1. Goldman, Robert J. MD

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Richard "Sal" Salcido, MD, and Kenneth Barner, PhD, have previously reported 1,2 on their use of telemedicine to evaluate and manage the progress toward healing of Dr Barner's chronic leg wound. Dr Barner, a 37-year-old, C5-C6 tetraplegic, had the wound for 11/2 years before he contacted Dr Salcido by E-mail for a consultation. Communication by electronic means is second nature to Dr Barner, an associate professor of electrical engineering at the University of Delaware, Newark, DE (about 100 miles round-trip from the University of Pennsylvania). Because of his engineering background and transportation issues related to seeking health care, Dr Barner enthusiastically endorsed an approach to care that allowed him to communicate with Dr Salcido by E-mail and digital transfer of wound photographs.


After 6 months of mostly remote treatment, the wound healed. Six months after healing, however, Dr Barner notified Dr Salcido that the wound had recurred. Dr Salcido referred Dr Barner to me for evaluation and treatment.


Evaluating the Wound

Dr Barner presented as a C5-C6 complete tetraplegic in a motorized wheelchair. He had +1 to +2 bilateral ankle pitting edema. On his left posterior lower leg, he had a 1.5 x 1.0 cm full-thickness wound with an 80% red base. The pedal pulses were easily palpable, except for the posterior tibial on the left. He was insensate on the lower extremitities. My diagnosis was venous stasis/edematous leg ulcer.


Because I could not easily palpate the posterior tibial pulse on the wound side, I obtained pulse volume recording (PVR) studies. The results were within normal limits. With adequate arterial blood flow assured, I prescribed compression dressings to reduce edema (ACE wrap; 2 rolls, toe to knee). In addition, I obtained new liver function tests and serum albumin levels; all were within normal limits.


When the results of Dr Barner's liver function tests came back normal, I started him on oxandrolone (Oxandrin), 2.5 mg twice a day. Oxandralone is an anabolic steroid used to promote weight gain after weight loss following surgery, chronic infections, or severe trauma. 3 It has been shown to enhance wound healing in patients with inadequate lean muscle mass and nonhealing wounds. 4-6 Because Dr Barner was quite thin, Dr Salcido had prescribed oxandrolone to help him gain weight. Dr Barner had tolerated the drug well and had gained 20 pounds.


As he did with Dr Salcido, Dr Barner communicated with me by E-mail. This was supplemented by 3 office visits: an initial evaluation and 2 follow-up visits. At the first follow-up visit (1 month after treatment was initiated), the wound was about 20% of its initial size and edema was significantly reduced at the ankle. To prevent recurrence after the wound closed, compression stockings (20 to 30 mm Hg) were prescribed; Dr Barner was instructed to apply them daily to maintain skin integrity.


Dr Barner experienced 1 episode of acute leg edema following a trip on an airplane. To rule out deep vein thrombosis (DVT), Dr Barner's primary care physician ordered a venous duplex that was negative for DVT. The edema eventually subsided; it was assumed to be caused by a leg contusion that occurred while Dr Barner was disembarking from the plane.


Dr Barner's wound healed in about 6 weeks, approximately one-fourth the time it took to close the first wound. At this writing, the wound is still closed.


Telemedicine for Wound Care

This updated case report illustrates both the promise and shortcomings of telemedicine for wound care. In this case, telemedicine offered visual updates on wound appearance and size and captured the history of the treatment program by E-mail. However, remote communication could not reproduce palpation to confirm adequate circulation or to quantify peripheral edema. In addition, face-to-face contact was needed to teach Dr Barner's caregiver how to apply compression dressings. For these reasons, more office visits were necessary than when caring for the initial wound.


Inevitably, many patients will be managed through some form of telemedicine. At present, however, telemedicine is limited by the number of patients who (1) have the access to the Internet or E-mail, (2) have a knowledgeable family caregiver to assist with treatment, and (3) have insurance that will cover management through telemedicine.


Technologic barriers

Technologic barriers will likely be the first to fall, if the phenomenal growth of the Internet during the past decade is any indication. In 1993, for example, there were only 30,000 Web sites and Internet access was rare. Today, there are millions of Web sites and Internet access is common. Broadband access (ie, a digital service line, or DSL) to upload or download large photographic files is now available. In addition, portable, handheld devices are revolutionizing access to medical information; many even offer wireless Internet access. Privacy concerns are of special interest to proponents of telemedicine; however, there are technologic approaches to resolve these concerns, such as encryption methods currently used in E-commerce. 7 The information-intensive videoconferencing currently being used in telemedicine is probably not necessary for successful wound care. A store-and-forward Web-based technology may do just as well. 8


In 10 years, we will be able to buy telemedicine effectively "off the shelf." Such a system will most likely include a handheld device with a tiny video camera connected to high-speed wireless Internet access. Because capacity (memory and speed) will probably increase by an order of magnitude, the cost of a telemedicine product for use in the field may be lower than the cost of an inexpensive digital camera today.


Reimbursement barriers

Predicting the level of reimbursement that will be available for telemedicine services by the year 2012 is more difficult because reimbursement is grounded in health policy. Although there are indications that telemedicine will save money without sacrificing patient satisfaction, 9 simple cost savings do not guarantee reimbursement.


Reimbursement issues are complex. For example, charge bundling is a common practice in which health insurance pays for only 1 procedure conducted during a visit to a wound clinic, even if many procedures and assessments are done. The unintended incentive is for the health care provider to require more visits, not fewer. This increases the transportation burden on patients. Telemedicine is intended to reduce this burden.


In addition, home care services are currently reimbursed under Medicare prospective payment rules. Prospective payment is a flat rate paid by Medicare for visiting nurse services for a 3-month period. Although the well-meaning rationale behind prospective payment is to decrease cost, it creates an incentive for home health care agencies to "undertreat" the most complex and difficult wounds. For instance, prospective payment does not have a modifier for the level of care required to keep patients with complex wounds out of the hospital.


What's Ahead

Telemedicine has the potential to revolutionize the way professionals in the field and in the office interact to treat the complex wounds of bedridden or homebound patients. If today's reimbursement environment is any indication, however, telemedicine will have a tough time making significant inroads over the course of a single decade. This does not necessarily have to be the case. Possible solutions include reimbursing telemedicine for patients with legitimate travel problems, adding a prospective payment modifier for complex wounds, and creating incentives for positive wound outcomes.




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