Aims and hypothesis: 
The aim of the Territory Kidney Care (TKC) system development is to design an integrated clinical decision support tool for early Chronic Kidney Disease (CKD) identification and management that consolidates patient records from government and non-government, primary and tertiary services, to:
  • close the information gap,
  • support the delivery of targeted, evidence-based care, and
  • improve the patient journey.

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

The TKC clinical support system is intended to facilitate integrated care through:

  • Better surveillance and earlier intervention
  • Appropriate referrals and reduction in remote community patient and specialist travel
  • Monitoring, standardising and supporting adherence to evidence-based care
  • Creating efficiencies in service provision
  • A platform for health services innovation
  • More robust data for:
    • Quality assurance
    • Service planning
    • Resource advocacy

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 Aboriginal Australians. In the Northern Territory (NT) kidney disease rates are the highest in Australia with Aboriginal people presenting for dialysis 20 years earlier than non-Aboriginal people. The need for dialysis has a major impact on health, lifestyle and social and emotional wellbeing, especially for people required to relocate for treatment.

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.

However, 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.

TKC 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:

Menzies has undertaken extensive engagement with the Department of Health and Aboriginal medical services to determine the key system requirements. The TKC system was released into the production environment in April 2019 with the subsequent release of V1.1 in September 2019, incorporating improvements based on user feedback.

The uptake of TKC by renal clinicians is expected to be high with users already noting the efficiencies created by the system. Additionally, the clinical decision support to remote based general practitioners (GPs) has been developed based on their needs with special attention to ensure GPs are not faced with “Alert” fatigue. Critically, TKC does not change the primary health service user interface, require the adoption of additional technologies or completion of paper-based records.

The Evaluation Framework will encompass an iterative process to ensure the system is fit for purpose and implementation will occur in a staged process to accommodate findings and issues form each health service.

A full economic impact evaluation is planned for years three to five.

TKC will be embedded in NT Renal Services business as usual processes.

Our research has found:

Our work with Aboriginal 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 that 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 the regular screening of people with hypertension, cardiovascular disease and diabetes, support for GPs in the management of people with complex conditions and the provision of care to people by people that know them and their family the best.

Chief Investigator:

Gillian Gorham

Project manager:

June Fairless

Project start date:

Early 2017


Philanthropic donations

  • NT Renal Services
  • Department of Health
  • Top End Health Services
  • Central Australian Health Services
  • Miwatj Health Service
  • Congress Aboriginal Health Service
  • Aboriginal Medical Service Alliance NT
  • NT Primary Health Network
  1. NT News | Funds for critical health issue studies

    NT News | Funds for critical health issue studies


    Report on Menzies NHMRC and MRFF Investigator grants.

  2. Five medical research projects recognised in the Northern Territory

    Five medical research projects recognised in the Northern Territory


    Five researchers based at Menzies have received recognition in the form of Investigator Grants from the NHMRC and the MRFF.

  3. $440 million funding boost for vital health and medical research for all stages of life

    $440 million funding boost for vital health and medical research for all stages of life


    $6 million in research funding for three Indigenous health grants in the Northern Territory. This includes $2.5 million for an NHMRC Centre of Research Excellence at the Menzies School of Health Research to prevent and manage bronchiectasis, a lung disease which results in recurrent chest infections and is particularly common in Aboriginal and Torres Strait Islander people.

  4. Senator reveals personal story of kidney disease

    Senator reveals personal story of kidney disease


    Nephrologist at the Menzies School of Health Research, Paul Lawton, said his research team had been investigating key causes that dramatically impact upon remote Aboriginal communities.

  5. Sunday Territorian | Gift of life

    Sunday Territorian | Gift of life


    Senator Malarndirri McCarthy discusses her kidney diseaese and treatment by Dr Paul Lawton

  6. Project newsletter | June 2019

    Project newsletter | June 2019


  7. The Health Advocate Episode 11 - Renal Patients in Remote Communities

    The Health Advocate Episode 11 - Renal Patients in Remote Communities


    AHHA's Director of the Deeble Institute for Health Policy Research, Rebecca Haddock, sits down with Stephanie Pushka.

  8. SMH | Hope and healing

    SMH | Hope and healing


    A new approach to treatment is helping Indigenous Australians fight kidney disease

  9. COAG Health Council | Communiqué 8 March 2019

    COAG Health Council | Communiqué 8 March 2019


    The Federal, state and territory Health Ministers met in Adelaide at the COAG Health Council to discuss a range of national health issues.

  10. Project Newsletter | December 2018

    Project Newsletter | December 2018


    The last two months of the build and development phase of the TKC have been very busy with both stakeholder engagement and application engineering

  11. Territory Kidney Care | Progress Report November 2018


  12. Project Newsletter | October 2018

    Project Newsletter | October 2018


    The build and development phase of the TKC system has continued with efforts focused on the areas of knowledge acquisition and engineering

  13. Win for dialysis patients in Northern Territory

    Win for dialysis patients in Northern Territory


    THE Territory’s kidney disease sufferers will be the major beneficiaries of a new Medicare item to be announced by the Turnbull Government today.

Participation in Territory Kidney Care (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 the TKC Project Manager.