Highlighting Telemedicine

Chronic wound management requires frequent assessment of the wounds’ needs to evolve the plan of care and reach complete wound closure in a timely manner. This is often easier said than done, particularly for persons residing in rural settings, long-term care facilities and those with transportation issues. For the patient, chronic wound care is not only an emotional and physical burden; it also proves to be a financial and social burden due to frequent visits to the wound clinic.
The evolution of technology and positive legislative change has made telemedicine a real possibility in the advancement of chronic wound management. Use of this technology has the potential to connect patients
and clinicians with wound care specialists in order to improve wound outcomes in a more cost effective and less burdensome manner.

TYPES OF TELEMEDICINE
Telemedicine refers to the transfer of medical information through electronic mediums for the purpose of providing medical care from a distance. Common sources of transmission include telephone, fax, interactive video, e-mail and electronic patient records. Telemedicine encompasses an assortment of items including computers, cameras, communication devices and networks, and specialized medical equipment. Key features of a good telemedicine system include human factors like convenience and ease of use, privacy and reliability. Telemedicine generally falls into one of two categories: real time or store-and-forward.
Real time, or interactive telemedicine, involves the simultaneous presence of the patient and clinician. Telephone consultation, video conferencing, and remote robotic surgery are all examples of real time technologies. One barrier to adoption of this category includes costly installation and maintenance of real time technology equipment.
Store-and-forward technology involves the storage and transmission of data for future use. Transfer of x-rays, scans and digital photos are commonly used store-and-forward applications. Electronic systems that can store and analyze data, as well as offer treatment algorithms, are another example of this technology. Store-and-forward applications tend to be easier to use and maintain, making this the most commonly used form of telemedicine today.

BENEFITS IN LONG TERM AND HOME CARE SETTINGS
It is difficult to substitute the expertise of a wound care specialist. These clinicians have extensive training and ability to triage and manage wounds that other clinicians may not have. Unfortunately, with the increasing prevalence of chronic wounds, availability and accessibility to a chronic wound specialist can be very challenging. Integrating telemedicine enhances the accessibility of chronic wound specialists to other clinicians to initiate a comprehensive wound treatment plan that can decrease complications and costs.
In addition to using telemedicine as a diagnostic and treatment tool, it can also be used as a teaching mechanism. For example, it is often difficult for clinicians in a long-term care or remote setting to stay abreast of the latest advances in the treatment of pressure ulcers.1 The ability to consult with specialists, participate in a wound care specific treatment plans, and the use of software with built-in decision support features are all ways to enhance the knowledge base of clinicians who might otherwise not have access to specialized instruction.
From the patient’s aspect, telemedicine may be most valuable for those who live in remote locations or have difficulty with ambulation or transportation. Imagine the ability to perform a ‘wound check’ using telemedicine from a center close to their home or through home health services. This would eliminate travel time, stress and costs associated with travel for the patient.
Immobilized residents of long-term care facilities also pose a great transportation issue. These residents could benefit greatly from the increased accessibility to specialized healthcare that telemedicine offers.Often such residents suddenly worsen and need immediate intervention. Unfortunately, the long-term care practitioner may have a geographical spread preventing them from being immediately available. With the use of telemedicine, practitioners and specialists can be consulted and instructed on treatment without the need to transport the resident to the emergency room.
Greater access to specialists, decreased transportation costs and reduced isolation for rural health care professionals are just a few of the benefits that can be realized through the use of telemedicine. Specialties such as radiology, pathology and dermatology, all of which have high visual components, lend themselves well to telemedicine.2 The time has come to integrate telemedical wound care.

BARRIERS TO INTEGRATION
For all the benefits, there still exist some barriers that have prevented the widespread use of telemedical wound care. Reimbursement is one of the most significant barriers; however, this seems to be evolving with time.
Medicare reimbursement for telemedicine appropriate to wound care services includes remote patient face-to-face services seen via live video conferencing. According to the American Telemedicine Association4, Medicare currently reimburses for telemedicine using live video conferencing if the services are performed in one of the following originating sites:
• The office of a physician
or practitioner.
• A hospital.
• A critical access hospital.
• A rural health clinic.
• A federally qualified health center.
January 1, 2009 brought about
additional reimbursable originating sites to include:
• Skilled nursing facilities.
• Hospital-based dialysis centers.
• Community mental health centers.
A remote physician, as well as several other advanced practice clinicians, consulting with a patient using telemedicine technology in any of the above originating facilities, can receive reimbursement from Medicare for those services. A 5% bonus payment is also provided for any physician or practitioner who uses telemedicine to consult with patients who reside in a federally designed Physician Shortage Area3. The originating facility will also receive an originating site fee.
Although store-and-forward technology is cheaper to implement and lends itself well to wound care, it does not meet the CMS definition of telemedicine and therefore has unique reimbursement challenges5. These services may, however, be reimbursed as part of a Medicaid coverable service under section 1905(a) of the Social Security Act.
Other barriers include cost of infrastructure, laws regarding interstate licensure, malpractice fears, and transfer of patient data and images using Health Insurance Portability and Accountability Act (HIPAA) regulated programs to ensure patient privacy.
The Obama economic stimulus bill holds promise in overcoming some of the above-mentioned barriers. The plan is expected to invest in the infrastructure necessary to allow for and promote the electronic exchange and use of health information. The plan includes details related to infrastructure and tools for the promotion of telemedicine, including coordination among Federal agencies in the promotion of telemedicine.
This plan also aims to boost security and privacy controls beyond those now required under HIPAA. For example, providers will be required to maintain audit trails of all patient transactions and have all patient health data encrypted. This certainly adds to the cost of infrastructure.

CONCLUSION
The current economic environment demands more efficient, cost-effective, and most importantly, efficacious treatment options become available. With current technological advances, telemedicine seems poised to become the primary medical modality in certain settings for treatment of chronic wounds. Therefore, it seems only logical that these barriers can and will be overcome.

Trisha Carlson, MSN, MBA-HCM, RN, CWCN, DAPWCA is the Director, Clinical Quality and Education National Healing Corporation. For more information she can be reached via email at tcarlson@nationalhealing.com.
Lori Collins is the Clinical Data Analyst for National Healing Corporation in Boca Raton, Fla.