telehealth for integumentary health

TELEHEALTH FOR TELEHEALTH FOR INTEGUMENTARY HEALTHINTEGUMENTARY HEALTH

Harriett B. Loehne, PT, DPT, CWS, FACCWSHarriett B. Loehne, PT, DPT, CWS, FACCWSClinical EducatorClinical Educator

Archbold Center for Wound Management & Hyperbaric MedicineArchbold Center for Wound Management & Hyperbaric MedicineArchbold Medical CenterArchbold Medical Center

Thomasville, GeorgiaThomasville, Georgia

TeleHealth: The Next Generation of Healthcare…No LimitsLake Oconee, Georgia

March 25, 2010

DisclosureDisclosure

No off-label product discussionNo off-label product discussion No conflict of interest with this No conflict of interest with this

presentationpresentation Advisory Board of Winchester Labs, Advisory Board of Winchester Labs,

Inc. (SalJet™)Inc. (SalJet™) Partial patent on Davol, Inc. PLWS Partial patent on Davol, Inc. PLWS

flexible tipflexible tip Board of Directors AAWCBoard of Directors AAWC President WMSIG SCE&WM/APTAPresident WMSIG SCE&WM/APTA

Goal of Medical SpecialistsGoal of Medical Specialists

Goal of wound care specialistsGoal of wound care specialists• Offer best known and available standard Offer best known and available standard

of careof care In timely, efficient, cost effective mannerIn timely, efficient, cost effective manner Consistent across the continuum of careConsistent across the continuum of care Progressed when appropriateProgressed when appropriate

Achievement of GoalsAchievement of Goals

Rural areas and where Rural areas and where specialists not availablespecialists not available• TELEMEDICINETELEMEDICINE

Electronic access to Electronic access to specialists for physicians, specialists for physicians, health care providers, and health care providers, and patientspatients

TelemedicineTelemedicine

Delivers care to those Delivers care to those who would otherwise who would otherwise • Do withoutDo without• Have to drive or be Have to drive or be

transported long transported long distances where distances where specialists availablespecialists available


Fuels economic developmentFuels economic development• Health care key consideration for Health care key consideration for

business prospects for rural business prospects for rural areasareas

Telemedicine in wound healingTelemedicine in wound healing

Wound healing and wound management is Wound healing and wound management is a prime candidate for telemedicine a prime candidate for telemedicine

Development of a suitable telemedical Development of a suitable telemedical system in this field could have a significant system in this field could have a significant effect on effect on • wound care in the communitywound care in the community• tertiary referral patternstertiary referral patterns• hospital admission rateshospital admission rates

Jones S, Banwell P, Shakespeare P. Jones S, Banwell P, Shakespeare P. International Wound JournalInternational Wound Journal. . 2004;2004;1(41(4):):225-230. 225-230.

History of Current Telemedicine in History of Current Telemedicine in GeorgiaGeorgia

$100$100 million grant from WellPoint Foundation million grant from WellPoint Foundation (parent company of Blue Cross/Blue Shield) (parent company of Blue Cross/Blue Shield) in 2004in 2004

GA Dept. of Ins. Commissioner OxendineGA Dept. of Ins. Commissioner Oxendine Established, equipped, and financed five Established, equipped, and financed five

sites in Georgia for telemedicine to serve sites in Georgia for telemedicine to serve rural communities “Rural Health Initiative”rural communities “Rural Health Initiative”

$11.5 million for three years - $11.5 million for three years - TelemedicineTelemedicine 2007 Archbold Medical Center became hub2007 Archbold Medical Center became hub 2008 grant expired; Georgia TeleHealth 2008 grant expired; Georgia TeleHealth

Partners took overPartners took over

Telemedicine at AMCTelemedicine at AMC Specialists for telemedicine and teleradiology Specialists for telemedicine and teleradiology

providing remote consultsproviding remote consults• DermatologistDermatologist• PsychiatristPsychiatrist• Surgeon Surgeon • PodiatristPodiatrist• NeurosurgeonNeurosurgeon• CardiologistCardiologist• Interventional cardiologistInterventional cardiologist• Physical therapist – Certified Wound SpecialistPhysical therapist – Certified Wound Specialist

Archbold Medical CenterArchbold Medical Center Flagship hospital - JDAMHFlagship hospital - JDAMH Out patient wound center – ACWM&HMOut patient wound center – ACWM&HM 4 affiliate hospitals4 affiliate hospitals 4 swing bed (sub-acute) hospitals4 swing bed (sub-acute) hospitals 4 nursing homes4 nursing homes Psychiatric hospitalPsychiatric hospital Specialty clinicsSpecialty clinics Urgent care facilityUrgent care facility Hospice Hospice Home health agencyHome health agency 2 Visiting Nurse Associations2 Visiting Nurse Associations

Archbold Medical CenterArchbold Medical CenterWound ManagementWound Management

Clinical EducatorClinical Educator Affiliate hospitals, swing Affiliate hospitals, swing

beds, and nursing homesbeds, and nursing homes• Visited once monthlyVisited once monthly

Consults, Wound Rounds, Consults, Wound Rounds, inservices, treatment inservices, treatment complex wounds, etc.complex wounds, etc.

• Send photos of every wound Send photos of every wound weekly – telemedicine laptopweekly – telemedicine laptop

• Nursing homes send wound Nursing homes send wound report of every wound weeklyreport of every wound weekly

Archbold Medical CenterArchbold Medical CenterWound ManagementWound Management

Clinical Educator Clinical Educator

Schedule dictates when patient seenSchedule dictates when patient seen• Emergent consultsEmergent consults• Problems with patient/resident Problems with patient/resident

treatmentstreatments• Other facilities seen on as needed basisOther facilities seen on as needed basis

Most distant facilities 2 hours awayMost distant facilities 2 hours away

Telemedicine ConsultsTelemedicine ConsultsWound ManagementWound Management

Clinical Educator Clinical Educator ConsultsConsults

• Clinician does not have to Clinician does not have to traveltravel

Time to spend with other Time to spend with other patients, etc.patients, etc.

GasGas Bad weatherBad weather

• Emergent and new patient Emergent and new patient consults consults

Scheduled quickly Scheduled quickly No long waitsNo long waits

Carlson T.Highlighting TelemedicineCarlson T.Highlighting Telemedicine.Today's Wound Clinic.3:Sept/Oct 2.Today's Wound Clinic.3:Sept/Oct 2009009


Real timeReal time• Interactive: patient and clinicianInteractive: patient and clinician

Store-and-forwardStore-and-forward• Transmission and storage of photos/data Transmission and storage of photos/data

for future usefor future use• Less expensiveLess expensive• Easier to use and maintainEasier to use and maintain• Most commonMost common

Equipment Equipment

Computers Computers Software Software Specialized Specialized

medical camerasmedical cameras Video equipmentVideo equipment High speed High speed

telephone linestelephone lines Encryption Encryption

technology technology

AdvantagesAdvantages

Patient can stay with Patient can stay with local physicianlocal physician

ConsultsConsults• Patient does not have to Patient does not have to

travel for access to a travel for access to a specialistspecialist

Rural areasRural areas Time off from Time off from

work/schoolwork/school Expense of ambulanceExpense of ambulance Time on stretcherTime on stretcher


FacilityFacility• Decrease ED Decrease ED

visitsvisits• Increase patient Increase patient

censuscensus• Decrease Decrease

complicationscomplications• Decrease costsDecrease costs

Real Time Telemedicine Real Time Telemedicine SitesSites

Image sending stationImage sending station Transmission networkTransmission network Receiving image Receiving image

review stationreview station• Two screensTwo screens

Wound on oneWound on oneConsultant on Consultant on

the otherthe other

Telemedicine Consult AdvantagesTelemedicine Consult Advantages ExaminationExamination

• Sound excellentSound excellent Can talk back and forth in real timeCan talk back and forth in real time Precise audioPrecise audio

• Visuals better than naked eyeVisuals better than naked eye Can enlarge, etc.Can enlarge, etc.

• Displays diagnostic data Displays diagnostic data ImagesImages Lab valuesLab values

• Interactive real time video - Split screen Interactive real time video - Split screen so both can see both partiesso both can see both parties

Integumentary Clinic - AMCIntegumentary Clinic - AMC

Once monthlyOnce monthly Facilities contact me re: patients Facilities contact me re: patients

needing to be seenneeding to be seen I identify patients to be seen on I identify patients to be seen on

monthly wound roundsmonthly wound rounds MD requests clinic consultsMD requests clinic consults New consult or follow upNew consult or follow up


Flagship hospitalFlagship hospital• Gregory Patterson, MD, FACS, CWSGregory Patterson, MD, FACS, CWS• Harriett Loehne, PT, DPT, CWSHarriett Loehne, PT, DPT, CWS

Affiliate hospital or nursing homeAffiliate hospital or nursing home• PatientPatient• PT/PTA/nursePT/PTA/nurse• Attending physicianAttending physician• Family/caregiverFamily/caregiver


Scheduled with person in charge of Scheduled with person in charge of main sitemain site

She notifies sites of times to have She notifies sites of times to have patients ready in telemed roompatients ready in telemed room

Remote site to send to meRemote site to send to me• Face sheetFace sheet• H & PH & P• Current medsCurrent meds• Wound culture reportsWound culture reports• Last wound assessmentLast wound assessment


Information available for MD at ClinicInformation available for MD at Clinic• Current prealbuminCurrent prealbumin• Current lab valuesCurrent lab values• Wound measurements day of consult, Wound measurements day of consult,

including depthincluding depth• Previous wound assessments (photo Previous wound assessments (photo

books for NHs)books for NHs)• Patients’ charts Patients’ charts • Swabs for probingSwabs for probing• Forceps if neededForceps if needed


Documentation of exam/consultDocumentation of exam/consult• Templates in programTemplates in program

Key immediately into systemKey immediately into system Print out at patient’s facility to include in Print out at patient’s facility to include in

chartchart

• Email/call with commentsEmail/call with comments• Consultation form sent for live visitConsultation form sent for live visit

Telemedicine ConsultsTelemedicine ConsultsWound ManagementWound Management

Disadvantages Disadvantages Unable to palpate the Unable to palpate the

wound or periwound tissuewound or periwound tissue Unable to determine depth Unable to determine depth

and undermining by feeland undermining by feel Unable to detect odorUnable to detect odor

PT/PTA/nurse with patient PT/PTA/nurse with patient can describe and measure can describe and measure for youfor you

TelemedicineTelemedicineStore and ForwardStore and Forward

Regular monitoring through Regular monitoring through photodocumentationphotodocumentation• Sent weekly to my Telemed laptopSent weekly to my Telemed laptop

HIPPA compliantHIPPA compliant Can do consult/follow-up from any locationCan do consult/follow-up from any location

• Program stores the dataProgram stores the data• Automatically placed in individual Automatically placed in individual

folders and archived for continuityfolders and archived for continuity

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PhotodocumentationPhotodocumentationPatient FoldersPatient Folders

Telemedicine FolderTelemedicine Folder• Demographic formDemographic form• Referral formReferral form• Scan inScan in

Recent labsRecent labsH & PH & PProceduresProcedures

• ImagesImages

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PhotodocumentationPhotodocumentationAdvantagesAdvantages

Can monitor status of woundCan monitor status of wound Appropriate dressingsAppropriate dressings Appropriate managementAppropriate management Detect progress or lack thereofDetect progress or lack thereof Can send back with notations and Can send back with notations and

questionsquestions

Technical overview of a Web-based Technical overview of a Web-based telemedicine system for wound telemedicine system for wound

assessmentassessment Store-and-forward telemedicine system Store-and-forward telemedicine system

using the Internet using the Internet Clinician obtains data from a patientClinician obtains data from a patient Transmits the data to a Web site that the Transmits the data to a Web site that the

physician may remotely access at his or physician may remotely access at his or her convenience her convenience

Allows for easy transmission and access of Allows for easy transmission and access of digital images of patients' wounds digital images of patients' wounds

Enables multiple types of data needed for Enables multiple types of data needed for comprehensive patient management to be comprehensive patient management to be summarized, organized, and displayed in a summarized, organized, and displayed in a meaningful waymeaningful way

Lowery JLowery J, , Hamill JHamill J, , Wilkins, EWilkins, E, , Clements, EClements, E. . ADV SKIN WOUND CARE. 2002;15:165-6, 168-9.ADV SKIN WOUND CARE. 2002;15:165-6, 168-9.


Continuum of careContinuum of care• ConsistentConsistent

Follow wound management ordersFollow wound management orders Use of productsUse of products

• Proper staging of pressure ulcersProper staging of pressure ulcers Appropriate interventionsAppropriate interventions

• Great addition to weekly wound reports Great addition to weekly wound reports from NHsfrom NHs

Telemedicine for Problematic Wound Management: Telemedicine for Problematic Wound Management: Enhancing Communication Between Long-Term Care, Skilled Enhancing Communication Between Long-Term Care, Skilled

Nursing, and Home Caregivers and a Surgical Wound Nursing, and Home Caregivers and a Surgical Wound SpecialistSpecialist

From 2003 through 2005, 120 patients From 2003 through 2005, 120 patients seen during the course of telemedicine seen during the course of telemedicine and subsequent direct consultationsand subsequent direct consultations

Email photos and Plan of Care onlyEmail photos and Plan of Care only In only 2 cases (1.67%), upon physical In only 2 cases (1.67%), upon physical

examination, the surgeon changed the examination, the surgeon changed the previously established diagnosis and previously established diagnosis and management plan management plan

Telemedicine consultations provide Telemedicine consultations provide accurate chronic wound assessmentaccurate chronic wound assessment

Management plans created prior to a Management plans created prior to a direct evaluation by a specialist are validdirect evaluation by a specialist are valid

Dobke M, Renkielska A, De Neve J, Chao J, BhavsarD. Wounds. 2006;18(9):256-261.Dobke M, Renkielska A, De Neve J, Chao J, BhavsarD. Wounds. 2006;18(9):256-261.

The impact of telemedicine on outcomes of The impact of telemedicine on outcomes of chronic wounds in the chronic wounds in the home care settinghome care setting

Improved healing rates Improved healing rates Decreased healing time Decreased healing time Decreased number of home health visits Decreased number of home health visits Decreased number of hospitalizations Decreased number of hospitalizations

related to wound complicationsrelated to wound complications Viable option for delivering quality, cost-Viable option for delivering quality, cost-

effective care to chronic wound patients in effective care to chronic wound patients in the home care settingthe home care setting

Kobza LKobza L, , Scheurich AScheurich A. Ostomy Wound Manage. 2000;46(10):48-53. Ostomy Wound Manage. 2000;46(10):48-53

Sean Flynn. Parade. Nov 22, 2009.Sean Flynn. Parade. Nov 22, 2009.16.16.

Surgeon ConsultsSurgeon Consults

Burn victim – saves unnecessary Burn victim – saves unnecessary transfers to other hospital + family transfers to other hospital + family journeyjourney

Rafael Grossmann, MD – Eastern Rafael Grossmann, MD – Eastern Maine Medical CenterMaine Medical Center• 59 emergency TM consults compared to 59 emergency TM consults compared to

telephone consultstelephone consults Unnecessary transfers practically eliminatedUnnecessary transfers practically eliminated Medical errors reduced 75%Medical errors reduced 75%

Feasibility and acceptance of telemedicine for Feasibility and acceptance of telemedicine for wound care in patients with chronic leg ulcerswound care in patients with chronic leg ulcers

41 chronic leg ulcers of different origin in 14 41 chronic leg ulcers of different origin in 14 patients patients

Initial in-person visit - leg ulcers were assessed Initial in-person visit - leg ulcers were assessed and classified, and underlying diseases noted and classified, and underlying diseases noted

Follow-up visits done by home-care nurses Follow-up visits done by home-care nurses Once a week 1-4 digital images of the wound and Once a week 1-4 digital images of the wound and

surrounding skin and relevant clinical information surrounding skin and relevant clinical information transmitted via a secure Website to an expert at transmitted via a secure Website to an expert at the wound care centre. the wound care centre.

Experts provided assessment of wound status Experts provided assessment of wound status and therapeutic recommendations and therapeutic recommendations

Feasibility and acceptance of telemedicine for Feasibility and acceptance of telemedicine for wound care in patients with chronic leg ulcerswound care in patients with chronic leg ulcers

89% of 492 teleconsultations 89% of 492 teleconsultations • Quality of images was sufficient or excellent Quality of images was sufficient or excellent • Experts were confident giving therapeutic Experts were confident giving therapeutic

recommendationsrecommendations• Treatment modalities were changed or Treatment modalities were changed or

adapted in one-third of the consultations adapted in one-third of the consultations • Significant decrease in visits to a general Significant decrease in visits to a general

physician or the wound care centrephysician or the wound care centre

Hofmann-Wellenhof R, Salmhofer W, Binder B, et al. J Telemed Telecare. 2006;12 Suppl 1:15-7Hofmann-Wellenhof R, Salmhofer W, Binder B, et al. J Telemed Telecare. 2006;12 Suppl 1:15-7

Halstaead LS, Dang T, et al. AdvanHalstaead LS, Dang T, et al. Advances in Skin&Wound Care. March/Apces in Skin&Wound Care. March/April 2003; 91-96.ril 2003; 91-96.

Teleassessment Compared with Live Teleassessment Compared with Live Assessment of Pressure Ulcers in a Assessment of Pressure Ulcers in a

Wound Clinic: A Pilot StudyWound Clinic: A Pilot Study

Plastic Surgeon reviewed laptop images 20 Plastic Surgeon reviewed laptop images 20 wounds, 17 individuals with spinal cord injurywounds, 17 individuals with spinal cord injury

Then assessed patient and wound liveThen assessed patient and wound live % of agreement% of agreement

• 95%:need to change wound management95%:need to change wound management• 95%: need for referral95%: need for referral• 85%: satisfaction for making treatment decisions85%: satisfaction for making treatment decisions• 80%: need to obtain additional information80%: need to obtain additional information


Continuum of careContinuum of care• Prevention of pressure ulcersPrevention of pressure ulcers

Go to computerized documentationGo to computerized documentation Check integumentary documentation Check integumentary documentation Coordinate Braden Score with ProtocolsCoordinate Braden Score with Protocols Check prealbuminsCheck prealbumins

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Wound ManagementWound ManagementAdvantagesAdvantages

EducationEducation• In-service – as many as 4 facilitiesIn-service – as many as 4 facilities

All see each other on split screenAll see each other on split screen Can talk and listen in real timeCan talk and listen in real time

• Patients and caregiversPatients and caregivers• Health care providersHealth care providers

Learning through telemedicine: Learning through telemedicine: case study of a wound care case study of a wound care

networknetwork Effective learning can be fostered in Effective learning can be fostered in

a telemedicine networka telemedicine network Contributes to quality healthcareContributes to quality healthcare Learning is in some respects more Learning is in some respects more

effective in the telemedicine setting effective in the telemedicine setting than it would be in face-to-face care than it would be in face-to-face care givinggiving

Hofmann-Wellenhof R, Salmhofer W, Binder B, Okcu A, Kerl H, Soyer HPHofmann-Wellenhof R, Salmhofer W, Binder B, Okcu A, Kerl H, Soyer HP. J Telemed . J Telemed Telecare. 2006;12 Suppl 1:15-7Telecare. 2006;12 Suppl 1:15-7

ReimbursementReimbursement Covered by insurance in Georgia Covered by insurance in Georgia

- Rural Health Initiative- Rural Health Initiative• If insurance covers being seen in person, If insurance covers being seen in person,

must cover via telemedicine if seen in must cover via telemedicine if seen in one of several sitesone of several sites

American Telemedicine AssociationAmerican Telemedicine Association. Medicare Payment of Telemedicin. Medicare Payment of Telemedicine and Telehealth Services.e and Telehealth Services.

Reimbursement Reimbursement Wound ManagementWound Management

Originating sites covered by MedicareOriginating sites covered by Medicare• Office of physician or practitionerOffice of physician or practitioner• HospitalHospital• Critical access hospitalCritical access hospital• Rural health clinicRural health clinic• Federally qualified health centerFederally qualified health center• Skilled nursing facilitySkilled nursing facility• Hospital-based dialysis centerHospital-based dialysis center• Community mental health centerCommunity mental health center

Chelmsford N. A Newly Approved CChelmsford N. A Newly Approved CMS Medicare Package Expands ReiMS Medicare Package Expands Reimbursement Coverage for Telehealmbursement Coverage for Telehealth Originating Sites Beginning Januth Originating Sites Beginning January 1, 2009. http://www.prweb.comary 1, 2009. http://www.prweb.com/releases/2009/01/prweb 1906724./releases/2009/01/prweb 1906724.htmhtm

ReimbursementReimbursement

5% bonus if patient 5% bonus if patient resides in federally resides in federally designated Physician designated Physician Shortage AreaShortage Area

Originating facility also Originating facility also receives site feereceives site fee

MLN Matters #MM6705. DecemberMLN Matters #MM6705. December 18, 2009 18, 2009


January 1, 2010January 1, 2010• SNF can use C0406-G0408 (previously SNF can use C0406-G0408 (previously

just for inpatient hospital setting)just for inpatient hospital setting) Modifiers GT or GQModifiers GT or GQ

PT in Motion.February 2010.PT in Motion.February 2010.


Store-and-forwardStore-and-forward• Not CMS definition Not CMS definition

of Telemedicineof Telemedicine• Reimbursable by Reimbursable by

Medicaid under Medicaid under section 1905 of SSA section 1905 of SSA in 27 statesin 27 states

1.Carlson T. Highlighting Telemedici1.Carlson T. Highlighting Telemedicine. Today's Wound Clinic.3:Sept/Ocne. Today's Wound Clinic.3:Sept/Oct 2009. 2.Arthur Little. Outcot 2009. 2.Arthur Little. Outcomes of an Integrated Telehealth Nemes of an Integrated Telehealth Network Demonstration Project. Teletwork Demonstration Project. Telemedicine Journal and e-Health. 200medicine Journal and e-Health. 2003.3.

FutureFuture Obama economic stimulus plan: Obama economic stimulus plan:

American Recovery and American Recovery and Reinvestment Act of 2009 – $2.5 Reinvestment Act of 2009 – $2.5 billion to invest in infrastructure billion to invest in infrastructure and tools for promotion of and tools for promotion of telemedicine in real timetelemedicine in real time

Annual net cost savings to Annual net cost savings to Medicare estimated $2-4 billion²Medicare estimated $2-4 billion²


Raises our standard of Raises our standard of care in an efficient care in an efficient and cost effective and cost effective mannermanner

Promise for continued Promise for continued efforts as wound efforts as wound specialists to serve specialists to serve our growing our growing communitiescommunities

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Wound Healing Society

telehealth for integumentary health

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