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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. Objectives.

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visn 11 wound care teleconsultation program
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

objectives
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
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
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 methods5
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
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 results7
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 results8
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 results9
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 results10
Feasibility Study: Results

Patient Satisfaction Surveys

97 First Visits

feasibility study results11
Feasibility Study: Results

Patient Satisfaction Surveys

277 Subsequent Visits by 59 Patients

retrospective and study patient chart review at remote site
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
feasibility study conclusion
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
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
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
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.