Telemedicine for Problematic Wound Management: Enhancing Communication Between Long-Term Care, Skilled Nursing, and Home Caregivers and a Surgical Wound Specialist
Telemedicine consultations are introduced to enhance communications between “specialist” and “primary care” providers. In the case of problematic wounds frequently affecting the elderly, frail, and non- or poorly-ambulatory patients and those individuals with poor health, telemedicine not only increases access to specialists for patients in rural settings but also facilitates communication in urban settings, reducing costly, emotionally and physically stressful transportation and shortening the time needed for implementation of the management plan with or without surgical intervention.1,2 Since accurate wound assessments, evidence-based management plans, and prompt access to specialists when needed are crucial to improve outcomes of care, particularly in patients with problematic wounds, this study was undertaken to determine the effectiveness of electronic communication for diagnostic and therapeutic plan development purposes.3,4
The study population included 120 patients with problematic, nonhealing wounds referred to the wound care program and surgical consultant by their primary care physicians. These patients were seen from January 2003 through December 2005 for telemedicine consultations followed by a direct examination by a surgical specialist (senior author, board-certified plastic surgeon) within 2 weeks from the initial telemedicine consult. Referred patients were seen within 48 hours by the wound care program nurse (RN or LVN) who was assessing the patient and obtaining a digital wound photograph. The appointment with the surgeon was made on the date when the consultation request was received. The result of telemedicine consultation based on e-mailed information had no bearing on the timing of the direct examination in the wound care clinic. Patients ranged in age from 32 to 86 years (mean age 68 years) and were residents of southern California long-term care facilities or skilled nursing facilities or had caregivers at home. There were 73 (61%) men, aged 37 to 82 years (mean age 68 years), and 47 (39%) women, aged 32 to 86 years (mean age 67 years). The majority (95%) of patients were of poor health and life-functional status as defined by presence of at least 2 of 4 health-related quality-of-life domains: 1) poor physical function with inability to ambulate and complete activities of daily living; 2) lack of psychological well-being with decreased level of alertness and presence of depression, anxiety, or fear; 3) impaired somatic functioning; and 4) impaired social functioning.5,6 Problematic wounds were defined as those that did not heal for at least 6 weeks since the date of injury or wound diagnosis and commencement of the initial treatment (not under the auspices of the wound care program).4 The epidemiology of conditions with which patients were referred is presented in Table 1. After the patient’s referral to the program, the “field wound care nurse” visited the patient, obtained the history, assessed the wound, and obtained digital photographs of the wound and involved body part. Summarized history, results of laboratory studies (if any), and photographs were transmitted via e-mail to the surgical specialist who discussed with the nurse and subsequently with the referring physician the initial patient management plan, including studies (eg, venous and arterial Doppler studies to assess extremity circulation). The initial assessment and management plan included diagnosis, including preliminary description of the problem, recommendations regarding laboratory studies, and treatment until the time of the patient visit with the surgeon. The treatment plan included specifics of conservative management (tests, other consultations, topical treatment) and tentative surgical intervention (eg, biopsy, debridement, flap or skin graft surgery). During the face-to-face consultation, the patient was reassessed, the initial management plan was reaffirmed, or the mode of care was changed.
To assess the accuracy of the telemedicine consults, the specificity, sensitivity, and positive predictive values were calculated with the assumption that correct diagnosis and indications (or lack thereof) for surgical intervention were established during direct consultations.7,8 Agreement levels between the 2 (telemedicine and face-to-face) assessments were judged by an independent investigator. Agreement rates were as follows: total agreement, trivial disagreement (not changing the overall management plan, eg, conservative versus surgical intervention), or clinically important disagreement (change of approach).9
The initial patient/wound assessment and management plan was developed for 120 patients with problematic, nonhealing wounds following a “field” evaluation by the wound care program nurse and telemedicine consult with a board-certified plastic surgeon. The surgeon (and wound care team) subsequently evaluated the patients in a hospital-based wound care center. Surgical intervention (eg, wound debridement, closure with a skin graft, skin or myocutaneous flap) was recommended in 48 (40%) of these patients in the initial assessment and management plan.
In only 2 cases, the definitive plan, developed during the face-to-face consultation, differed (clinically important difference, change from conservative to surgical or from surgical to conservative [1.67%]) from the initial management plan.
Case 1. A 78-year-old nonambulatory, moderately obese woman in a long-term care facility with Alzheimer’s disease, non-insulin dependent diabetes, and urinary incontinence developed a Grade III right buttock pressure ulcer. The wound seemed to be healing in the course of conservative treatment. The wound dimensions decreased from 4 cm x 3 cm x 3 cm to a seemingly 2-dimensional 0.5 cm x 5 cm defect within 3 weeks, and the drainage ceased (Figure 1).
The surgical telemedicine consultant recommended continuation of the conservative treatment. During direct examination, a large, “crater” like wound, approximately 8 cm in diameter, extending medially toward the sacral bone was found. The management plan was changed, and the patient underwent a single-stage reconstructive surgery: wound excision with ostectomy and defect repair by means of a myocutaneous flap. The digital photograph was not misleading; rather, the examiners did not appreciate the presence of a wound cavity beneath a practically closed, drainage- and infection-free, fibrosed wound. Actually, the ulcer cavity was detected by a relatively forceful probing of this seemingly closing wound.
Case 2. A 49-year-old woman with melanoma in home care developed a left leg wound distally to the lateral ankle. The wound, which was approximately 6 cm x 2 cm and probably resulted from pressure, was treated conservatively and healed. A few weeks later, the patient notified the wound care team that she redeveloped the ulcer, and a digital photo of her “wound” was e-mailed to the surgical consultant. The wound appeared to be “re-opened” in the form of a shallow defect filled with fibrosed granulation tissue (Figure 2). With the anticipation that surgical intervention was going to be needed based on the electronically transmitted picture, the patient was examined. The wound was maroon in color but healed with a relatively stable epidermis. Features of the digital photo were misleading. On the digital image, the previous wound cavity area, which was found completely reepithelized upon physical examination, mimicked a granulating defect in appearance. Discoloration, which led to the misleading photo, was even more apparent when the leg became somewhat congested in a gravity-dependent position.
In both cases of clinically important differences between electronically transmitted photo and direct examination-based management plans, digital images were 300 dpi or less. The definitive plan focused on protecting the area from pressure and shearing. In both cases, the strategy of patient management had been completely changed.
Ultimately, in no cases were decisions made that would lead to significant, unnecessary risks or morbidity. In no case did the type of procedure (debridement versus closure) change following face-to-face consult. The sensitivity of the telemedicine consultation as measured by correctness of establishment of indication for intervention (validated during the direct consult) was 94%, the specificity was 99%, and the positive predictive value was 94%.7,8 Even in the case of the patient with a seemingly healing wound who required surgical intervention, the telemedicine consult did not really delay her care; rather, it only led to assumptions and expectations not reaffirmed during direct consultation.
Telemedicine technology enhances the ability of physicians to efficiently provide quality diagnostic and management services to problematic long-distance wound patients who are unable to present to the surgical specialist.1–3 In the case of wounds, a history obtained initially by a wound program nurse in conjunction with visual material is sufficient for a specialist with appropriate expertise to formulate a diagnosis and management plan. The rate of wound judgments requiring correction was low (1.67%). The accuracy of a telemedicine consult (high sensitivity, specificity, and positive predictive value and greater than 95% confidence interval) is close to “gold standard,” meeting guidelines for the standard of care in terms of accuracy of diagnostic tests.7,8 The objectives of telemedicine consultation—diagnosis and establishment of an initial management plan that allows the patient safe “bridging” to the time of face-to-face consultation when the diagnosis can be more detailed and a more definitive treatment plan can be construed—have been accomplished.
Given the accuracy of “telemedicine assessments,” one could raise the question of whether face-to-face consults are needed at all. Obviously, a more detailed assessment of symptoms and signs can only be performed during a direct consultation. Limitations of current telemedicine tools, whether digital photography transmitted via e-mail or phone technologies, relate to the absence of direct patient-physician interaction and to some extent to the quality of the photograph (eg, Case 2). The purpose of this study was to assess the accuracy of wound evaluations based on electronically transmitted records and images. Therefore, without establishing the degree of this accuracy, it would be premature to deliberate whether there was even an indication for subsequent face-to-face consult with a wound care surgical specialist. This need would be difficult to establish for the following patient- and surgeon-related reasons. For example, surveying a patient with decreased cognition might not provide valid answers. Since in many instances informed consents were obtained from authorized custodians of care, the direct encounter with a physician seems irreplaceable. Although no general type of planned procedure (debridement versus closure) has been changed based on findings during face-to-face consultation, specific technical details of reconstructive surgery were determined during direct examination. For example, selection of a flap for defect repair depends on such factors as tissue mobility, suppleness, and degree of scarring, which cannot be assessed by evaluation of photographic images. Similarly, reduced or absent proprioception, numbness, or even loss of temperature sensitivity in diabetic neuropathy cases is practically impossible to detect utilizing currently available telemedicine tools. Consequently, design of such accommodative devices as orthotic shoes based on electronically transmitted history and photographs would not be adequate. Telemedicine-based assessment will not replace a face-to-face and comprehensive assessment of a patient with a chronic wound with members of a multidisciplinary wound management team but will, however, streamline the management. Occasional errors or differences in judgment based on telemedicine versus direct assessment obviously may pose a legal problem.10 However, since telemedicine consults, as the preliminary management steps, appear safe and relatively free of medical errors, they should be available in the compassionate care model for patients with problems and nonhealing wounds.4,11 The facilitation of wound assessment and establishment of even tentative management plans is especially important given the degree of suffering related to wounds, particularly among the elderly due to their difficulty accessing caregivers, and morbidity related to care delay.6 There were no charges related to telemedicine consults. There is no clear legal liability coverage policy for telemedicine consults; medical and communication progress is ahead of regulators. However, it appears that these services could be coded and charged similarly to case management services by telephone (CPT 99371 through 99373).12