Telemedicine Solutions for Chronic Wound Management: Bridging the Gap Between Wound Expert Supply & Demand

The utilization of telemedicine will offer clinical and financial incentives for wound clinics as the U.S. healthcare system continues its transition to a value-based structure.  

Frequent assessment of chronic wounds is essential to ensure appropriate prevention and treatment strategies are in effect throughout the dynamic wound healing process. Prompt identification of subtle changes in wound appearance and character helps guide treatment decisions, with timely wound closure being a fundamental goal. Studies have long demonstrated that wound management programs incorporating an interdisciplinary team of clinicians who are proficient and exclusively dedicated to wound science will markedly improve patient outcomes.¹ Considering the vast shortage of qualified wound clinicians throughout the United States, the capacity to provide high-quality, evidence-based wound care is sorely lacking. Patient populations in need of wound management services are increasing at a rate greater than the current supply of wound experts, making this healthcare dilemma even more concerning.² Lack of wound management expertise isn’t just limited to remote, rural areas. This shortage is also prevalent in many urban healthcare settings, including post-acute care, long-term care (LTC), home care, and even correctional facilities. The Wound, Ostomy and Continence Nursing Certification Board and American Board of Wound Management, organizations that certify wound care specialists, currently report a collective estimate of less than 15,000 certified specialists nationwide available to manage more than 6.5 million chronic wounds.^3-5 This article will explore the modality of telemedicine as an option for outpatient providers to consider and as a means to expose patients to an interdisciplinary team of experts given the increasing patient population requiring chronic wound care. 

Acknowledging Challenges: Availability & Adherence 

Most healthcare settings refer (or at least should refer) patients who are living with complex, problematic chronic wounds to outpatient centers equipped with advanced diagnostic and therapeutic modalities and offering access to experienced interdisciplinary staff. Advanced wound healing practices such as serial sharp debridement, cellular and tissue-based product application, and bedside skin grafting are just a few of the routinely provided modalities at these centers that can not easily be afforded to patients in other clinical settings. However, while reimbursement guidelines are currently favorable for wound centers and similar types of hospital-based and freestanding outpatient facilities, logistical problems remain for patients who are seeking access to expert care. Patients living with chronic wounds may find themselves unable to keep scheduled appointments for a variety of reasons and are often continuously challenged to adhere to the respective wound center’s timetable, which is often inflexible due to the volume of patients being seen at any one facility. A typical visit frequency of 1-2 encounters per week can present social and financial challenges for those patients facing mobility and transportation issues. Additionally, challenges often exist in maintaining consistent caregivers, who themselves may be challenged by increased frequency of wound center appointments.⁶

Telemedicine Growth, Convenience 

The evolution of biotechnology and a rapidly changing healthcare regulatory environment have paved the way for advances in how chronic, nonhealing wounds are managed. As a modality, telemedicine can provide patients with convenient and improved access to wound experts while reducing the financial burden associated with challenges such as transportation costs and lost workdays. Telemedicine also serves as an excellent medium to extend best practices and educational opportunities to providers who care for patients located in remote and medically underserved areas. Specialties such as dermatology, radiology, trauma response, and stroke care have all demonstrated safe and efficacious delivery of care using telemedicine platforms.⁷ A variety of telemedicine technology options have been developed that provide either synchronous (real-time interactive or real-time remote monitoring) or asynchronous (stored and forwarded) clinical encounters. In the mid-1970s, the U.S. military and NASA had 15 separate telemedicine programs in place. The military first recognized the validity of real-time interactive telemedicine encounters for wounded troops on the battlefield. Early success led to virtual encounters between patients and providers and the modality quickly found a place in the civilian sector.⁸ Today, telemedicine is a significant and rapidly growing component of U.S. healthcare. There are currently about 200 telemedicine networks with 3,500 service sites across 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.2

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

Today’s wound centers pursue a standard of care that is evidenced based and incorporates a variety of outcome measurements (eg, wound healing rates, patient satisfaction scores, fiscal efficiency, recidivism). Treatment decisions are rooted in a foundation of strong clinical evidence with attention given to the appropriate use of advanced modalities and products. Wound specialists know how and when to use these costly therapies to achieve optimal clinical outcomes without adding unnecessary costs. In the current financially strapped economy, prudent and appropriate supply utilization is a must.⁸ Privately owned and operated wound centers and their providers are currently reimbursed under a fee-for-service (FFS), or episodic, model, which drives revenue through volume-based activity. Specific components of the wound center visit are billed individually to reflect the complexity of the encounter. Initiating a telemedicine encounter in lieu of a clinic visit does not provide a fiscal benefit for the wound center; therefore, use of telemedicine is usually limited in these facilities. Telemedicine is more commonly found in multi-facility health, hospital, and prison systems where it can help extend wound care expertise to affiliated satellite offices and patient care facilities. Under the current wound center reimbursement model, telemedicine is rarely used for ongoing surveillance of closed wounds or to prevent wound recurrence in patients at high risk for recidivism, partly due to the modest reimbursement for this care. Telemedicine is currently a reimbursed service for individual providers; however, guidance for reimbursement and encounter specifications is always changing, and routine updates are available through the following resources:²

• Centers for Medicare & Medicaid Services (CMS) Policy:⁹ “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.”
• Code of Federal Regulations:¹⁰ “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.” 
• An update of physician encounter codes came from CMS in 2016¹¹ after seven physician codes were added in 2015.¹² 
• 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.^{7, 13} 
• Center for Connected Health Policy: State Telehealth Laws and Medicaid Program Policies: Publication “provides policymakers, health advocates, and other interested healthcare professionals the most current summary guide of telehealth-related policies, laws, and regulations for all 50 states and the District of Columbia.”¹⁴

Future Implications

As wound centers transition from volume-driven FFS reimbursement to value-based care that incents providers to contain costs across the continuum, the success of this model for individual clinics will depend on appropriate, cost-effective wound management strategies being initiated in the acute care setting. Care coordination after discharge (post-acute care, long-term settings, home care, etc.) will be paramount to preventing costly rehospitalizations. To orchestrate the delivery of safe, appropriate, effective care, wound centers will need to fully evaluate each patient’s preferences and needs, monitor wound progress between follow-up visits, and continuously communicate information to the right people at the right time.⁶ According to the Agency for Healthcare Research and Quality and the National Academy of Medicine (formerly the Institute of Medicine), care coordination is a key strategy that has the potential to improve the effectiveness, safety, and efficiency of American healthcare. Well-designed, targeted care coordination can improve outcomes for everyone involved: patients, providers, and payers. However, there are obstacles within the American healthcare system that must be overcome to achieve quality outcomes. Consider:

• Current processes required for good care coordination are often poorly defined and vary among providers, resulting in misplaced information and inefficient care.
• Specialists don’t receive consistent or thorough information about the reason for a referral, results of previous diagnostic tests, or other information needed to drive treatment recommendations. 
• Patients are often unclear about the reasons for referral to a specialist, how to make appointments, and what to do after seeing a specialist.
• Primary care physicians don’t consistently receive follow-up information from the specialist following a referral.¹⁵

Outpatient wound centers have a great opportunity to embrace telemedicine as a tool for preventing and managing chronic wounds across the continuum of care. Successful care coordination will require standardization of evidence-based clinical practice guidelines as well as process-improvement initiatives to ensure seamless flow of communication among sites of care. Consider the following situations. (These examples highlight the delivery of prudent care without unnecessary financial burden to the health system.): 

1. A patient who has been referred to the wound center for management of a chronic leg ulcer is also referred to home health for dressing changes as needed. During a home visit, the nurse observes that the wound appears to be rapidly deteriorating. Instead of sending the patient to the emergency department (ED), a telemedicine encounter is initiated with the wound center to get direction on how the wound should be managed. 
2. A patient is discharged from the hospital with a stage III pressure ulcer and is admitted to a skilled-nursing facility (SNF). Discharge orders include weekly visits to the wound center for wound management. In a value-based reimbursement model, transporting a patient to and from the wound center is labor intensive for the nursing home, inconvenient for the patient, and a financial burden to the healthcare system. Instead, the wound center staff schedules weekly telemedicine encounters to teach proper dressing technique, to monitor wound progress, and to ensure that pressure-relief interventions are being followed. 

Expanding Focus on Prevention 

Today, telemedicine is used in wound care primarily for the management of new or existing wounds. However, value-based care will also demand an increased focus on comprehensive prevention programs. As an example, in the late 1990s a diabetes foot program was established at Louisiana State University (LSU) Health Sciences Center in Baton Rouge. This comprehensive program was a critical component of a diabetes disease-management initiative and was directly based on the research and work completed previously by Dr. Paul Brand and the LSU Diabetes Foot Program (DFP) leadership at the nearby Carville Hansen’s Disease Center & Museum. The DFP specialized in the prevention and management of foot problems in patients living with diabetes and related neuropathy. Upon being admitted to the DFP, patients had their feet examined and management strategies were identified that stratified individuals based on their risk level for developing a wound or foot problem. Patients were provided educational materials, foot wound evaluation and management, and accommodative protective footwear — appropriate through all stages of wound healing, including remodeling. Professional education and training regarding the Carville approach to the Lower Extremity Amputation Prevention (LEAP) program was provided for referring health professionals and clinic staff. LEAP was designed to shift the site of comprehensive diabetes foot care from the central site of the LSU Health Sciences Center to an LSU foot clinic in the community parishes where patients resided. The DFP and LEAP programs worked collaboratively to establish statewide clinical networks with a goal of improving care and promoting 100% access and 0% disparity of care to underserved populations. As might be expected, successful implementation of LEAP required a major shift in operationalizing the delivery of care from a hospital or acute care setting to an outpatient setting. Since the target population was medically underserved patients, protocols had to be standardized across the entire network to ensure appropriate care was being delivered, regardless of location. Evidence-based clinical pathways were written to guide appropriate management and referral of patients. Rural clinics were operationally remodeled to accommodate the increase in patient volume. Also, because foot injuries can be an emergent problem in a neuropathic population, network providers in the parishes had to alter scheduling patterns to accommodate same-day or next-day appointments. The LEAP program chose a telemedicine platform to help facilitate this shift in the site of care. Telemedicine technology was in its infancy at this time and not without its challenges. However, it proved to be an effective mechanism for facilitating timely access to expert opinion and for reducing the number of foot-related complications in a high-risk, underserved diabetes patient population. A published study compared patient outcomes among the DFP’s African American population one year before and one year after enrollment in LEAP.  Analysis of data using paired t-tests (analysis of two population means through the use of statistical examination) showed a significant reduction in foot-related ulcer days (-49%), inpatient hospitalizations (-89%), hospital days (-90%), ED visits (-81%), antibiotic prescriptions (-57%), foot operations (-87%), amputations (-79%), and missed workdays (-70%). Ulcer incidence was lower in African American patients than in non–African American patients in the follow-up year.¹⁶ With the capability to disseminate information using “smart” devices with HIPAA-compliant applications, telemedicine is rapidly becoming commonplace. Diagnostic data such as wound images and measurements can be digitally captured at the bedside and transmitted to multiple points of care to ensure continuity and to decrease unnecessary clinic visits. With the shift to value-based care, emerging technology, such as bedside “quick” lab testing and handheld radiology devices, will become standard practice in the very near future. 

Summary

The benefit of active learning for a referring provider through telemedicine with wound experts cannot be overstated. Telemedicine in the outpatient clinic provides a tremendous opportunity to augment management of wound care patients. Expansion of clinical models of care that are consistent with value-based care ideology will become a necessity sooner rather than later.

Myra Varnado is director of clinical services at Corstrata, a Georgia-based telemedicine company that delivers a range of wound and ostomy services. Jan Cuzzell is vice president of clinical quality at Corstrata. Carolyn H. Cuttino is president of Carolina Wound Management Consultants, Charleston, SC, and serves as Corstrata’s vice president of clinical services. Katherine Piette is chief executive officer and founder of Corstrata.
 

References

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2. Guthrie SD, Guthrie, BR, Arja MA. The evolvement of telemedicine in complex wound management & prospects for effectiveness in the wound clinic. TWC. 2016;10(3):16-20.

3. Certification Statistics. ABWM. Accessed online: www.abwmcertified.org/about-us/certification-statistics

4. Exam. WOCNCB. Accessed online: www.wocncb.org/recertification/exam

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9. Telehealth. Centers for Medicare & Medicaid Services. Accessed online: www.cms.gov/medicare/medicare-general-information/telehealth/index.html

10. 42 CFR 410.78 – Telehealth Services. U.S. Government Publishing Office. Accessed online: www.gpo.gov/fdsys/granule/CFR-2011-title42-vol2/CFR-2011-title42-vol2-sec410-78

11. Measures Codes. Centers for Medicare & Medicaid Services. Accessed online: www.medicare.gov/coverage/telehealth.html

12. CMS Added Seven New Telemedicine Billing Codes to the 2015 Medicare Physician Fee Schedule. Audio Educator. Accessed online: www.audioeducator.com/news/seven-new-telemedicine-billing-codes-2015.html

13. State Telemedicine Gaps Analysis Coverage & Reimbursement. mTelehealth. Accessed online: www.mtelehealth.com/state-telemedicine-gaps-analysis-coverage-reimbursement

14. State Telehealth Laws and Medicaid Program Policies. Center for Connected Health Policy. 2017.  Accessed online: www.cchpca.org

15. 1Agency for Research Healthcare and Quality. U.S. Department of Health & Human Services. Accessed online: www.ahrq.gov

16. Patout CA Jr, Birke JA, Horswell R, Williams D, Cerise FP. Effectiveness of a comprehensive diabetes lower-extremity amputation prevention program in a predominantly low-income African-American population. Diabetes Care. 2000;23(9):1339-42.