visn 11 wound care teleconsultation program julie lowery, phd implementation research coordinator...
TRANSCRIPT
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.