VISN 11 Wound Care Teleconsultation Program

Julie Lowery, PhDImplementation Research Coordinator

Leah Gillon, MSWAdministrative Coordinator

Diabetes Mellitus QUERICenter for Clinical Management Research

HSR&D CoEVA Ann Arbor Healthcare System

Objectives

• Determine feasibility of store-forward telemedicine system for providing consultations on chronic wounds.

• Significance: Patients with chronic wounds have problems accessing specialized wound care centers.

Background

“Pressure Ulcer Assessment via Telemedicine”

(HSR&D funded study)

•Evaluation of accuracy of Web-based, store-forward telemedicine system for monitoring status of patients with chronic wounds

Feasibility Study: Methods

• October – September 2008• Ann Arbor VAMC wound care team: wound

care NP, plastic surgeon, ID specialist • Referring centers: Battle Creek and Grand

Rapids Wound care nurse requested consultations via

CPRS Digital images uploaded to VISTA Imaging Additional clinical data entered into CPRS

wound care template

Feasibility Study: Methods

Ann Arbor wound care NP:• Screened all consultations• Discussed complicated cases with

plastic surgeon or ID physician• Forwarded diagnostic and treatment

recommendations back to nurse via CPRS

Feasibility Study: Results

• 100 patients• All male• Mean age = 64 (range = 36 – 89)• 100 initial visits, 366 follow-up visits• 254 tele-consultations sent• 1.95 mean wounds (range = 1-7 per

patient)

Feasibility Study: Results

• Wound type (N = 181 wounds, 100 patients)

43% (78) Diabetic lower extremity ulcers 4% (8) Pressure ulcers 8% (14) Non-diabetic PV lower extremity

ulcers 34% (62) Venous stasis ulcers 11% (20) Misc (trauma, burn, surgical)

Feasibility Study: Results

• Mean wound surface area = 10.59 cm2 (range = .01 – 404.22)

• In FY07, there were 44 Ann Arbor wound care clinic appointments for Battle Creek and Grand Rapids patients vs. 5 in FY08

Feasibility Study: Results

• Average response time for diagnostic & treatment recommendations: 3.72 days (range = 0-12 days)

• Increased observed use of debridements, biopsies for culture, topical antimicrobials, topical growth factors.

Feasibility Study: Results

Patient Satisfaction Surveys97 First Visits

Did not mind having photographs taken of their wound.

94%

Expressed some level of concern about the privacy of their medical information.

26%

Felt it was more convenient to receive care at home site

94%

Felt that had received good care during their visit

98%

Would have been more confident of care in Ann Arbor

9%

Feasibility Study: Results

Patient Satisfaction Surveys277 Subsequent Visits by 59 Patients

Visits during which patient felt they had received good care

98%

Visits during which patient wanted services that were not provided (total of 10 patients, most of which were for supplies, not services)

6%

Retrospective and study patient chart review at remote site

• January-May 2005– 39 wound care patients

• 31 with one wound• 8 with two wounds

• Random sample of 31 study patients, February 2007-August 20008– 27 wound care patients

• 15 with one wound• 9 with two wounds• 3 with three wounds

Retrospective and study patient chart review at remote site

Wound care 2005 Study period

Dimensions of wound noted

60% 100%

Wound bed described

45% 100%

Debridement performed when appropriate

94% 91%

Pulses checked when appropriate

54% 81%

Retrospective and study patient chart review at remote site

Wound care 2005 Study period

Antibiotics prescribed w/ no infection noted

21% 14%

Culture and/or antibiotics when infection suspected

98% 98%

Offloading plan noted with foot ulcers

96% 100%

HbA1c ordered when appropriate

95% 100%

Dressing plan noted 62% 100%

Feasibility Study: Conclusion

Increasing access to specialty care via telemedicine:

• Increases probability of identifying a problem• Increases likelihood of aggressive treatment,

and provides this treatment sooner• Identifies unnecessary treatment—especially

use of antibiotics

Note: Telemedicine management takes place in collaboration with local clinician. It is designed to supplement—not supplant—existing care by local provider. (Important in cases where sensitivity of telemedicine diagnosis is only fair.)

Feasibility Study: Challenges and Limitations

• Substantial support necessary from local DSS coordinators, clinical applications coordinators, coding specialists, and Vista Imaging and medical media experts

• Ensuring capture of both direct patient care and tele-consultation workload credit

• Time constraints on staff providing consultation

• Difficulty in scheduling live consultations• Challenges of working with remote IT staff to

install hard- and software• Procedures to adequately capture response to

consultation suggestions need development• Has not been piloted with nurses untrained in

wound care

Challenge to VA

To improve access to high quality health care (with corresponding improvement in outcomes) within financial constraints.

Can teleconsultation provide the solution?

Who will take the lead in implementing these solutions?

Next Steps

• Implement in Saginaw VAMC (with wound care NP).

• Implement in CBOCs (no wound care NPs).– Training?– Credentialing?

• Hold wound care symposium.• Track amputations.

New Wound Template, page 1

New Wound Template, page 2

New Wound Template, page 3

Follow-up Wound Template, page 1

Follow-up Wound Template, page 2