JC Lowery, VA Center for Practice Management & Outcomes Research; EG Wilkins, VA Center for Practice Management & Outcomes Research; University of Michigan Section of Plastic Surgery; JB Hamill, VA Center for Practice Management & Outcomes Research

Objectives: The primary objective of this pilot study was to evaluate the clinical accuracy of a telemedicine system for assessing the status of pressure ulcers. The store-and-forward telemedicine system consists of three major data collection components: (1) digital photographs; (2) quantitative measurements (i.e., ulcer area and volume); and (3) other wound and patient data. The data are collected using a laptop by a nurse and transmitted via the Internet to a database, which formats the data and posts the output onto a World Wide Web page for access by the consulting physician. The system incorporates assessment data recommended by the Agency for Health Care Policy and Research’s (AHCPR) Clinical Practice Guideline, "Treatment of Pressure Ulcers."

Methods: Two VA medical centers and two specialties participated in the study: Ann Arbor (plastic surgery) and Augusta (plastic surgery, physical medicine and rehabilitation). All study patients (inpatients and outpatients with a pressure ulcer of stage II, III, or IV) were assessed both in-person (the "gold standard") and with the telemedicine system. The in-person and telemedicine physicians were blinded to each other’s assessments and provided yes/no responses to four diagnostic questions concerning wound healing and infection, based on AHCPR guidelines. Accuracy of the telemedicine system compared to the in-person assessments was measured using agreement rate, sensitivity, and specificity.

Results: A total of 105 patients were enrolled in the study, with data collected on 430 visits. Results of a preliminary analysis of a subset of the data showed the rates of agreement between the participating PM&R physicians on assessment of chronic pressure ulcers were 64.2% (N=95 visits) for "Is the wound healing?"; 67.3% (N=150) for "Is necrotic tissue present?"; and 95.7% (N=161) for "Is cellulitis suspected?". Rates of agreement of between the participating plastic surgeons (Ann Arbor) were 59.0% (N=83 visits) for healing; 76.5% (N=136) for necrosis; and 79.4% (N=136) for cellulitis. When compared with "baseline" % agreement (i.e., agreement between the same physicians when both assessed a different sample of patients in person), these rates of agreement are significantly lower for the PM&R physicians when identifying necrosis, and for the plastic surgeons when assessing healing and cellulitis. A link to a demonstration Web site of the system can be found under "Telemedicine Projects" at: http://www.hsrd.ann-arbor.med.va.gov/.

Conclusions: While agreement rates between the telemedicine and in-person assessments tend to be lower than between comparable in-person assessments, feedback from the participating physicians indicates that the telemedicine system could still be very useful for patients who are not currently receiving routine monitoring by qualified nurses or physicians—e.g., spinal cord injury patients residing at home. The agreement rates and sensitivity and specificity data from this study are important for understanding limitations of the system.

Impact: A relatively inexpensive, store-and-forward telemedicine system for monitoring the status of pressure ulcers has the potential to improve access to specialty care for spinal cord injury patients. Improved access to care should reduce the occurrence of infected wounds and the associated costs of outpatient visits, hospitalizations, and surgeries.