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How an Innovative Telewound Module May Aid the Wound Clinic

A new telewound module can aid patients by facilitating virtual visits. Today’s Wound Clinic recently interviewed Bob Bartlett, the Chief Medical Officer at Swift Medical and a certified physician executive (CPE) with over 30 years of experience managing hundreds of hospital wound care programs. Bob has accepted the role as Executive Director of the newly formed Telewound Coalition.

TWC: Swift Medical’s telewound module was slated to be released in 2021. In light of the COVD-19 pandemic, the product’s release was accelerated and deployed at scale and is provided to patients free of charge. Before delving into the telewound solution’s impact on the field of wound care and the formation of the Telewound Coalition, can you explain the difference between telehealth and telewound?

Bob Bartlett: Modern telemedicine represents a quantum leap from the early days of virtual care delivery. Initial telemedicine solutions offered simple two-way video sessions where a clinician would diagnose patients based on their symptoms. However, wound care is a “visually demanding” specialty and video alone cannot meet the clinical requirements. Video fails to color correct, it fails at enlargement for details, and it pixelates. Video also lacks the basic requirements of “store and forward,” which is essential for cross consultation, communication, and coordination. Finally, video cannot provide a discrete comparison of the wound bed over time. Specifically, how does the wound bed compare to a week ago, a month ago?

Different lighting conditions change color bias. The color bias leads to incorrect assessments from too red, suggesting an improvement; to pale, suggesting ischemia; to green hues, suggesting Pseudomonas infection. The Swift HealX marker (Swift Medical), which is registered with the Food and Drug Administration (FDA), is your assurance for clinically correct and reliable color, proper focus, and a standardized distance perspective. Getting a well focused, properly “framed” picture at the right distance is difficult to explain, time consuming, and frustrating to patients and providers alike. If a camera is too close, shadows are created, and the moist surface of a wound creates a distorting white glare if flash photography is used. The HealX marker provides a clear color change, which lets the patient or assistant know everything is correct. It’s like a traffic signal changing from red to green, letting you know you are “good to go.” The HealX marker makes medical photography really simple, which everyone likes.

Video also lacks the capacity for “macro” viewing to inspect the detailed anatomy and tissues within the wound bed. Because video is highly compressed, any enlargement leads to immediate “pixelation” and degradation.

Swift Medical’s Telewound Module, with an “enhanced video session,” combines video with precision images while providers are connected to the patient. The Swift solution has store-and-forward tools that allow a provider in one location to share precision imaging and clinical data with a specialist in another location. In brief, it is now easy to have a quick peer-to-peer consultation. Equally important is the capacity for discrete image comparison over time comparing the current wound bed to previous images over time.

Today’s virtual care delivers sophisticated, evidence-based medicine using real-time dashboard analytics, risk stratification, and clinical alerts to ensure appropriate treatment using evergreen clinical practice guidelines. All of this is done using an application program interface (API), which seamlessly integrates into any existing electronic medical record (EMR) and provides seamless interconnection to any device at the bedside and beyond.

There are numerous reasons for using Swift’s Telewound Module in wound care:
• Visual nature of wound care requires a visually precise method for imaging and measurement;
• Patient frailty and mobility issues, which are associated with clinic cancellations;
• Lack of trained wound care professionals in various settings, especially in rural areas, who are looking for referral guidance/consultation; and
• Patients with chronic wounds often transition through multiple sites of care (e.g., inpatient hospital, outpatient wound center, home health care, or nursing home), making continuity of care extremely challenging. Again, a visual record with the associated metadata should be immediately available for all points of care.

TWC: Connecting over 2,000 wound care clinicians and 3,500 health care facilities in the United States, Swift’s Telewound module will facilitate thousands of daily virtual visits. Did the acceleration of the pipelined project impact initial goals for the product?  

Bob Bartlett: Writing wound care software for telemedicine is complicated. There are considerations to ensure efficient workflow, there is the integration layer connecting back to the EMR to further aid in that seamless workflow, and then there is cloud architecture, which orchestrates deployment of the software across the mobile devices, the web and the EMR. All of this data remains encrypted and secure, not only at rest but also in flight.

“Human factors” should always be a high priority in design. If users don’t like it, it won’t get used often. The following are examples of human factors. Are the menus simple? Can the user operate features with one hand while holding the leg with the other hand? How many “clicks” does it take to get something done? Each click matters. Elderly patients often have impaired vision, so screens need special fonts and high contrast. Creating a user experience that is intuitive and simple is both art and science. Fortunately, the Swift Medical team has years of experience and hundreds of thousands of lines of code as a starting foundation to fast track an intelligent design.  

TWC: The Telewound Coalition is a collaborative initiative consisting of health care providers, technology innovators, and clinical experts who are working together to provide wound care to patients across the country. Was the pandemic the catalyst for both the creation and establishment of the Coalition, or was the concept of the Coalition also in the pipeline?

Bob Bartlett: Swift has always been very partnership focused, even though the concept of the Coalition was formed after the pandemic started. The Swift platform is currently used to monitor 300,000 patients per month, which provides us with deep insights for improving workflow and analytics to improve clinical care and manage programs more effectively.  

As Coalition members, we can share lessons learned and leverage the experience of many over organizations. In short, it is a very effective method for cross-pollination of ideas.

TWC: Your mission is “to ensure the best possible level of wound care for patients across the care continuum during the pandemic and beyond.”1 With the mission in mind, what are the main objectives of the Coalition?

Bob Bartlett: Our objectives are stated on the landing page for the Telewound Coalition (TelewoundNow.org). “Our mission is to provide the knowledge, guidance and networking needed to accelerate the adoption of Telemedicine in Wound Care.” Health care is largely a knowledge driven service. Knowledge is medicine.  

Many wound care providers are aware of telemedicine and are in the process of developing the knowledge and practical experience with the where, when, and how to use this tool. The Telewound Coalition will use knowledge engineering to empower providers with more efficient telemedicine workflows and solutions to effectively deliver telewound services. Specifically, we are employing two central strategies:

Collective intelligence. Multiple studies indicate that collective intelligence can generate more accurate decisions than the decisions made by a single expert. Terms such as “collective intelligence,” “wisdom of crowds,” and “crowdsourcing,” are used to describe collaborative decision-making. As Kenneth H. Blanchard wrote: None of us is as smart as all of us. We are executing this strategy using a forum within our website. Users will post questions that will be answered by others. This is only the first step in the collective intelligence process. The answers can then be vetted based on the qualifications and experience of the person answering the questions. In addition, we will employ a modified Delphi process where readers can upvote and downvote the answers. In effect, this serves as a triage system to move the very best thinking to the top of the stack. Other collective intelligence strategies will be employed for diversification and gamification.  

Social networking. Knowledge or information alone has no real value. The real value of knowledge is only revealed when it is applied in action. This where social networking comes in. The application of collective intelligence through others to effect real outcomes or change is the bottom line for real progress. The Coalition will serve as an exchange for people to connect with others who share the same problem or ideas within the telewound arena.

It is important to take a moment to share what the boundaries are for the Telewound Coalition—in brief, what we are about and not about. There are many organizations and societies that are active in the wound care arena, providing clinical guidance or assistance. The coalition certainly does not wish to duplicate the great work that others are doing. We begin and end within the telemedicine vertical of health care, which is our wheelhouse. Telewound is a new frontier in need of an organization willing to foster and facilitate its growth and provide guidance to payors, providers, and patients.  

Telemedicine has been growing rapidly in other areas of health care. The pandemic was simply a catalyst to thrust this care delivery option on the wound care community by necessity. Because this pandemic is so novel, we need to be and must be flexible in the way we deliver care. There is universal agreement that telemedicine clearly fulfills the need for social distancing. In addition, telewound is patient-centered because many wound care patients have mobility problems which make travel difficult. This “travel barrier” is frequently associated with missed appointments, which are frustrating to hospital providers and patients.   

We understand that not all wound care can or should be delivered by telewound. However, it is equally true that not all wound care must occur in the clinic. Especially in this day and age, the pandemic has limited the ability for some people to leave their home/facility setting for care. The recent article entitled “The Wound Center Without Walls” provides insights on what care may look like in the immediate future.2 There are already studies indicating that, for select patients, healing can occur faster at a lower cost when telewound plays a role in overall care.3

TWC: In the United States, 2% of the total population (6.5 million) struggle with chronic wounds. Failure to heal indicates some form of compromise. The pandemic has limited patient access to care, resources, and opportunities for both patients and health care practitioners, especially in relation to wound care. Wounds that do not receive proper treatment are prone to infection, amputation, and fatalities. As a whole, what are the biggest risks to wound care during the pandemic? How does the Telewound Coalition aim to offset the impact of the pandemic?

Bob Bartlett: The operative word for COVID-19 is the term “novel.” In a short period of time, we have come to appreciate that there are numerous novel manifestations of this disease affecting multiple organs. One feature that is especially relevant to chronic wounds is hypoxia in all of its different forms. Some wounds suffer from intermittent tissue hypoxia due to pressure. For other wounds, it is a diffusion barrier from edema, and, of course, there are many with occlusive vascular disease or vasculitis. For all of these scenarios, the patient has little physiologic reserve to compensate for additional hypoxia or stress. The novel coronavirus possesses an immediate hypoxic threat by injuring the lungs. In addition, we have come to understand there is also a thrombotic/embolic effect, which also impairs the delivery of oxygen.

Swift Medical is the largest provider for wound imaging and management analytics in North America. We are currently adopted by over 3,500 healthcare organizations across the country, which provides the kinds of big data needed for machine learning. Very early in the pandemic, our data science team clearly identified a significant rise in mortality rates (Figure 1). This kind of insight underscores the importance of eliminating unnecessary exposures by using telewound services as a component of a comprehensive plan for wound management and surveillance.

TWC: What has happened since the formation of the Coalition?

Bob Bartlett: We’ve had a series of productive meetings with the founding members and have formed an executive committee. I am pleased to find the executive committee is a very diverse group of individuals with backgrounds in administration, accounting, information technology, marketing, and of course, clinical care. With such an array of talent and experience we can avoid “siloed thinking” and have a well-rounded approach to projects and coalition governance.

In just the first 90 days we created a website, collective intelligence forum, governance structure, completed one webinar with a series to follow, infographics, numerous press releases, and helpful resources.   

TWC: In the press release, Carlo Perez, the founder and CEO of Swift Medical, said, “The innovative solutions we create today will not only ensure continuous and compassionate care now, but will also permanently shape the future of care delivery.” Beyond the Coalition, what are the most important innovations in telehealth? How do you see the potential of telehealth evolving?

Bob Bartlett: Convenience. Telehealth is convenient, particularly in rural areas where access to care can be difficult. However, the same may also be true in large cities with the growing problem of traffic congestion and parking. In addition to being “seen” by your doctor, telemedicine makes it easier to get assistance by using peer-to-peer telemedicine consults given the visual nature of wounds.  

Cost savings. Policymakers and insurance companies like the cost savings which are associated with telehealth. Communication is easier, post-procedure surveillance is better, and there are fewer emergency department visits because it is easier to determine who needs to be seen immediately versus those who could safely wait to be seen in clinic the next day. No wonder telemedicine is one of the few areas of health care with bipartisan agreement.

Patient friendly. Telehealth offers care for older adults. Americans are living longer than ever before, and the population of older Americans is growing at an unprecedented rate. Consequently, costs associated with their health care needs are expected to strain the health care system. The good news? The vast majority of older adults are open to telemedicine, despite assumptions that they would be less willing to use technology. Seventy-nine percent of patients said scheduling a telemedicine follow-up visit was more convenient than arranging an in-person follow-up, according to Massachusetts General Hospital.

TWC: Finally, how can an organization or individual join the Telewound Coalition?

Bob Bartlett: You can visit http://www.telewoundnow.org/register/ and sign up. It’s free to join and it will give you access to all the online resources, along with the Collective Intelligence Forum where you can ask questions and participate in discussions. I would encourage everyone in this audience who is asking questions about telemedicine within their own organizations to submit those same questions to the Collective Intelligence forum as a free and easy second opinion. There is a reason that airlines have co-pilots and engineers always have other engineers check their calculations.

 

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References

1. Telewound Coalition. http://www.telewoundnow.org/mission/ .
2. Rogers LC, Armstrong DG, Capotorto J, et al. Wound center without walls: the new model of providing care during the COVID-19 pandemic. Wounds. 2020; epub April 24.  
3. Le Goff-Pronost M, Mourgeon B, Blanchère JP. Real-world clinical evaluation and costs of telemedicine for chronic wound management. Int J Technol Assess Health Care. 2018 Jan;34(6):567-575.

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