Informatics, Perception, and 

andF d orwar

d Tld t

e

e

derma

to

John D. John D. Whited, MD, MHS , MD, MHS

Harry S. Truman Memorial Veterans’ Hosp

Columbia, Missouri Columbia, Missouri

john.whited@va.gov
Store and Forward Store and Forward

Teledermatolo

g

y

Standardized History

Location

Duration of presence

Change in size

Symptoms or signs (pruritis, pain, etc.)

Skin cancer historyFamily history

Meds, allergies
Teledermatology 

Technology- Digital Camera- Imager- Imaging protocol- Image review for quality control- Upload images- Attach standardized history 
Surveys

 VA HSR&D IIR 98-159

 Whited, et al., Telemed J E Heal

2004;10:422-31

 Referring clinicians, patients, a

dermatologists

 Clinician survey y s were anonym Users of both consult modalitie
Referring Clinicians

 60 clinicians referred patients a

(88%) completed a survey

 All 53 clinicians completed a us

All 53 clinicians completed a us

survey

 38 clinicians completed a 

teledermatology y surve
Referring Clinicians

Patients receive timely appointments referred to dermatology

95%

90%

100% Agree

Neutral

70

60%70%80%

%

Disagree

30% 23%40%50%

5% 7% 0%

0%

10%20%

Teledermatology (n = 38) Usual Care (n = 
Referring Clinicians

I receive information from the consulthe patient’s appointment

Agree

90%

87% 100%

NeutralDisagree

68%

60%70%80%90%

13% 17% 15

30%40%50%

13% 17%

0%

15

0%

10%20%

Teledermatology (n = 38) Usual Care (n = 5
Referring Clinicians

I get an educational benefit from the referral

55%

45% % 50%

60% Agree

Neutral

34%

45% 41%

30% 2540%

Disagree

20%

0%

0%

10%

Teledermatology (n = 38) Usual Care (n = 5
Referring Clinicians

Overall, I am satisfied with the dermaconsult process

92%

80%90%

100% Agree

NeutralDisagree

50% 42%60%70%

23%

35

20%30%40%

5% 3%

0%

10%

20%

Teledermatology (n=38) Usual Care (n = 5
Referring Clinicians

I prefer teledermatology consultationtraditional referrals

84%

70%80%90%

AgreeNeutralDisagree

50%60%70%30%40%

13%

10% 3%20%

0%

Response (n = 38) 
Results

Dermatologists

 8 resident dermatologists were 

surveyed

 Attending dermatologist was n

Attending dermatologist was n

surveyed as a study co-investig
Dermatologists

Teledermatology makes it easier to triage pclinic appointments compared to traditional 

100% 100%

80%60%40%

0% 

20%

0%

Agree Neutral 
Dermatologists

Teledermatology is a more efficient use of tspend as a consultant

%

60%

50.0

3 %

50%

37.5%

30%40%20%10%

0%

Agree Neutral 
Dermatologists

Teledermatology consults take longer to pedo clinic visits

100% 100

80%60%40%

0% 0%

20%

0%

Agree Neutral 
Dermatologists

I am less confident in my diagnoses and maI am less confident in my diagnoses and ma

plans using teledermatology than seeing paclinic

100%

80% 75.0%60%40%

12.5% 

20%

0%

Agree Neutral 
Dermatologists

Overall, I am satisfied with using teledermaconsult method

100%

80% 75%60%

25%

40%

25%

20%

0%

Agree Neutral 
Results

Patients

 101 of 135 teledermatology pa

(75%) completed a survey

 93 of 140 usual care patients (

93 of 140 usual care patients (

completed a survey
Usual Care Usual Care – Patients

In terms of your satisfaction, how would yofollowing...

Excellent Very 

Good

Good Fa

...how long 

it d you waited 27% 22.5% 23.5% 12% 

for an appt.

the

convenience 

...the 40% 31% 20% 7% 

of the clinic

40% 31% 20% 7% 

...the visit overall 45% 33% 14% 8% 
Teledermatology

- Patients

In terms of your satisfaction, how would yofollowin

g

...

Excellent Very 

Good

Good Fa

...how long you waited you waited 41% 24% 15% 12% 

to hear results

...tderm’s convenience 57% 15% 24% 2% ...tderm overall 52% 27% 16% 3% 
Patients

Teledermatology

15%

I have confidence that the dermatologist can 

help me by looking at my pictures (n=101)

1%

6

help me by looking at my pictures. (n=101)

11%

23%

6

The teledermatology consult is more convenient 

than going to the dermatology clinic. (n=100)

7%

11%

I am satisfied with the outcome of my 

teledermatology consultation. (n=101)

36 5%

22%

I would rather have a teledermatology 41.5%

consultation than go the the clinic to see a 

dermatologist. (n=101) 36.5%

0% 20% 40% 60% 
Summary

 All users expressed overall sati

with teledermatology

 Referring clinicians Referring clinicians

 Timeliness of the referral proces

ed ti l b fit d f 

ducational benefit, and preferre

teledermatology
Summary

 Dermatologists

 Improved triage decisions, unsu

efficiency, , less confident, but ovsatisfied

 Patients

 Pleased with both consult modal

cl f fid ith lear preference, confidence with

teledermatology
VISN 11 Wound Care

Teleconsultation Pro

gram

VIREC Clinical Informatics Cyberse

March 18 2010 March 18, 2010

Julie Lowery PhD MHSA Julie Lowery, PhD, MHSA

julie.lowery@va.gov

Associate Director Associate Director

Center for Clinical Management Resea

HSR&D CoE

Implementation Research Coordinato

Diabetes Mellitus QUERI Diabetes Mellitus QUERI

VA Ann Arbor Healthcare System

1
Poll Questions

• Which of the following apply to you? 

one or more.) one or more.)

– I am interested in teleconsultation for wou– I i t t d i t l lt ti f d 

I am interested in teleconsultation for der

– I am interested in teleconsultation in gene

– I am a clinician.– I am a researcher. I am a researcher.

2
Objectives

• Determine feasibility of store-forward teleme

system for providing consultations on chronic 

• Evaluate the VISN 11 wound care teleconsult

program by examining: (1) utilization of serv

use of state-of-the-art treatment modalities; (3amputation rates; and (4) quality of care as mvari i di ous process indicators. 

• Significance: Patients with chronic wounds h

problems accessing specialized wound care c

3
Background

“Pressure Ulcer Assessment via Telem

Pressure Ulcer Assessment via Telem

(HSR&D funded study)

• Evaluation of accuracy of Web Evaluation of accuracy of Web-base

base

forward telemedicine system for mostatus of patients with chronic wounstatus of patients with chronic woun

4
Feasibility Study

“Evaluation of VISN 11 Wound 

Evaluation of VISN 11 Wound 

Teleconsultation Program

(Funded by VISN 11 and QUERI R(Funded by VISN 11 and QUERI R

5
Methods

• October 2007 October 2007 – September 2008 September 2008• Ann Arbor VAMC wound care team: w

care NP l ti ID i li t NP, plastic surgeon, ID specialist

• Referring centers: Battle Creek and Gr

Rapids

 Wound care nurse requested consultations 

Wound care nurse requested consultations 

 Digital images uploaded to VISTA Imagin Additional clinical data entered into CPRS 

care template

6
Methods

Ann Arbor wound care NP:• Screened all consultations• Discussed complicated cases with plas

Discussed complicated cases with plas

surgeon or ID physician

• Forward d di i d ded diagnostic and treatment 

recommendations back to nurse via CP

7
Methods

• Quasi-exp g erimental design.• Intervention group: patients enrolled in FY 

VISN 11 teleconsultation program VISN 11 teleconsultation program.

• Historical control group: chronic wound pa

at the Battle Creek VAMC and Grand Rapidat the Battle Creek VAMC and Grand Rapid

2005. 

• Data sources

– Austin databases for demographics, comorbiditi

utili ti d t ti t tilization, and amputation rates.

– CPRS for data on wound type, treatments, and p

care

8

. 
Results

• 92 patients were enrolled in teleconsultation 

between October 1 2007 and September 30 between October 1, 2007, and September 30

• Data were collected from the initial visit as w

follow-up visits for a year following their fir

up visits for a year following their fir

a total of 368 visits. 

• D i h i i 227 l During those visits, 227 tele-consul i tat ons w

provided. 

• Historical control consisted of 105 patients 

visits.

9
Results

Historical 

Study Patients Controls 

# of Patients # of Patients 92 105# Male 92 (100 %) 102 (97.1%) Age 64.0 (11.2) 63.4 (12.7) Mean # of wounds/pt at i d i it 1.54 (0.87) 1.11 (0.32) index visit 1.54 (0.87) 1.11 (0.32) 10
Results

T fW d t

Study 

Patients

H

Types o 

f Wounds at

Index Visit

Patients

N = 142

Diabetic foot ulcers 46 (32.4%) 2Venous stasis ulcers Venous stasis ulcers 48 (33.8%) 48 (33.8%) 1

1

Arterial ulcers 18 (12.7%) 1Pressure ulcers 12 ( %) 8.5 1Misc ( g) trauma, burn, surg) 18 ( ) 12.7% 1TOTAL 142 (100.0%) 8Unknown 0 

11
Results

Study Patients

Historical 

Study Patients Controls 

(N = 92)

Controls

(N = 105)

# f A t ti # of Amputations 6 (6 5%) 6 (6.5%) 4 (3 8%) 4 (3.8%) # of Visits to AAVAMC Wound Clinic

7 (7.6%) 21 (20.0%) 

Avg # Inpt Admits for W dC

0.36 (0.66) 0.15 (0.50) 

Wound Care

Avg # Inpt Bed 

Days for Wound 5 02 (12 24) 2 26 (10 79) 12Days for Wound

Care

5.02 (12.24) 2.26 (10.79) 
Results

Historical 

Process Measures

Study Patients

N = 515 wound 

Controls

N = 127 woun

i i

visits visits

Dimensions of 

d td

491 (95.3%) 76 (59.8%) 

wound notedWound bed described

493 (95.7%) 57 (44.9%) 

Debridement when necrosis noted

142/167 (85.0%) 15/28 (53.6%

necrosis notedCulture and/or antibiotics when i f ti t d

27/38 (71.1%) 32/34 (94.1%

13infection suspected
Results

P St d P ti t

Historical 

Process Controls 

Measures

Study Patients

N = 515 wound 

visits

Controls

N = 127 woun

visits

visits visits

Antibiotics prescribed when no 

87/123 (70.7%) 29/61 (47.5%

infection notedOffloading plan 

t df f t l

247/287 (86.1%) 6/51 (11.8%

noted for foot ulcers

Dressing plan noted 488 (94.8%) 81 (63.8%) 

HbA1c ordered 348/417 (83.5%) 58/83 (69.9%14when needed
Results: Consultation Recommend

Recommendation # 

( 

Dressings 64 (1Labs 51 (1X

-rays 40 (1

40 (1

Offloading 36 (1Debridement 33 (9Stop antibiotics Stop antibiotics 30 (8 

30 (8

Compression 24 (615
Results: Consultation Recommend

Recommendation # 

( 

Refer to Ann Arbor 23 (6Remove pressure 16 (4Order culture Order culture 10 (3 

10 (3

Start or change antibiotics 8 (2Refer to PCP 5 (1Cancel Ann Arbor visit Cancel Ann Arbor visit 4 (1 

4 (1

Order shoes 4 (116TOTAL 348 (1
Results: Patient Satisfaction

1st Visit 

( ) N = 88

)

Statement Did not mind having photographs taken of their wound

8

Expressed some level of concern about the privacy of their medical information

2

Felt it was more convenient to receive care at home site

8

Felt they had received good care during their visit 8Would have been more confident if seen at Ann 17Would have been more confident if seen at Ann

Arbor VAMC
Conclusions

The teleconsultation system had a mixed 

use of health services:

• Frequency of traveling to the referral c

Frequency of traveling to the referral c

significantly reduced.

• I ti t d i i d d f 

Inpatient admissions and days of care 

reduced (actually greater for the teleco

group). 

• No significant difference in amputatio

between the two groups.

• Significant difference for most proces

18

Significant difference for most proces

measures of quality. 
Challenges and Limitations

• Support necessary from local DSS coo

clinical app , 

lications coordinators

, codi

specialists, and Vista Imaging experts 

• Staff time required for providing consu

Staff time required for providing consu

• Difficulty in scheduling live consultati19
Challenges and Limitations

• Procedures to adequately capture respo

consultation suggestions need developmconsultation suggestions need developm

• Has not been piloted with nurses untrai

wound care

• Limitations in study design Limitations in study design

20
National Survey of Wound Ca

Level of Wound Care (N = 56 facilities) Interdisciplinar

y 6 

6 

MD Certified nurse 2Nurse 6 

6 

No wound clinic 1TOTAL 56 

21
National Survey of Wound Ca

Appropriateness of Referrals (N = 64 facili

t

ies)

ac t es)

Too soon 1Too 

late 

Both too soon and too late 1Appropriate 2TOTAL 55 Missing

22
National Survey of Wound Care

Barriers to Wound Care Barriers to Wound Care• Transportation to expert care• Scheduling the consultation or transfe

r

• Understanding by PCP that expert wou

Understanding by PCP that expert wou

needed

• Knowld b f d l

e

dge 

by PCP o

f woun

d care reso

23
Challenge to VA

To improve access to high quality health 

(with corresponding improvement in o(with corresponding improvement in o

within financial constraints.

Can teleconsultation provide the solutionWho will take the lead in implementing tWho will take the lead in implementing t

solutions?

24
New Wound Template, page 1

25
New Wound Template, page 2

26
New Wound Template, page 3

27
Follow-up Wound Template, page 

28
Follow-up Wound Template, page 

29