The Evolvement of Telemedicine in Complex Wound Management & Prospects for Effectiveness in the Wound Clinic

Traditionally, an increase in the need for specialized medical services, such as wound care, has been met by increasing the number of physician extenders. An additional solution is proposed here: to utilize telemedicine to amplify, multiply, or expand the seasoned physicians’ expertise at qualified outpatient clinics.

While there are myriad uncertainties in the field of complex tissue restoration practiced within outpatient wound clinics and limb-salvage centers, two truths are acknowledged:

1) The practitioners of these disciplines, the contemporary diagnostic and therapeutic modalities, and the multidisciplinary centers exclusively dedicated to wound care strikingly improve patient outcomes.^1,2 2) The patient populations in need of such services are increasing at a rate greater than are these specific resources.³ The challenge addressed here is to find the most efficient method for broadening the reach of the proficient wound clinics and limb salvage centers so that the accomplishments of this first acknowledged truth are never overwhelmed by the magnitude of the second truth.

Traditionally, an increase in the need for specialized medical services has been met by increasing the number of “physician extenders” (nurse practitioners, advanced nurse practitioners, and physician assistants). An additional solution is proposed here: to utilize telemedicine to amplify, multiply, or expand the seasoned physicians’ expertise at qualified wound clinics. At the risk of introducing yet another denomination in an already crowded cast of characters, the concept embraced here is that telemedicine allows “provider amplification” without the hazard of potentially diluting the quality of care provided. Further, there are explicit imperatives in the Affordable Care Act for a Physician Quality Reporting System (PQRS) and Meaningful Use (MU) implementation that can effectively be achieved by increasing the availability of the specific expertise of these centers. Establishing a telemedicine capability for the management of complex wounds furthers that institution’s compliance with these directives.

Introduction

While Morse’s most-remembered saying is “ What hath God wrought” — his first telegraph message sent in 1844 — the precept captured in the above quote lies at the heart of why the virtual exchange of patient information supplies that desired “amplification” of the highly experienced practitioner. The origin, the moment, and the nature of human language are vigorously debated, with expert opinions ranging from 500,000-30,000 years ago.⁴ Regardless of which date is chosen, human communication was verbal and face-to-face. The printing press, while it removed the exchange from what we recognize as conversation,⁵ enormously increased the breadth of information exchange. Digital communication provides another quantum expansion of individual-to-individual information exchange. At present, most of our communications are no longer face-to-face, but rather interface-to-interface.

History

The earliest recorded use of distant communication for medical purposes was likely the practice of African villagers using smoke signals to warn neighboring communities of the presence of diseases at their localities.⁶ In the early 1900s, people living in remote areas of Australia used two-way radios powered by a dynamo driven by a set of bicycle pedals to communicate with the Royal Flying Doctor Service.⁷ In 1961, the National Institutes of Health funded a two-way, closed-circuit TV link between two psychiatric hospitals in Nebraska. Since face-to-face physician encounters were often obviated by the circumstances, NASA was an early adopter of this modality. By the mid-1970s, NASA and the United States military had 15 separate telemedicine programs in place. The military also recognized the application of this technology for wound management and this utility quickly found a place in civilian medicine.⁸

Current Technology

Telemedicine systems can be broken into three main categories: store-and-forward, real-time remote monitoring, and (real-time) interactive services. While all three platforms have utility in wound clinic facilities, the immediate, real-time interactive application may pertain only to facilities where specific time slots and the requisite personnel can be allocated. The necessary mechanical infrastructure is the same for all three methods.

Resources Available

The American Telemedicine Association (ATA; www.americantelemed.org) was founded in 1993 and currently has 10,00 members. The ATA is the linchpin national organization and the most immediate source for information regarding accreditation, federal and state mandates for payers, practice guidelines, and educational resources. The ATA also offers the most reliable advice on private administration companies for institutions or individuals interested in entering this discipline. The regional implementation of telemedicine capability is uneven, but expanding rapidly. There are regions where several institutions are linked through a state framework, such as in Maine, where, in 1995, four hospital systems joined to create and manage a single, state-administered telemedicine system (www.maine.gov). Similarly, the Upper Midwest Telehealth Resource Center (www.umtrc.org) has sites in Indiana, Ohio, and Iowa. Additionally, there are several organized and experienced telemedicine systems based at individual teaching hospitals, including the University of Vermont, the University of Virginia, the University of Michigan, and the University of Mississippi, to name just a few.

Current Utilization Worldwide

In the World Heath Organization’s 2010 survey, 60% of all nations had some form of telemedicine and 38% of all nations had programs in teledermatology, a hint at what utilization of this modality for wound care could achieve. Ajami and Lamoochi reviewed the worldwide application of this modality in 2014, emphasizing its crucial role in large disasters and in accessing remote locations.⁹ There are presently no summary statistics on the number of telemedicine encounters for wound management worldwide, but there is in place a monitoring entity (European Wound Management Association) that will soon do such an accounting globally.

Nationally

Telemedicine is a significant and rapidly growing component of healthcare in the U.S. There are currently about 200 telemedicine networks, with 3,500 service sites in the country. In 2014, the Veterans Health Administration delivered more than 300,000 remote consultations using telemedicine. Over half of all U.S. hospitals now use some form of telemedicine.

Authors’ Experiences

In 2000, a cooperative effort was launched between a metropolitan New York City Hospital (Nassau County Medical Center [NCMC]) and the Visiting Nurse Services of New York City [VNSNY] to monitor topical wound care for patients who had completed their hyperbaric oxygen therapy (HBOT) at NCMC. The primary outcomes (reducing the number of hospital follow-up visits required, achieving outcomes consistent with patients who did have their follow up at the hospital, and interdicting any healing problems before any limb-threatening circumstances developed) were all realized. 

In the following example (Figures 1.0 and 1.1), an open transmetatarsal amputation procedure patient at the end of HBOT treatments is living with a wound that is healing secondarily but still requires active wound management. At the time, metropolitan New York City had only three HBOT centers and this patient’s travel time from the Bronx to NCMC was almost two hours. VNSNY provided the necessary home care with remote monitoring and no further visits to NCMC were necessary. 

The equipment used here, in an era long before smartphones and capable only of store-and-forward functionality, did allow transmission from residencies without Internet service. From 2011-14, at another metro New York City hospital (Hudson Valley Hospital Center [HVHC], Peekskill), a telemedicine link was established with a regional rehabilitation/long-term care facility (North Westchester Restorative Rehabilitation Center; Mohegan Lake, NY [NWRT]). In addition to involving the same providers who managed these complex wounds during their inpatient stay and preempting readmissions, this system had real-time-interaction capability for assisting with complicated NPWT (as seen in the next example; Figures 2.0-2.3).

This NPWT dressing could be directly supervised without having to transport the patient to the hospital’s wound clinic. In addition to remotely observing the three-dimensional contours of a wound and shepherding the placement of complex dressings, an accurate assessment of bioburden and granulation density can be done with a simple colorimetric grading scale — the Granulometer.¹⁰ This calibration of granulation percentage has been used since 1998 to empirically rank a wound base regarding its ability to accept an autologous skin graft (Figures 3.0 and 3.1). Until the advent of fluorescence vascular angiography (FVA), there has not been any other method (beyond the observer’s subjective opinion) to get an immediate appraisal of a wound bed’s reparability.^11-13 

There are several other measures of a wound’s liabilities for unaided secondary healing (quantitative cultures, growth factors, inflammatory markers, matrix metalloproteinases, etc.), but none with the immediacy of FVA.

The latest application of telemedicine technology in the arena of wound care and limb salvage is developing at Hurley Medical Center (HMC), Flint, MI. This facility is designed to use the store-and-forward mechanism with static images for managing wound care patients discharged from HMC to long-term acute care/rehab centers, the real-time remote monitoring where the dynamics of the wound assessment and dressing need to be addressed, and the real-time interactive capacity for consultations. 

This last mode will also be used for the analysis of FVA studies, a crucial capability as this important emerging technology is being adopted by the wound care community. Tremendous diagnostic insight and therapeutic guidance has been gained in the past three years using FVA in complex, nonhealing wounds.^12,13 This includes delineation of the abnormal microvascular channels in the wound/periwound tissue that characterize this clinical state.¹⁴ Interpretation of the FVA images entails a significant learning curve. The immediate availability of experienced FVA practitioners, via a telemedicine link, hastens this training in the same way experienced radiologists mentored their novice colleagues honing their skills interpreting MRI images.¹⁵ In this next example, a patient living with a nonhealing second toe amputation site has demonstrable arterial inflow obstruction. A successful femoropopliteal bypass restored the ankle-brachial index in that limb to normal levels, but that study has no objective information about the actual microcirculation at the level of the wound. The wound as it appears in Figure 4 (taken after the bypass surgery) is unchanged from that seen before surgery and essentially unchanged from the patient’s initial intake. FVA at this point provides empirical information about how the actual perfusion of this wound bed has been affected by the inflow procedure. This obviates waiting for continuing aggressive topical care to demonstrate if the wound can heal secondarily and avoids the risk that unrelenting nonhealing might lead to a deep infection imperiling the entire forefoot. 

Interpretation of the FVA sequence requires experience with the subtleties in pixel intensity, timing, and the cumulative linear display of the indocyanine green molecules detected moving through the wound and periwound tissue. In Figures 5.0 and 5.1, a single fluorescence image is extracted at the point of maximal intensity before the bypass procedure (Figure 5.0) and one week after the surgery (Figure 5.1).

The pixel density in these images is then quantitatively mapped and the differences at specific anatomic sites can be compared (red arrow). 

The entire recorded FVA sequences before and after the surgery, viewed simultaneously, further demonstrates (albeit on a subjective level) the effect the surgical procedure had on the microperfusion of the wound. 

The FVA recordings preoperatively and postoperatively can be viewed simultaneously. (Video 1 and Video 2) With a telemedicine interface, an experienced practitioner can see the study as it is being performed, assist in selecting the specific mapping points for the quantitative survey, and discuss the interpretation of the FVA study in real time with a novice colleague.

Future Utilization 

The immediate expectation for telemedicine in the wound care and limb salvage discipline is for increased implementation of what has already proven to be effective and efficient. This will be in response to not only the logic of the issue, but also in acknowledgement of rapidly changing healthcare policies. Consider:

• Centers for Medicare & Medicaid Services (CMS) Policy (visit www.cms.gov/medicare/medicare-general-information/telehealth/index.html): “Telemedicine seeks to improve a patient’s health by permitting two-way, real-time interactive communication between the patient and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment.”
• “Telemedicine is viewed as a cost-effective alternative to the more traditional face-to-face way of providing medical care (eg, face-to-face consultations or examinations between provider and patient) that states can choose to cover under Medicaid. This definition is modeled on Medicare’s definition of telehealth services.” (42 Code of Federal Regulations 410.78)
• Another update of physician encounter codes is due from CMS in 2016 (visit www.medicare.gov/coverage/telehealth.html) after adding seven more physician codes in 2015 (www.americantelemed.org/news-landing/2014/11/07/update-on-cms-paymentdecisions).
• Regarding Medicare/Medicaid reimbursement, there are now fee parity laws in 27 states and Washington, DC, with fewer than 10 states that ranked as “F” regarding geographic setting, state employment status, or approved providers (visit www.americantelemed.org/docs/default-source/policy/2016_50-state-telehealth-gaps-analysis--coverage-and-reimbursement).

The need for digital information integration pertains not only between institutions or practitioners, but also with intramural communication. The accompanying Appendix (see online version of this article at www.todayswoundclinic.com/issue) provides a graphic portrayal of this integration, both within an institution (horizontal component) and between institutions (vertical component). The reconstructive surgeon in the operating room may need to know during the reconstructive procedure how that patient originally presented and his/her clinical course during wound care. This may even be true for the fluorescence vascular imaging results as well, since the FVA imaging may be repeated intraoperatively.  This level of data amalgamation is achieved through the MU initiatives of the institution. Inter-institutional integration may be more difficult to achieve, but the imperatives are the same. The emergency department physician first seeing a new complication in a wound care patient treated at another hospital would benefit from immediate access to the photographs, FVA images, and treatment records at the patient’s primary hospital. 

Ideally, that could include real-time interaction with the treating wound care practitioner. Despite the ubiquitous adoption of electronic medial records and their increasing collation through MU initiatives, telemedicine seems unorthodox to unschooled practitioners. A basic understanding that clinical outcomes, resource utilization, and patient acceptance all validate its efficacy is essential for this discipline to realize the promise it has so extensively demonstrated. 

Morse likely did not envision the full realization of his judgment that indeed there was no reason “ … why intelligence may not be transmitted instantaneously by electricity …”. It is equally unlikely that we understand just how important that is today and how much more important it will be in the future. 

Stephen D. Guthrie (stephen_guthrie@mac.com) is president and Barbara R. Guthrie is chief executive officer of Designed Altobaric Research Foundation, Livonia, MI. Mohamad A. Arja is on staff at Hurley Medical Center, Flint, MI.

References

1. Hellingman AA, Smeets HJ. Efficacy and efficiency of a streamlined multidisciplinary foot ulcer service. J Wound Care. 2008;17(12):541-4.

2. Barshes NR, Sigireddi M, Wrobel JS, et al. The system of care for the diabetic foot: objectives, outcomes, and opportunities. Diabet Foot Ankle. 2013;4:10.

3. Krishnan S, Nash F, Baker N, Fowler D, Rayman G. Reduction in diabetic amputations over 11 years in a defined U.K. population: benefits of multidisciplinary team work and continuous prospective audit. Diabetes Care. 2008;31(1):99-101.

4. Tallerman M, Gibson KR. The Oxford handbook of language evolution. Oxford; New York: Oxford University Press (2012).

5. Warren, M. Features of Naturalness in Conversation. John Benjamins Publishing, Jan 1, 2006.

6. Nakajima I, Sastrokusumo U, Mishra SK, Komiya, R, Malik AZ, Tanuma, T. The Asia Pacific Telecommunity’s Telemedicine Activities, IEEE Xplore.com website, 17-19 Aug. 2006, pp. 280-282. 

7. Strehle EM, Shabde N. One hundred years of telemedicine: does this new technology have a place in paediatrics? Arch Dis Child. 2006;91(12): 956–59. 

8. Ablaza V, Fisher J. Telemedicine and wound care management. Home Care Provid. 1998;3(4):206–11; quiz 212-3.

9. Ajami S, Lamoochi P. Use of telemedicine in disaster and remote places. J Educ Health Promot. 2014;3:26.

10. Cohen M, Giladi M, Mayo A, Shafir R. The granulometer--a pocket scale for the assessment of wound healing. Ann Plast Surg. 1998;40(6):641-5.

11. Alander JT, Kaartinen I, Laakso A, et al. A review of indocyanine green fluorescent imaging in surgery. J Biomed Imaging. 2012;7.

12. Guthrie SD, Salzberg AS, Hourani H, Rogers C. Indocyanine Green Scanning: Emerging Metrics of Wound Analysis and Hyperbaric Oxygen Treatment Efficacy. UHMS. 2014;41(5). 

13. Guthrie SD, Guthrie BR. Utilizing indocyanine green wound imaging in the management of hyperbaric therapy. TWC. 2014; 8(8):19-22.

14. Guthrie SD, Guthrie, BR. Detecting abnormal angiogenesis in nonhealing wounds with ICG microangiography. TWC. 2015;9(9):26-28.

15. Hata N, Tokuda J, Hurwitz S, Morikawa S. MRI-compatible manipulator with remote-center-of-motion control. J Magn Reson Imaging. 2008;27(5):1130.