T

hough the use of communications technology in healthcare is changing rapidly, telehealth is generally defined as using telecommunications to support or provide healthcare from a distance.1 Telehealth can be as simple as a telephone conversation between clinicians and can be as complex as a two-way interactive television link. In this article, the experience of a home healthcare network using teleconferencing, computerized medical records, and digital photographs to consult remote certified nurses on patients with complex wounds will be reviewed. We found evidence suggesting that telehealth facilitated improved patient outcomes through the use of evidence-based protocols when individualizing plans of care for patients in the home.
       Our home health agencies (HHAs) became interested in integrating new technology for several reasons. Recent changes in Medicare reimbursement from a fee-for-service payment system to prospective payment system created new financial pressures. This change reduced costs to Medicare and also encouraged HHAs to explore alternatives to traditional home healthcare delivery models.
       Another reason HHAs are exploring advanced technology is to improve the quality of care. Under the same legislation that changed the Medicare payment system, HHAs were mandated to collect and transmit assessment information as the Outcome and Assessment Information Set (OASIS) for every patient admitted, recertified, and discharged. Like the Minimum Data Set (MDS), OASIS includes information on a patient's functional status and can be analyzed in order to measure the impact of home healthcare on a patient's health and independence. Medicare has directed regulatory organizations to begin using this data to measure quality and to guide surveys of HHAs.
       With the reduction in payments by Medicare, HHAs quickly identified wound care as an area of concern because wounds are common for patients receiving home healthcare. According to OASIS data, 46 percent of all home healthcare patients admitted in second quarter 2001 to a Medicare-certified home healthcare agency had at least one wound. Additionally, we found that wound care was historically an area where visit utilization had been high, where care planning rarely followed protocols, and where advanced wound care product usage was low. Furthermore, several of our locations found improved outcomes and reduced utilization when a certified wound care specialist was involved in planning care for patients with wounds. A review of the wound care literature also indicated that others found a similar impact from the use of wound care specialists. In Arnold and Weir's study,2 healing rates increased from 36 to 79 percent when a wound care specialist managed the patient's care.
       Unfortunately, this specialized care for home healthcare patients is often not available due to a shortage of certified wound care nurses or therapists. To overcome this limitation, we explored using these scarce clinicians remotely to impact the progress of more patients. Our experiences and literature review suggested that advanced technology and remote wound care specialists could enhance care planning and improve patient outcomes. In 2000, Kobbza and Schuerich3 published a study using two-way interactive television to connect remote wound care specialists to nurses in the home for support and enhanced care planning. Their study evaluated the impact on 76 patients with diagnoses of pressure ulcers, venous ulcers, and diabetic ulcers. They found healing improved from 37 to 58 percent and the average number of visits per patient decreased from 60 to 33. This is significant because of the economics of home healthcare--the cost of every visit is a direct cost. This means that any improvement that reduces visits has a profound impact on the cost of care.
       Even though their study used real-time video conferencing, we felt digital images and on-line information reviewed during care planning teleconferences could also be effective. In 1998, Wirthlin, et al.,4 offered further support for this approach. In their study, remote wound evaluation using photographs compared well to evaluation done at the bedside. Over six weeks, researchers evaluated 38 different wounds using eight surgeons and found that the agreement on both wound description and approaches to wound management was very high between assessments based on physical evaluations versus those based on viewing a digital photograph.
       Our approach focused on improving access for any field nurse to remote clinical support staff. We organized a remote resource team to consult on complex wound cases consisting of a certified wound care specialist and certified case managers. Clinical managers at locations would review each new admission and each ongoing case involving a wound. For each new case, they evaluated the plan of care to determine the potential need for advanced dressings, to ensure consistency with evidence-based protocols, and to help identify realistic goals. For ongoing cases, they evaluated the plan of care to see if progress was being made toward realistic goals. If the plan of care failed to meet these criteria, a teleconference was scheduled to include a member of the remote resource team.
       In preparation for the teleconference, the remote support clinician was given access to the patient's on-line record, and if needed, digital photographs were taken and shared for the review. Remote support clinicians had access to computerized versions of the physician's plan of care and to OASIS assessments, which included diagnoses, procedures, medications, and the prescribed wound care.
       We also selected digital photography because the technology has improved rapidly, and cameras have recently become more reliable and affordable. We selected the Kodak DC-215 and later the DX3200 as our preferred cameras, because they were cost effective and easy to use. They capture images in one megapixel resolution. We found this resolution was adequate for prints and resulted in a small enough file size for reasonable transmission via our closed network. These digital cameras had several beneficial features for clinicians new to the technology. For example, the built-in liquid-crystal display allowed clinicians to immediately review each photograph before printing to ensure accuracy. Downloading the images via computer cable did not require significant training because the camera software was integrated into Windows. Digital alteration of photos was not allowed.
       Digital photography training was provided through the self-paced camera guide from the manufacturer. Clinicians were encouraged to experiment by taking several photographs and then reviewing the images before transferring to the computer and printing. This approach minimized cost without limiting the experimentation needed to develop competency. We found that most clinicians were able to take adequate photographs quickly. All digital images collected were deleted from computers after printing or were stored on electronic media in the medical records department to ensure our patients' confidentiality was protected.
       What was the impact? Our review of the data available suggests that patient outcomes improved and the cost of care decreased. The impact on patient outcomes was measured by the improvement in the OASIS severity of illness index from admission to discharge for all patients in our HHAs. We found this index improved for 70 percent of patients in third quarter 2001, after implementation, compared with a 50-percent improvement in the preceding quarter. The impact on costs was measured as the change in visits per patient. The average number of visits decreased from 37 visits per month before implementation to 23 visits per month after implementation. It is important to note that improvement reflects the change for all patients and not just those involved in this project. In the future, we hope to identify funding to retrospectively review records of patients whose care planning involved remote support and compare their outcomes to a similar control group. Nevertheless, due to the high percentage of patients with wounds, we felt these available indicators merited reporting.
       These preliminary findings are consistent with the impressions of many of our nurses. Both the field clinicians and remote support team felt that this telemedicine process improved communication, reduced costs, and increased the consistency of care for patients with complex wounds. It also led to a willingness on the part of field nurses to proactively contact the clinical support team for guidance. Many field nurses also told us they felt more confident in their ability to manage complex cases knowing that they had access to clinical experts who could help them select dressings and plan care. The remote resource team also noted more consistent wound assessments when the teleconferences were conducted and increased interest by the field nurses in pursuing advanced wound care education.
       So what's next? Based on the success of this effort to improve outcomes and reduce utilization, the organization built a comprehensive web-based education resource to support our field clinicians. We are also revising our wound care protocols based on patient outcomes during this early phase, evaluating supply utilization and our product formulary to improve consistency, and supporting the highest quality wound care in the home.