Telemedicine: The Key to Opening the Door to Wound Closure in Rural Communities?

The goal of any wound care provider is to offer the best-known and best-available standard of care, regardless of setting or location. As such, all patients should receive care in a timely, efficient, cost-effective manner — and that care should never fail to be consistent across the healthcare continuum. When integumentary specialists are unavailable, as is often true in clinics found in rural communities, providing optimal wound care becomes more challenging as more patients often must be transported long distances in order to see a specialist. Today, however, wound care clinicians are realizing a new solution to this problem and are achieving better wound management outcomes through the use of telemedicine programs that offer patients and providers alike electronic access to remote specialists who can assist in the delivery of care for chronic, nonhealing wounds. The benefits of telemedicine service also are seen on the financial side in that it fuels economic development within the rural areas it’s used. Business prospects consider healthcare a key factor when deciding on location, and the opportunity to be seen by specialists, whether integumentary or otherwise, is significant. At Archbold Medical Center (AMC) in Thomasville, GA, the use of telemedicine has allowed staff to augment our overall physical presence in the five surrounding counties we serve by providing expertise in smaller, rural communities. In essence, the “path” to advanced wound management has been repaved.

A New Undertaking

  Staff at AMC began utilizing telemedicine in 2004 through a grant from the Rural Health Initiative of Georgia, a project aimed at improving availability of technology to rural healthcare providers in an affordable manner that’s sponsored by the WEDI (Workgroup for Electronic Data Interchange Foundation) in conjunction with Mercer University School of Medicine and Morehouse School of Medicine. In 2007, AMC joined the Georgia Partners for TeleHealth (GPT), a statewide network that aims to increase access to healthcare through innovative use of technology. As a “hub and spoke site” for telehealth, AMC (a network of one main hospital, three affiliate rural hospitals, three subacute swing bed hospitals, three nursing homes; a psychiatric hospital; a rural specialty clinic; an urgent care facility; a hospice program; two visiting nurse associations and a home health agency) is considered an information “hub.” As a “hub,” AMC houses a computer server that stores patient records and other valuable information. AMC also serves as a “specialty site and as a patient-presenting site, referring patients to other consultants within the telemedicine network while providing consultations for patients outside of AMC. Telemedicine and teleradiology specialists providing remote consults at AMC include a dermatologist, a psychiatrist, a surgeon, a podiatrist, a neurosurgeon, a cardiologist, an interventional cardiologist, and a physical therapist (PT) who’s also a certified wound specialist (CWS®). The majority of our consults are provided by the dermatologist, psychiatrist, and, PT, who, according to GPT, is performing more consults than any other clinician in Georgia.   Telemedicine is available in two forms: “real time” (which features interactivity on the part of both the patient and the clinician) and “store-and-forward” (the transmission and storage of photos and/or data for future use — not as expensive, easier to use and maintain, and the most common type used today¹). Equipment needed to conduct the service includes a computer and applicable software, specialized cameras and video equipment, high-speed telephone lines, and encryption technology. Real-time telemedicine offers live consulting, which requires a transmission network with an image-sending station. The software also displays diagnostic data, lab values, etc.

Conducting Tele-Wound Care

  As the clinical educator of wound management my role includes providing monthly patient visits to affiliate facilities (all located within an hour’s drive of each other) to conduct consults, complete rounds, provide formal and informal education, and to treat complex wounds, among other services. Detailed weekly reports of all wounds and skin tears are sent to me by network nursing home staff, and all facilities that I visit are required to send me photo documentation of each wound I treat on a weekly basis. All information is stored on a dedicated telemedicine laptop. At John D. Archbold Memorial Hospital (JDAMH), our flagship hospital, I host live telemedicine integumentary clinics monthly (along with a surgeon) to allow rural facilities to have their patients seen without having to be transported many miles to the physician’s office or the wound center.   Local physicians can also request clinic consults, either new or follow-up. Prior to a consult, I receive the patient’s history, wound culture reports, and wound assessments. Information and equipment they are to have for the physician at the clinic includes current prealbumin, lab values, and wound measurements; previous wound assessments (including photo documentation); patient charts; swabs for probing the wound; and forceps. The most common type of integumentary telemedicine in use today, according to the GPT, is the store-and-forward method, which can serve in a stand-alone capacity or be used in conjunction with real time. Using the Internet, this method provides regular monitoring through photo documentation. Consults or follow up can be done from any location, and the program stores data and automatically places photos in individual patient folders listed chronologically. Files are archived, allowing for continuity of care and follow up. Each folder also contains a demographics form, a referral form, and all images. If desired, recent labs, history and physical, and related procedures can be scanned in, summarized, organized, and displayed in a meaningful way.² This also allows an intervention for prevention of pressure ulcers and assists in the continuum of care.

Telewound Documentation

  There are templates included within the program that assist in the documentation of the exam/consult. Terms can be keyed immediately into the system by the physician (and/or allied clinician) and printed. A consultation form can be sent for a live visit. Email and phone can be used for comments following the visit. By going to the computerized documentation and checking integumentary documentation, it is easy to coordinate Braden scores with facility protocols (for pressure ulcer prevention interventions), and to check prealbumin labs to monitor protein nutrition. Wound status can be monitored regularly while appropriate dressings and management can be determined. At AMC, we are fortunate in that all facilities utilize the same products and essentially the same policies and protocols, which are adapted to facility type. It’s also easy to monitor whether physicians’ orders are being followed, pressure ulcers are being correctly identified and staged, and interventions are being conducted appropriately.   In 2000 a study by Kobza et al discussed telemedicine and chronic wounds in the home care setting. Outcomes showed improved healing rates, decreased healing times, decreased number of home health visits, and decreased number of hospitalizations related to wound complications. The latter is an important factor in current reimbursement and regulatory issues. Kobza concluded that telemedicine is a viable option for delivering quality, cost-effective care to chronic wound patients in the home care setting.³   Reimbursement is covered by insurance in Georgia through the Rural Health Initiative, which states if insurance covers being seen in person, it must cover telemedicine if conducted in one of several sites. The originating sites covered by Medicare include the office of the physician or practitioner, hospital, critical-access hospital, rural health clinic, federally qualified health center, skilled nursing facility, hospital-based dialysis center, and community mental health center.⁴ There is a 5 percent bonus if the patient resides in a federally designated “physician shortage area.” The originating site also receives a site fee.⁵ As of Jan. 1, 2010, a skilled nursing facility can use C0406-G0408, which previously was just for the inpatient hospital setting. Modifiers GT and GQ may be used.⁶ Only real-time telemedicine consults are reimbursable under Medicare. Store-and-forward does not meet the Centers for Medicare and Medicaid Services’ definition of telemedicine. However, it is reimbursable by Medicaid under section 1905 of the Social Security Act in 27 states.⁷ The annual net cost savings to Medicare is estimated to be $2 billion-$4 billion.⁸ The future looks bright for telemedicine and our rural communities. The American Recovery and Reinvestment Act of 2009 calls for $2.5 billion to invest in infrastructure and tools for promotion of telemedicine in real time.⁹

Advantages/Disadvantages

  Development of a suitable telemedical system in the wound care field can have a significant effect on a community as well as tertiary referral patterns and hospital admission rates.¹⁰ With the advent of telemedicine for wound management, advantages include the ability to schedule emergent and new-patient consults more quickly, with shorter wait times for the patients/residents (hereafter referred to as “patient”). Additional advantages for clinicians include reduced travel and associated costs as well as patient-centered care, more streamlined care planning, easier wound management, and decreased costs.   Advantages of telemedicine for patients are many: They can stay with their local physician, which also is a physician’s advantage; travel to see a specialist is not necessary; and cost savings are seen in not having to call an ambulance and/or go to an emergency department (ED). Major hospitals see a decrease in ED visits, which can result in an increase in patient census, in areas where telemedicine is utilized.   Of course, there are a few disadvantages of the telemedicine system for an integumentary consult. There’s an obvious inability to palpate the wound or periwound tissue and an inability to determine the depth of the wound and any undermining by palpation. There’s also an inability to detect odor, but all noted disadvantages can be overcome by having the PT/PT assistant/integumentary nurse who’s with the patient provide descriptions and measurements.   However, a study by Dobke et al indicated that telemedicine consultations provide accurate chronic wound assessments. Between 2003 and 2005, 120 patients in a variety of settings were seen by a surgical wound specialist via telemedicine and subsequently via direct consultation. Settings included long-term care, skilled nursing, and home care. Store-and-forward was used, with only photos and the plan of care being emailed. Upon physical examination, only two cases (1.67 percent) showed a surgeon change the previously established diagnosis and management plan, demonstrating validity of telemedicine consultation.¹¹   A 2003 small pilot study¹² published by Halstead et al compared wound assessment of spinal cord injured patients via telemedicine and live exam. A plastic surgeon reviewed laptop images of 20 wounds among 17 individuals, then assessed the patient and wound live. The percent of agreement was:     • 95 percent need to change the management of the wound     • 95 percent need for referral     • 85 percent satisfaction for making treatment decisions     • 80 percent need to obtain additional information   A significant study published in 2006 by Hofmann-Wellenhof et al addressed the feasibility and acceptance of telemedicine for wound care in patients with chronic leg ulcers. Forty-one ulcers of different origin in 14 patients were included. During the initial in-person visit the leg ulcers were assessed and classified, and underlying diseases were noted. Follow-up visits were done by home health nurses. Digital images of the wound, periwound tissue, and relevant clinical information were transmitted weekly via a secure website to an expert at the wound care center. These experts provided assessment of the wound status and therapeutic recommendations. In 89 percent of 492 teleconsultations the quality of the images was sufficient or excellent. The experts reported being confident giving recommendations. Treatment modalities were changed or adapted in one-third of the consultations. A significant decrease in visits to the physician or the wound center was noted.¹³   A “bonus” benefit of a real-time system is its effectiveness in educating healthcare providers in rural areas while online with the specialists. Likewise, it is efficacious in educating family and caregivers. Hofmann-Wellenhof et al published an article stating that effective learning can be fostered in a telemedicine network, and in some respects is more effective than it would be in face-to-face caregiving. They determined the education component of telemedicine contributes to quality healthcare.14 Another important function of the real-time system is its use to conduct inservices and lectures. As many as four facilities can participate simultaneously on screen.

Telemedicine’s Reach

  Even the lay public is learning more about the value of telemedicine and wound management. In 2009, Parade magazine published an article about Rafael Grossmann, MD, at Eastern Maine Medical Center, that featured the use of telemedicine in his work as an expert in burn injuries. Grossmann compared 59 emergency telemedicine consults with telephone consults. With telemedicine, unnecessary transfers were practically eliminated and medical errors were reduced by 75 percent. This also saves unnecessary transfers to other hospitals and saves the family journeys.¹⁵ 

Harriett B. Loehne is clinical educator at Archbold Center for Wound Management & Hyperbaric Medicine, Thomasville, GA.