1. VISN 11 Wound Care Teleconsultation Program Julie Lowery, PhD Implementation Research Coordinator Leah Gillon, MSW Administrative Coordinator Diabetes Mellitus QUERI Center for Clinical Management Research HSR&D CoE VA Ann Arbor Healthcare System

2. 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.

3. 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

4. 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

5. 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

6. 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)

7. 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)

8. Feasibility Study: Results Mean wound surface area = 10.59 cm 2 (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

9. 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.

10. Feasibility Study: Results Patient Satisfaction Surveys 97 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 site94% Felt that had received good care during their visit98% Would have been more confident of care in Ann Arbor9%

11. Feasibility Study: Results Patient Satisfaction Surveys 277 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%

12. 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

13. Retrospective and study patient chart review at remote site Wound care2005Study period Dimensions of wound noted 60%100% Wound bed described45%100% Debridement performed when appropriate 94%91% Pulses checked when appropriate 54%81%

14. Retrospective and study patient chart review at remote site Wound care2005Study period Antibiotics prescribed w/ no infection noted 21%14% Culture and/or antibiotics when infection suspected 98% Offloading plan noted with foot ulcers 96%100% HbA1c ordered when appropriate 95%100% Dressing plan noted62%100%

15. 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.)

16. 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

17. 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?

18. 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.

19. New Wound Template, page 1

20. New Wound Template, page 2

21. New Wound Template, page 3

22. Follow-up Wound Template, page 1

23. Follow-up Wound Template, page 2