidence which suggests that patients who have intense monitoring, follow-up and treatment according to evidence-based protocols have better health outcomes, reduced health service utilisation and make timely and more informed choices about treatment options. Additionally, there is extensive evidence on strategies to facilitate the earlier identification of people with CKD which include monitoring, surveillance and the regular screening of people with hypertension, cardiovascular disease and diabetes. Importantly, the provision of care to people by people that know them and their family the best - the community health service- is key to increasing and maintaining patient engagement and this requires support for GP in the management of people with complex conditions.

Chief Investigator:

Gillian Gorham

Project contact:

Gillian Gorham

Paul Kamler

Project start date:

Early 2017


The Territory Kidney Care (TKC) database is only available to clinical staff who are providing care to Renal patients and you must have a NTG LAN ID to be able to access the system at https://territorykidneycare/. 

To gain access to the Territory Kidney Care System, please contact Paul Kamler.


Participation in TKC for non-government health services is voluntary. Participation is formalised through execution of the TKC Participation Agreement, which outlines the working relationship between the partners and the data security, data management, access and privacy protocols. The following links are provided for your information. 

A staged roll-out of TKC across the Territory is planned for 2020 to ensure the level of data integrity required for the type of clinical decision support TKC provides is maintained, and to allow the TKC Project Team to support newly participant Health Services to enact their implementation plans. To assist Health Services to identify and work through activities to support successful implementation on TKC an Implementation Plan Template has been developed.

For more information on how your health service can participate in TKC, or to arrange a presentation / information session for key stakeholders at your health service please contact Paul Kamler.

Lastest update: 

Earlier updates:

  • Philanthropic
  • NT Renal Services
  • Department of Health
  • Miwatj Health Service
  • Congress Aboriginal Health Service
  • Aboriginal Medical Service Alliance NT
  • NT Primary Health Network
  • Katherine West Health Board 
  • Mala’la Health Service Aboriginal Corporation 
  • Ampilatwatja Health Care Aboriginal Corporation
  • Wurli Wurlijang Health Service 
  • Laynhapuy Homelands Aboriginal Corporation
  • Purple House
  • Department of Corporate and Digital Development 
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