Technology in the Clinic: From A Wound Care Professionals View

  If you look at a timeline of advances in medicine it is not only the volume but also the rate of change, which is shocking. In ancient times, major advances in medical knowledge were measured in mellinia. By the middle ages the speed of technological advance was measured in centuries, after the Enlightenment it was in decades, and by the 19th century it was in years. We can ague that major medical discoveries now occur weekly (https://en.wikipedia.org/wiki/Timeline_of_medicine_and_medical_technology).   These technological changes in medicine bring increased longevity, improved quality of life, and less time absent from work—estimated by some economists to be worth trillions of dollars. In fact, the value of biomedical innovation to the US may equal the value of innovation in all other sectors of the American economy combined, according to Mark McClennan, the former administrator of the Centers for Medicare and Medicaid Services. Technological innovation is a major source of increase in real per-capita medical spending in the US which may actually reduce spending on medical care. A key question is whether the benefits of innovation are rising faster or slower than the costs. This is true in all areas of medicine, not just the wound care industry.   Over the last 10 to 15 years, an increasing understanding of the “science of wound care,” fueled an explosion of innovation leading to the commercialization of a wide range of new products. The worldwide market for these products is estimated at $4.5 billion annually, with double-digit growth projected over the next three to five years. We use these products and devices daily and the representatives for new ones ask for time to show us the latest inventions. We now have biological dressings, surgical sealants, wound healing devices, debriding devices, and novel mechanical or electrical devices, which tout increased wound healing by a variety of mechanisms. There are now products with ‘nano particles,’ and even medical textiles. Just keeping track of their names is daunting, much less keeping track of how and if they even work.

A Snapshot of Twenty Years

  I have already alluded to what a fossil I am in terms of my practice. In a previous editorial I have told the story of starting my clinic with a three page handout on leg ulcer compression given to me by Dr. Claude Burton at Duke. There was certainly no textbook or other resource for me to use. In 1990, we needed exactly three products: Duoderm (the first hydrocolloid on the market), Unna’s boots, which were essentially unchanged since their development by Dr. Unna in the late 1800’s, and ace wraps, which we placed on the outside of the Unna’s boots. Like Dr. Burton, we washed our leg ulcers with washcloths and warm tap water. Despite such humble products, our healing rate was over 85%. However, the clinic was very messy and smelled awful and we went through a lot of cans of air freshener. We made our clinic notes by hand until we got “sophisticated” and worked out a check box system for documentation. We did not have to worry about Methicillin resistant Staphylococcus aureus, HIPAA regulations, or even complicated Medicare reimbursement policy. I dictated letters to referring physicians (on a Dictaphone) that were transcribed by a clinic secretary (who still could take shorthand in a pinch.). In fact, I am actually old enough to have said to a secretary, “Verna, take a letter …” It all seems like the stuff from old movies now.   When the 1995 Medicare guidelines for physicians came out, I studied them carefully and came to the conclusion that only a computer program could calculate them correctly. I made the decision that same year that my clinic would begin using computers for wound care documentation, even though I knew nothing about computers. We “went live” with the first version of such a system at Hermann in 1998. The years between 1996 and 1998 represent important years. In 1997 I used “the VAC” for the first time. I remember saying to the sales representative, “You want to do what to a wound?” We participated in the Becalpermin trial and the Apligraf trials, which also happened between 1996 and 1998. New compression bandage systems, new dressings, and advanced wound treatment options came on the scene at a breakneck pace between 1995 and 2005. Suddenly there were books about wound care, courses one could go to, and medical meetings about wound care. We had to manage an actual formulary. Questions came up like—which products to pick? Should we contract with a specific manufacturer? What about the fact that no one company carried all the things that we wanted?   In 1998, our wound center was actually the first outpatient center in our hospital system to adopt an electronic medical record (EMR), the first version of WoundTrak (Intellicure, The Woodlands, Tex). However, the hospital itself eventually went electronic and is now among the most sophisticated in the country. Eventually ‘web developers’ wanted to know what we wanted to put on our clinic website. How was I supposed to know that? Decisions had to be made regarding whether and how we would communicate with patients electronically and how we would meet HIPAA standards if we did it. Would electronic communication save me time (by reducing my phone call load), or just make me crazier? We used to have mailboxes in the hallway for staff so we could communicate via written memos (I often dropped notes and copies of papers into their mailboxes), but now we communicate via email, but does that make it better?   Then there are the management of digital photos, and the challenge of making sure we have correctly defined the medical record. Electronic media has made the medical record a very complex entity. Pieces of it are now everywhere, in cameras, in the hospital EMR, in our clinic EMR. HIPPA requires that you know where all those elements are, and that you can put it all together at any time. Documentation is more legible, easier to retrieve, and can be analyzed in all sorts of ways, but far more complex.   And what about all those products being created at an alarming pace? How should you evaluate new products? How should you handle company representatives with new products to demonstrate? How do you incorporate new products into your practice? How do you decide if they are cost effective, and exactly who is paying for them? Representatives often come to demonstrate something and say confidently, “It’s reimbursable.” But in fact, it often isn’t reimbursable if used by my staff, in my setting. Sales representatives will “It will save money.” Well, it is possible that some technologies save money in a universal sense. However, if they cost money to my center, and I can’t recuperate the cost some way, then I simply can’t have it—or so says my hospital administrator.

The Future

  I now find that I need an information technology degree, a marketing degree, and an MBA to run a clinic, which used to be so simple. While I know that there are patients I can now heal whom I could not have healed in 1990. However, I am quite sure that it now costs much more to do even the simplest things. As healthcare costs have gone up, it is increasingly important to make sure we are realizing the full value of the new medical technologies that we create. Maximizing our public health gains and our economic gains from new medical technology requires that we encourage high value innovations and realize more value from the products that we use. This is important for the future, because while the cost of new medical technologies may continue to rise, the potential benefits of new treatments could grow even more dramatically. We must find better ways to increase value and to keep modern care affordable, while still encouraging medical innovation. A statement that a physician friend relayed haunts me to me, made by an unnamed Medicare official. My friend went to a hearing about Medicare coverage for a novel technology and the Medicare official said, “If it raises the dead and costs a dollar, we can’t afford it.” Encouraging medical innovation in the future with the bankruptcy of Medicare on the horizon will be a tall order. Caroline Fife is currently co-editor of TWC and a Board Member of the Association for the Advancement of Wound Care. Fife is the Director of Clinical Research at the Memorial Hermann Center for Wound Healing, Houston, Tex. She can be reached at cfife@intellicure.com