INTEGRIS Telewoundcare Network

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Project Details -
Completed

This study was designed to demonstrate the clinical effectiveness and cost-effectiveness of utilizing telehealth technology to reduce the days to heal for chronic wounds. This was accomplished through the utilization of health information technology to improve access to knowledgeable caregivers, point of care processes, and dissemination of best practice information. The study approached wound care as a continuum of care addressing underlying etiology (diabetes) as well as the immediate wound treatment regimen.

The study was a controlled trial to evaluate a telehealth strategy, which incorporated evidence-based guidelines, by comparison to the current standard care provided in the community. The primary outcome measure was the time to healing of the wound. The unit for allocation was the different counties in Oklahoma, but the unit of analysis was the individual patient. This strategy was used to avoid contamination of the standard care control group by the telehealth/evidence-based strategy, which would occur if the same providers in a county were delivering care in both the control and intervention groups.

A true randomized allocation to the intervention or control groups was not possible due to logistic reasons, and to avoid withdrawal of telehealth services from counties in which this has already been implemented. We minimized bias in allocation by using matching counties by their demographic and other characteristics, and then allocating counties within these pains to receive either the experimental telehealth intervention or the community standard care (control group). Bias in the assessment of the outcome of wound healing was avoided by taking pictures of the wound, using a standardized method, at fixed intervals in all patients, and having these pictures interpreted by an independent clinical expert, without knowledge of the patient's group assignment, clinical features or other information. The study incorporated a combination of broadband, analog, and web-based applications to serve patients in a variety of settings including clinics, homes and long-term care facilities.

Charles Bryant, M.D.When it comes to healing chronic wounds -- those that haven't mended within three weeks -- Charles Bryant, M.D., believes that telecare not only will speed up the healing process but also cut costs.

Supported by a grant from the Agency for Healthcare Research and Quality (AHRQ), Bryant and his colleagues at EvidentTelehealth Services have launched a web-based telewoundcare network in Oklahoma linking nursing home aides, home health workers, and other direct care providers to wound care and other specialists.   

The new, experimental telewound network primarily serves rural counties in Oklahoma. Because the state's two major academic and referral centers are in Oklahoma City and Tulsa, much of central Oklahoma is left without convenient access to specialty care. This means that people in approximately two-thirds of the state -- mostly in rural areas -- must travel long distances to get to the centers in the main cities. Accordingly, Bryant and his team devised the network so that patients could be treated by their local providers without having to travel far. 

Wound care centers at INTEGRIS Baptist Medical Center in Oklahoma City -- where the specialty team is located -- INTEGRIS Southwest Medical Center, Oklahoma City, and INTEGRIS Bass Home Health Care in Enid, serve as the primary wound care centers for the project.

The network's specialty team includes a burn/wound care specialty physician and a staff of wound care nurses working with diabetes management specialists. This expert team monitors the patients and provides interventions when necessary. 

A former pediatrician, Bryant says that he's a big believer in prevention and early intervention, as well as standardization of care.  By improving access to specialty wound care, he believes that wound care patients will get needed care sooner.  And Bryant adds that he hopes the network will establish and communicate evidence-based wound care protocols among providers and expedite healing.  "What we're trying to show is that eliminating variation improves quality," says Bryant. 

Streamlining and standardizing wound care is a big part of the clinical equation here.  But Bryant notes that about40 percent of patients in the network also have diabetes, so special attention is paid to managing that condition.   Although wounds may have many causes -- bed sores, surgery, radiation, or even spider bites -- diabetes and uncontrolled blood-sugar levels frequently explain why a wound becomes chronic.  For that reason, glucose screening is conducted before treatment begins.

The project is still in its early stages -- patients started enrolling 18 months ago -- but preliminary findings indicate cost savings and quicker healing in the intervention group.  The network will be evaluated by comparing results from a control group that receives usual care and an intervention group that's treated through the telenetwork.

Enrolling patients in the project is a continuing challenge.  Offering compensation to the various providers for additional time spent on program documentation finally led to a spike in enrollees, but enlisting patients for the control group is still difficult.  Currently, the network has 40 patients enrolled in the intervention group, and only three in the control group.

In the beginning, Bryant and his colleagues sought the involvement of physicians and hospital executives in the project.  Eventually, they learned to focus their efforts on those entities and people at the point of care:  the nursing home aides, employees at wound care centers, and home health workers.  They are with patients every day, changing the wound dressing, examining the wound, documenting changes, and implementing the blood-sugar control protocols when needed.   These caregivers must be on board with the project and willing to work with the network team in order to enroll patients. 

In addition, Bryant and his team are working with the Oklahoma Physicians Resource/Research Network, a statewide physician research network established through the Department of Family Medicine at the University of Oklahoma.   Although the network has been somewhat successful -- two doctors have sent referrals -- Bryant says that it's difficult to enlist physicians' interest because of their time constraints.

The "tele" part of the network is working well, Bryant says.  The system is an Internet-based model from which the project staff and point-of-care provider can access the same information, which includes vital signs, digital photographic documentation of the patient's wound, lab results, and any other relevant notes about the patient's progress. 

During each patient visit, the provider takes the patient's vital signs and enters them and any relevant notes to the EHR via plain old telephone from wherever the patient is.  This information is downloaded to a security-protected database, and can then be viewed by the wound care specialty team.  The team can read and see -- through digital pictures, including images of the patient's wound -- the patient's progress. 

Because some facilities have technical or personnel limitations, providers may also take digital pictures and send them on a chip.  Other data such as lab results are sent via fax. 

Education offered through the telewoundcare network, such as teleconferences on wound care and diabetes, has been well-received by the providers.  The teleconferences are offered quarterly to train new providers and keep current providers up to date on treatment protocols.  Additional training is received as needed through videophones that link a wound care specialist to a provider while the provider is working on-site with a patient.

Ultimately, Bryant says, he hopes that the project will show that standardization of care is key to:

  1. Decreasing cost -- not just for patients, but also for taxpayers, because patients with chronic wounds tend to be costly and many of them are covered by Medicare.
  2. Improving clinical outcomes.  Patients in the network receive more consistent and coordinated evidence-based care because of better communication among providers. Bryant says that improved coordination should translate to quicker healing for patients.  Another mission is to control glucose levels in patients with diabetes who are particularly vulnerable.
  3. Enhancing quality of life for patients.  By reducing the healing time of chronic wounds and helping regulate glucose levels in patients with diabetes, Bryant hopes that patients will be both healthier and happier.