INTEGRIS Telewoundcare Network (Oklahoma)

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Summary:

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.

INTEGRIS Telewoundcare Network - 2008

Summary Highlights

  • Principal Investigator: 
  • Organization: 
  • Funding Mechanism: 
    RFA: HS04-011: Transforming Health Care Quality through Information Technology (THQIT)
  • Grant Number: 
    UC1 HS 015359
  • Project Period: 
    09/04 – 09/08, Including No-Cost Extension
  • AHRQ Funding Amount: 
    $1,063,213
  • PDF Version: 
    (PDF, 71.35 KB)


Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

Summary: Chronic wounds, defined as wounds not healed in 30 days, are a national health problem. Chronic wounds have a high rate of occurrence and have significant clinical, cost, and social implications. It is estimated that five million patients in the United States have chronic wounds, and that one to two million people develop new pressure ulcers each year. Costs to treat chronic wounds are high. Wound care constitutes 48 percent of home health services provided in the Nation according to the Centers for Medicare and Medicaid Services (CMS) Case Mix Report. A major, but often overlooked, contributing co-morbidity to chronic and non-healing wounds is diabetes. If blood sugars are too high, healing will not occur; thus, controlling blood sugars should be addressed as part of the wound treatment plan. Oklahoma has the second highest diabetes rate in the Nation and the second lowest in expenditure for diabetes services. Many Oklahomans with diabetes remain undiagnosed since the disease is generally asymptomatic until complications develop.

The study design was a controlled trial to evaluate outcomes utilizing a telehealth strategy incorporating evidence-based practice guidelines as compared with outcomes using the current standard of care in the community. Most physicians were willing to refer to the telewound intervention group but never referred to the standard care group. They voiced concern over referring to the standard group because it was extra work for their staff without immediate benefit to the patient. As a result, although a total of 56 individuals participated in this study, only two individuals were allocated to the comparison group. Because the comparison sample’s small size prohibits between-group comparison, analysis had to be made within the telewound group for outcomes.

Specific Aims

  • Add to the network pioneered during prior grants by increasing physician and case manager awareness of telemedicine services, linking with additional sites, expanding coverage to new care settings, and demonstrating evidence-based practice. (Achieved)
  • Improve the quality of wound care by collecting wound care and diabetes documentation, improving diabetes management using videoconferencing and vital sign monitoring, and conducting more timely interventions. (Achieved)
  • Develop business strategies for sustainability. (Achieved)

2008 Activities: Data collection for the study of wound care outcomes continued into 2008 and concluded during the year so that analyses could be conducted. Educational presentations about chronic wounds, diabetes, and home health services continued.

Impact and Findings: The study investigated whether patients with longstanding wounds healed relatively quickly; however, the results were mixed. Certain patients with longstanding wounds healed quickly once enrolled in the program, but overall only about half of all wounds were healed by the end of the study. Underscoring the relationship between diabetes and wound care, 73 percent of the patients had characteristics of diabetes or other metabolic syndromes at enrollment, and about half of those metabolic conditions were uncontrolled or undiagnosed. Due to incomplete data collection for blood glucose and hemoglobin A1C, as well as the small sample size, no specific conclusions could be drawn from longitudinal tracking of the clinical outcomes data. Data suggest that early identification and intervention resulted in significant decreases in healing time; however, this has not reached statistical significance, and so the question of whether using an evidence-based telewound approach leads to superior healing times remains open. It can be speculated, however, that the improved access to specialized evidence-based wound care provided via telemedicine led to more timely referral and intervention.

Providers involved in the study cited the educational component as a major benefit to them. Group education was offered quarterly on diabetes care over broadband videoconferencing to rural sites, while metro participants attended onsite. Educational materials were sent to the attending sites in advance. The class was conducted by a certified diabetes educator, with time at the end of the session for questions and answers. Wound care group education was offered twice over videoconferencing, and a few home health inservices were provided locally.

The project team reported several issues that impacted use including unfamiliarity with digital cameras, a lack of time or expertise in sending the pictures to the central data administrator, fear pictures would be accidentally erased, or a general lack of computer skills. One change from the original protocol implemented as an alternative was to save photos of wounds onto a memory card, then to send the memory card in a self-addressed, stamped envelope weekly to the project manager. This slowed the availability of the pictures to the system, but it did increase participation at three sites. Another technical issue was use of the online vital signs monitoring in conjunction with an electronic health record. In some sites, computers were old or did not have the required operating capabilities to use the ASP-based database. In addition, broadband, required for the Web site, was not always available at the care sites. Limitations inherent in real world settings, including lack of incentive for control group participation, resistance to adding to staff workloads, competitive concerns, medical liability concerns, and technical issues, make more traditional research models difficult to implement. The results this project was able to produce reflect these realities. Although a statistically valid comparison of telewound care to standard practices was not feasible, it is hoped that this study will contribute to the understanding of care for chronic conditions, co-morbidities, and home monitoring.

Selected Outputs

This project has no outputs to date.

Grantee’s Most Recent Self-Reported Quarterly Status (as of September 2008): The project is completed. Although the initial goal of implementing a controlled trial was not achieved due to referral problems, some patient outcomes improved dramatically, and the dissemination of information about telehealth programs and health information technology will be beneficial to the community.

Milestones: Progress is mostly on track.

Budget: Significantly underspent, more than 20 percent.

INTEGRIS Telewoundcare Network - Final Report

Citation:
Bryant C. INTEGRIS Telewoundcare Network - Final Report. (Prepared by Integris Health, Inc. under Grant No. UC1 HS015359). Rockville, MD: Agency for Healthcare Research and Quality, 2008. (PDF, 187.19 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
Document Type: 
Medical Condition: 

Telewound Care Network Patient Informed Consent and Authorization for Use and Disclosure of Health Information

PDF: Telewound Care Network Patient Informed Consent and Authorization for Use and Disclosure of Health Information (PDF, 28.67 KB)

Telewound Care Network Standard Group - Process Guide for Point of Care Providers

PDF: Telewound Care Network Standard Group - Process Guide for Point of Care Providers (PDF, 20.39 KB)
This project does not have any related survey.
This project does not have any related project spotlight.
This project does not have any related survey.

AHRQ-Supported Telewound Care Networks Aims to Speed the Healing Process

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.
This project does not have any related emerging lesson.