Wound teleconsultation in patients with chronic leg ulcers

The Utility of Smartphone Applications and Technology in Wound Healing

Appropriate management of both acute and chronic wounds is a dynamic practice that consumes large amounts of time and financial resources within the health care system. Traditionally, wounds were measured clinically and subjectively, leading to inaccuracies in assessing wound progression and healing over time. The recent development of mobile applications and digital equipment in medicine provides an opportunity for significant improvement in wound care through the incorporation of “smart” technologies in clinical practice. The utility of these technologies has been assessed regarding the treatment of diabetic foot ulcers, burns, and general wounds. The focus of this review is to provide an update on the current status of mobile applications and digital technology in the management of wounds.

A smartphone-based teleconsultation system for the management of chronic pressure injuries

We investigated the accuracy of pressure injury evaluation using tele-devices and examined the concordance between automatically generated recommendations and primary manual recommendations. Caregivers took photos and videos of pressure injuries using smartphones with built-in cameras and uploaded the media to the application. The wound team evaluated the wound using a specially modified version of the Pressure Sore Status Tool. This was compared with the Pressure Sore Status Tool score assessed during the actual examination of the patient. We developed an automatic algorithm for dressing based on the Pressure Sore Status Tool score, checking for consistency between this and the primary manual recommendation. A total of 60 patients diagnosed with pressure injuries were included. The κ coefficients indicated substantial agreement for wound size and total score, and excellent for all other items. We found that the overall concordance rates were statistically significant for all items (p < 0.001). For the primary dressing, the κ coefficient for the concordance rate of automatic algorithm and manual recommendation was 0.771, while that of teleconsultation system and manual recommendation was 0.971. For the secondary dressing, the figures were 0.798 and 0.989, respectively. All values were statistically significant (p < 0.001). We presented strong evidence documenting the utilization of a smartphone, patient-driven system, and demonstrated that the measurements obtained were comparable to the ones obtained by a trained, on-site, wound team. Furthermore, we confirmed agreement between automatically generated recommendations and primary manual recommendations.

Health and lifestyle management via interactive TV in patients with severe chronic cardiovascular diseases

A pilot trial of an interactive TV system took place at the Royal Brampton Hospital, involving nine hospitalized and 12 non-hospitalized patients with adult congenital heart disease. Following a short training session, patients took their measurements (blood pressure, ECG measurement, oxygen saturation, bodyweight) and submitted their data through the interactive TV system. The majority perceived the system as useful, efficient and appropriate for use with their condition (67%), and they were satisfied with the usability of the system (71%). They considered that the information provided by the system was easy to understand and they liked using the system (62%). Overall, most patients (20) were satisfied with the system. The majority of the participants did not feel that the system affected their relationship with their doctor.

Improved wound management at lower cost: a sensible goal for Australia

Chronic wounds cost the Australian health system at least US$2·85 billion per year. Wound care services in Australia involve a complex mix of treatment options, health care sectors and funding mechanisms. It is clear that implementation of evidence-based wound care coincides with large health improvements and cost savings, yet the majority of Australians with chronic wounds do not receive evidence-based treatment. High initial treatment costs, inadequate reimbursement, poor financial incentives to invest in optimal care and limitations in clinical skills are major barriers to the adoption of evidence-based wound care. Enhanced education and appropriate financial incentives in primary care will improve uptake of evidence-based practice. Secondary-level wound specialty clinics to fill referral gaps in the community, boosted by appropriate credentialing, will improve access to specialist care. In order to secure funding for better services in a competitive environment, evidence of cost-effectiveness is required. Future effort to generate evidence on the cost-effectiveness of wound management interventions should provide evidence that decision makers find easy to interpret. If this happens, and it will require a large effort of health services research, it could be used to inform future policy and decision-making activities, reduce health care costs and improve patient outcomes.

The Empirical Foundations of Teledermatology: A Review of the Research Evidence

INTRODUCTION

This article presents the scientific evidence for the merit of telemedicine interventions in the diagnosis and management of skin disorders (teledermatology) in the published literature. The impetus for this work derives from the high prevalence of skin disorders, the high cost, the limited availability of dermatologists in certain areas, and the promise of teledermatology to address unmet needs in this area.

MATERIALS AND METHODS

The findings are based on a targeted review of scientific studies published from January 2005 through April 2015. The initial search yielded some 5,020 articles in Google Scholar and 428 in PubMed. A review of the abstracts yielded 71 publications that met the inclusion criteria for this analysis. Evidence is organized according to the following: feasibility and acceptance; intermediate outcomes (use of service, compliance, and diagnostic and treatment concordance and accuracy); outcomes (health improvement and problem resolution); and cost savings. A special section is devoted to studies conducted at the Veterans Health Administration.

RESULTS

Definitions of teledermatology varied across a wide spectrum of skin disorders, technologies, diagnostic tools, provider types, settings, and patient populations. Outcome measures included diagnostic concordance, treatment plans, and health.

CONCLUSIONS

Despite these complexities, sufficient evidence was observed consistently supporting the effectiveness of teledermatology in improving accessibility to specialty care, diagnostic and treatment concordance, and skin care provided by primary care physicians, while also reducing cost. One study reported suboptimal clinical results from teledermatology for patients with pigmented skin lesions. On the other hand, confocal microscopy and advanced dermoscopy improved diagnostic accuracy, especially when rendered by experienced teledermatologists.

Teledermatology: from historical perspective to emerging techniques of the modern era: part I: History, rationale, and current practice

Telemedicine is the use of telecommunications technology to support health care at a distance. Technological advances have progressively increased the ability of clinicians to care for diverse patient populations in need of skin expertise. Dermatology relies on visual cues that are easily captured by imaging technologies, making it ideally suited for this care model. Moreover, there is a shortage of medical dermatologists in the United States, where skin disorders account for 1 in 8 primary care visits and specialists tend to congregate in urban areas. Even in regions where dermatologic expertise is readily accessible, teledermatology may serve as an alternative that streamlines health care delivery by triaging chief complaints and reducing unnecessary in-person visits. In addition, many patients in the developing world have no access to dermatologic expertise, rendering it possible for teledermatologists to make a significant contribution to patient health outcomes. Teledermatology also affords educational benefits to primary care providers and dermatologists, and enables patients to play a more active role in the health care process by promoting direct communication with dermatologists.

Telemedicine in wound care: a review

Telemedicine (TM) is a new, rapidly evolving area and can be of great value in the provision of healthcare to remote and rural populations. Wound healing and wound management are prime candidates for TM. The treatment of skin ulcers requires frequent assessments of local wound status and adjustment of therapy. The availability of reasonably priced photographic equipment and quick electronic transfer of high-quality digital images should make the assessment of wound status by remote experts possible. Several studies showing the feasibility and the usefulness of teleconsultations in dermatology have already been described in the literature, and high accordance for diagnosis and treatment between face-to-face visits and teleconsultations has been reported. Some used digital photographs and sent the image and clinical data via the Internet to a wound care specialist (store and forward), whereas others used a webcam (televideoconferencing). Tele-wound care offers great potential for the future in chronic wound care. By reducing the need to travel long distances to the hospital or to consult with a physician, TM decreases the costs and improves the quality of life for patients with chronic wounds, while still maintaining high standards of wound care. The intent of TM is to reduce, in a clinically equivalent way, the number of visits to a specialized clinic, but not necessarily to eliminate all visits. Further well-designed research is necessary to understand how best to deploy TM services in healthcare.

Clinical unity and community empowerment: the use of smartphone technology to empower community management of chronic venous ulcers through the support of a tertiary unit

BACKGROUND

Chronic ulcers affect roughly 60,000 Irish people, at a total cost of €600,000,000, or €10,000 per patient annually. By virtue of their chronicity, these ulcers also contribute a significant burden to tertiary outpatient vascular clinics.

OBJECTIVE

We propose utilizing mobile phone technology to decentralise care from tertiary centres to the community, improving efficiency and patient satisfaction, while maintaining patient safety.

METHODS

Bespoke mobile software was developed for Apples iPhone 4 platform. This allowed for the remote collection of patient images prospectively and their transmission with clinical queries, from the primary healthcare team to the tertiary centre. Training and iPhones were provided to five public health nurses in geographically remote areas of the region. Data were uploaded securely and user end software was developed allowing the review and manipulation of images, along with two way communication between the teams. Establishing reliability, patients were reviewed clinically as well as remotely, and concordance analysed. Qualitative data were collected through focus group discussion.

RESULTS

From October to December 2011 eight patients (61-83 yrs, mean 75.3 yrs) with chronic venous ulceration and their five public health nurses were recruited. Data were transmitted using 3 G, Edge, GPRS and WiFi, at a mean speed of 69.03 kps. Concordance was 100% for wound bed assessment, 80% for skin integrity/colour and 60% for exudate assessment. Focus group analysis explored the concept, practicalities and future applications of the system.

CONCLUSIONS

With an evolving national data network, the secure transmission of clinical images is a safe alternative to regular clinic appointments for patients with chronic venous ulceration. With further development, and packaged as a freely downloadable application, this has the potential to support the community care of chronic wounds.

Teledermatology: its role in dermatosurgery

Dermatologic surgery and aesthetic dermatology are rapidly emerging and expanding specialties in India. However, dermatologists practicing surgeries and aesthetics in India represent a highly selected group and are mostly confined to metros. Dermatologists in the peripheral and remote regions need to reach these specialists for the benefit of their patients and teledermatology is an invaluable tool for this purpose. Video-conference, store and forward, Satellite communication, Hybrid teledermatology, mobile teledermatology, Integration model, nurse-led teledermatology, teledermatology focusing difficult-to-manage cases, screening and triage services are the various teledermatology services developed to suit the needs of dermatology care from a distance. Types of teledermatology service, pattern of net work connectivity and purpose of dermatology service are the three cardinal parameters for management of the dermatoses from a distance. This article reviews the literature, and analyzes the possible options available for a teledermatosurgery practice.

Geriatric teledermatology: store-and-forward vs. face-to-face examination

BACKGROUND

Telemedicine could be useful in countries like Italy to meet the needs of elderly patients and in particular in those in precarious general conditions, for whom travelling even short distances can pose considerable practical and economical difficulties.

OBJECTIVE

The aim of this study was to determine the efficacy of store-and-forward teledermatology vs face-to-face consultations in elderly patients.

METHODS

A total of 130 geriatric patients with skin diseases requiring dermatological examination were enrolled. The patients examined, consisting of 60 men (46.15%) and 70 women (53.85%), were aged between 66 and 97 years (mean age 80.58 years). Three dermatologists of the department, with equal experience took turns in face-to-face examination and teledermatology (store-and-forward). To compare face-to-face dermatological examinations with the asynchronous store-and-forward approach of teledermatology, we considered diagnostic agreement (ICD-9 code), therapeutic agreement and concordance of diagnostic confidence.

RESULTS

One hundred and fourteen of 130 patients were diagnosed with the same ICD-9 code, making a total observed agreement of 87.7% with a Cohen's κ estimated of 0.863. Agreement between therapies was 69.6% (Cohen's κ = 0.640). As it concerns diagnostic confidence, dermatologists appeared generally slightly less certain of their diagnosis by telemedicine.

CONCLUSIONS

Store-and-forward teledermatology can improve diagnostic and therapeutic care for skin disease in elderly who lack easy and/or direct access to dermatologists.

One size doesn't fit all: bringing telehealth services to special populations

Telehealth applications and information communication technologies can be customized and scaled to meet the healthcare service needs of a wide variety of special populations. Categorization of those special groups can be viewed from a spectrum of perspectives such as by gender, age, culture, families, communities, chronic conditions, or particular types of locations, as well as when addressing a specific or unique health need. The emergence of innovations in the use of a range of technologies and connectivity offers exciting new approaches to the integration of telehealth aimed at improving quality and continuity of care to better meet the needs of special populations.

Telemedicine in wound care

Telemedical wound care is one of the applications of teledermatology. We present our experience using telemedicine in the successful assessment and treatment of three patients with hard-to-heal ulcers. Three patients were seen at the PEMEX General Hospital in Veracruz, Mexico. The first patient was a 53-year-old man with hypertension, morbid obesity, chronic venous insufficiency, recurrent erysipelas, leg ulcers and lymphoedema. There was one ulcer on his left lower leg (20 x 10 cm) and one on his right leg (9 x 7 cm). The second patient was a 73-year-old woman with class III obesity and ulcers in her right leg, secondary to surgical debridement of bullous erysipelas. The third patient was a 51-year-old female with rheumatoid arthritis with one ulcer on each leg and chronic lymphostasis. Photographs with a digital camera were taken and sent weekly via email to a wound care specialist in Mexico City. The photographs allowed the expert to diagnose and evaluate the chronic wounds periodically. In the present cases, telemedicine allowed us to have a rapid evaluation, diagnosis and treatment. The images were of enough quality to be useful and small enough to be sent via regular email to the remote physician who immediately gave his feedback. The expert was confident to give therapeutic recommendations in this way, and we considered this method to be very cost-effective, saving the patient and the health care system, especially in transportation.

Mobile teledermatology: a feasibility study of 58 subjects using mobile phones

We investigated the diagnostic agreement between teledermatology based on images from a mobile phone camera and face-to-face (FTF) dermatology. Diagnostic agreement was assessed for two teledermatologists (TD) in comparison with FTF consultations in 58 subjects. In almost three-quarters of the cases (TD1: 71%; TD2: 76%), the telediagnosis was fully concordant with the FTF diagnosis. Furthermore, the diagnosed diseases were almost all in the same diagnostic category (TD1: 97%; TD2: 90%). If mobile teledermatology had been used for remote triage, TD1 could have treated 53% subjects remotely and 47% subjects would have had to consult a dermatologist FTF. TD2 could have treated 59% subjects remotely, whereas 41% subjects would have had to consult a dermatologist FTF. Forty-eight subjects responded to a questionnaire, of whom only 10 had any concerns regarding teledermatology. Thirty-one subjects stated that they would be willing to pay to use a similar service in future and suggested an amount ranging from euro5 to euro50 per consultation (mean euro22) (euro = pound0.7, US $1.4). These results are encouraging as patient acceptance and reimbursement represent potential obstacles to the implementation of telemedicine services.

A mobile-phone based teledermatology system to support self-management of patients suffering from psoriasis

Psoriasis is one of the most common chronic skin diseases, affecting about 2% of the population world wide. Continuous clinical monitoring with periodic assessment of the state of the disease is essential for long-term therapy optimization. We present a mobile phone based telemedical compliance management system for psoriasis-patients. Using special software, patients can acquire health parameters such as their body weight, take photos of their psoriasis lesions, and report adverse effects. The data are automatically sent to a monitoring centre, where they are provided to the patient's physician via the use of a web-browser. In case of therapy relevant events, email or SMS notifications can be sent to the physician. If necessary, the physician can send feedback messages to the patient, e.g. for admitting the patient to the clinic for further examinations. The system has been implemented and functional tests have proven its functionality. Currently, the system is used in the course of a medical case series.

Maturity of teledermatology evaluation research: a systematic literature review

BACKGROUND

There is a growing interest in teledermatology in today's clinical practice, but the maturity of the evaluation research of this technology is still unclear.

OBJECTIVES

This systematic review describes the maturity of teledermatology evaluation research over time and explores what kind of teledermatology outcome measures have been evaluated.

METHODS

Systematic review of literature found in Medline database (1966 up to April 2006). A telemedicine evaluation strategy consisting of four consecutive research phases (parallel to drug and diagnostics evaluation research) extended with a fifth postimplementation phase was used to classify all included studies by two independent reviewers. In addition, main characteristics (store-and-forward or real-time, study design, outcome measures) were registered.

RESULTS

Three hundred and forty-five papers were systematically selected from Medline, and 244 papers were excluded. For two randomized controlled trials (RCTs), multiple papers in phase III were found. After correcting for this, 99 studies remained included (11 phase I, 72 phase II, two phase III, six phase IV, eight postimplementation phase). The number of phase II studies is the largest and still growing, while other phases are much less represented. Diagnostic accuracy was the most often used outcome measure and was found in phase I, II and IV. Store-and-forward teledermatology has been evaluated more since 2001, but most phase IV studies (RCTs, including cost aspects) are on real-time teledermatology.

CONCLUSIONS

Most teledermatology evaluation studies are classified as feasibility studies (phase II). The number of phase III and IV studies remains low through the years. Compared with other specialties in telemedicine (i.e. telesurgery, telepaediatrics), teledermatology seems to be a mature application. However, more evaluation studies with a focus on clinical outcomes such as preventable referrals or time to recovery are needed to prove that teledermatology indeed is a promising and cost-saving technology.

The Prevention and Treatment of Pressure Ulcers

Pressure ulcers remain a significant secondary complication for many individuals with spinal cord injury (SCI). Technological advances have the potential to affect both the prevention and treatment of pressure ulcers. The focus of this article is hi-tech devices and methodologies. The current state-of-the-art methods are discussed and conceptual approaches are presented.

Feasibility of a Web-Based Continuing Medical Education Program in Dermatology: The DermoFAD Experience in Italy

BACKGROUND

Web-based systems are increasingly being considered for medical education. A draft legislation on distance-learning programs was licensed in Italy by the National Commission for Continuous Education in November 2003. A series of pilot studies were developed, among these the DermoFAD project, based on five simulated clinical cases of acne and a systematic appraisal of the evidence for their clinical management. From July 1 to August 27, 2004, a total of 500 medical doctors participated in a free of charge evaluation program of the project.

OBSERVATIONS

Users were distributed all over Italy. Two hundred and eighty-one (56.2%) were primary care physicians, 83 (16.6%) dermatologists, and 136 (27.2%) other medical specialists. A wide range of connecting times was observed. The pass rate of each individual case, at first attempt, ranged from 44 to 77%. When asked to assess the overall distance-learning experience, 98% of the doctors considered it to be enjoyable. A total of 2,152 continuing medical education (CME) credits were awarded. Over 50% of the users stated they would still use the system if they had to pay for it.

CONCLUSIONS

Our experience shows that distance learning is feasible and is well accepted by physicians. The DermoFAD program was an efficient means of delivering CME to the Italian medical community at large.