4 Ways to Integrate Digital Health into the Wound Center Today

With companies such as Amazon, Apple, and Google wading deeper into health care, there has been much talk and anticipation regarding what digital and mobile health will do to transform how health care is delivered and consumed. However, despite speculation, many of the most cited scenarios are still years away from becoming a reality in most wound care settings. This does not mean that applying digital technology to your day-to-day practice is all “pie in the sky.” 

This author uses his experience both directing wound clinics and advising industry to illustrate several ways that digital health can be, and in many cases is already being, leveraged by wound care stakeholders.

1. Incorporate prevention, assessment, and treatment protocols into the clinical workflow

Compared to other areas of health care, wound care is often referred to as “The Wild West” due to the high variability in training, diagnosis, and treatment approaches. However, there do exist protocols that most experts can agree on (even though they may not be uniformly practiced). Some examples include:

• Assessing and optimizing nutritional factors (and blood glucose for diabetics)
• Confirming adequate circulation and perfusion for at-risk patients—especially prior to treatment with compression therapy or aggressive surgical debridement
• Offloading pressure and minimizing friction and shear around the wound

Regardless of these and other generally accepted precautions, their real-world practice can be hit-or-miss at best. This is related to a number of factors, including lack of specialized training, time and other resources, patient compliance, and poor clinical practice. Building agreed upon protocols into the workflow has the potential to improve both the education level and outcomes for skin, wound, and burn care.

Perhaps the only real downside to such protocols is that when implemented very broadly, they may increase the time required to document. This, of course, can detract from time spent on actual patient care as well as contribute to electronic medical record (EMR) fatigue. Fortunately, we are seeing the emergence of “smart workflows” that can dynamically highlight the protocols of importance to each patient based on their characteristics, history, wound location and healing progression, and bypass those deemed irrelevant. Machine learning allows such systems to learn and improve with time.

Kara Couch, MS, CRNP, CWS, CWCN-AP, a nurse practitioner at George Washington University Hospital in Washington, DC, and Secretary of the Association for the Advancement of Wound Care, shares how she sees digital health impacting both the efficiency and confidence in the level of care delivered. “EMR technology is improving steadily for wound care clinicians and allows for efficiency in many areas to decrease overall time spent on documentation. Examples of this are the digital imaging platforms that virtually eliminate the common interrater reliability errors with manual wound measurements by importing wound images and characteristics directly into the EMR.”

Even as the smart workflows are being tested at a handful of particularly innovative facilities, clinical protocols are already incorporated into workflows used by clinicians across the globe. Who is seeing the most benefit from this development? Organizations who have embraced integrated mobile documentation,¹ as they are most likely to use the tool while actively treating the patient rather than documenting after the fact.

“The use of mobile-based applications puts evidence-based practice at the fingertips of clinicians,” explains Couch. “This allows for both rapid reference of cutting-edge best practice and the ability to query a clinical question in the middle of a clinic session without causing significant delays. As traditional EMRs work to implement clinical decision support into the massive, existing systems, such apps will be continually customized and at the fingertips of clinicians, for the benefit of the patient.”

2. Objective trialing, adoption, and evidence generation for new products

Any clinician, administrator, or sales executive experienced in wound care can relate to the following scenario: 

A product company performs an in-service training for a wound care team. Afterwards, the team is either genuinely interested in trialing the product, or they simply appreciate the free meal. Either way, the sales representative leaves a few samples of the product, with perhaps a suggested paper sheet for tracking patients. A few weeks later, the representative follows up with the team. Assuming that the samples are not still sitting untouched in a drawer or have not been given to an indigent patient for use at home, there is a good chance that the samples were used on patient(s), but 1 or more of the following has occurred:

• Patient(s) had the wrong indication(s) or did not have resolutions to other conditions affecting healing (pressure offloading, vascular status, debridement, etc.);
• Patient(s) had correct indication(s), but no formal tracking of outcomes was measured versus the pre-trial status quo;
• Patient(s) had the correct indication(s), but the samples were scattered across many patients/wounds/treating clinicians, so an objective conclusion is impossible due to inconsistencies in assessments and other variables; and/or
• The clinician(s) trialing would like to order the new product but lack the kind of impactful real-world evidence needed to convince facility committees/purchasing/administration stakeholders.

As a result, the cycle can repeat and may or may not be successful for similar reasons. Regardless, there will be wasted time and resources all around, and any decision taken is likely to be more anecdotal and subjective than data driven. How is digital health helping to solve this problem?

Utilizing fast, objective assessment tools that may also incorporate tutorials on proper patient selection, wound bed preparation, and product application leads to a scenario benefitting all stakeholders. In some cases, the patients themselves may provide feedback via a patient-facing application on important quality of life and healing indicators such as changes in pain levels. At the end of the trial period (or even in real time), the facility’s clinicians and administrators view reports on the impact (or lack thereof) of certain treatments on their own patient population.

When all parties consent, de-identified patient data from these “micro-trials” (even if each trial is just 1 or 2 patients) can be shared with the product firms and combined with data from other micro-trials as well as traditional clinical trials and other data sources into a real world evidence engine to supplement traditional, small wound care clinical trials, which have come under increasing scrutiny in recent years.²

The digital wound care phenomenon is not confined to the United States, either. As explained by professor and physician Dr. Harikrishna K.R. Nair, Vice President of the Asian Wound Care Association and Head of the Wound Care Unit at Kuala Lumpur Hospital (Malaysia), “With the advancement of technology in the digital era, we [have updated to] the latest software in digital health, specifically in terms of data collection and analysis. This is a powerful tool to assist us in our everyday practice of managing patients comprehensively.” 

3. Reduce need for expensive, offsite diagnostics (lab, imaging, etc.)

Digital and related point-of-care assessment and diagnostic tools are beginning to reduce reliance on external laboratories, imaging, and invasive procedures for certain diagnostics, or at least to reduce delays in treatment in order to receive preliminary results. From automated and inexpensive ankle-brachial index machines, hyperspectral imaging, and early pressure ulcer detection to tests for biomarkers and visualization of bacteria, there exist a multitude of solutions that can at least inform initial decision making at the point of care without waiting days or weeks for separate external appointments—and even longer to receive the relevant documentation. In addition to many of these solutions being digital in nature, there is a movement for these to interface, and even integrate, with EMRs to ensure that the relevant results are quickly and accurately captured and incorporated into patient treatment plans.

4. Improving both continuity of care and revenue generation via telemedicine

The majority of patients in the United States with nonhealing wounds are insured by the Centers for Medicare and Medicaid Services (CMS) (Diligence Wound Care Global, unpublished data, 2018). Since 2015, CMS has had a mechanism (Current Procedural Terminology [CPT] and Healthcare Common Procedure Coding System [HCPCS] codes) for billing for certain telehealth services. Like all government programs, the precise rules and qualifications are a bit complex and can be confusing, so it is important to review and understand them before submitting claims. The general idea is a billing provider may enroll a CMS patient with 2 or more chronic conditions (i.e., virtually all patients with chronic wounds, with the wound itself counting for at least 1 chronic condition) whom they have seen face-to-face within 12 months.

The program includes CPT and HCPCS codes for remote chronic care management (CCM), transitional care, patient monitoring, and certain straightforward telemedicine consults. Many of the services can be performed by nonprovider staff within the practice (e.g., a nurse) and include activities already routinely performed by wound care specialists, including care coordination with other providers and facilities, reviewing results, and speaking with patients and their families. 

In the past, health care providers did not traditionally use these telehealth/remote monitoring coding. One of the top reasons behind this was “burdensome IT requirements.”³ But as mobile assessment tools, seamlessly integrated within EMRs, gain traction, those barriers will dissolve. In fact, we are already witnessing increased usage of CCM coding by both wound specialists as well as other providers (primary care, endocrinologists, infectious disease) who see many patients with chronic wounds.

Besides the fee-for-service revenue generation, organizations not chasing fee-for-service models are embracing digital health for remote monitoring of patients with wounds as well. Allowing patients to report changes in wound size, temperature, appetite, and medication compliance, with these changes fed directly into the organization’s EMR for review by clinical staff, gives them tremendous quality and financial advantages over those waiting for a face-to-face encounter to render treatments or changes in the care plan.

Remote monitoring and treatment of patients with chronic wounds is a great use case for telemedicine, and tools already exist for facilitating those types of service—with more solutions entering the market each year. The ability to gather objective information from and communicate with patients at home and to review, perform, and log an increasing number of eligible activities with cloud-based mobile technology is making it easier than ever for providers to realize a tangible return on investment for chronic wound care by using digital health tools. 

Rafael Mazuz is Managing Director of Diligence Wound Care Global, a leading advisory firm providing executives, investors, and specialists confidence in their wound care business decisions. He also serves on the board of directors for Tissue Analytics, an integrated digital health platform for wound, skin, and burn stakeholders, and is a Today’s Wound Clinic board member. He can be reached at rafael@diligencewcg.com.

1. Cerner Corporation. How Intermountain Healthcare is tapping into open innovation to improve care. YouTube. https://youtu.be/tfTKVfo5GI0. Published Dec. 6, 2018.

2. Taylor M. When wounds won’t heal, therapies spread—to the tune of $5 billion. Kaiser Health News. http://tinyurl.com/y6cfjo7u. Published Aug. 3, 2017.

3. Tyrell R, Sinclair H. CCM codes: Are you leaving money on the table? Advisory Board. http://tinyurl.com/yyy6w432. Published May 12, 2018.