High-tech documentation solutions not only free up clinicians to spend more time on patient care, but also assist them in tracking outcomes and targeting quality improvement initiatives. Such innovations take time to work their way into healthcare delivery—in part because they often require fundamental changes for practitioners. However, one area that is ripe for these types of solutions is wound care management, a field that requires mounds of documentation for both clinical and financial reasons. Further, some estimates suggest that wound care accounts for as much as 5% of U.S. healthcare costs.
A handful of innovators are, in fact, already leveraging the power of information technology to improve wound care delivery, and they are beginning to see results. Here, DMA profiles two innovative approaches—one that uses both telemedicine and sophisticated algorithms to deliver evidence-based care, and another that uses computers to streamline the complicated documen-tation required in wound care so practices can operate more quickly and efficiently. Both are taking advantage of new technologies to driveclinical and financial outcomes.
Caroline Fife, MD, established a wound center at Houston–based Memorial Hermann Medical Center in 1990, but it wasn’t long before she became frustrated by the countless hours she spent on required paperwork that could have been better used for patient care. Just to keep up, Fife woke at 5 a.m. every morning to complete documentation from the day before.
“I would dictate histories and physicals on the hospital dictation system. Then I would dictate letters to the referring physicians, which contained much of the same information—a brief review of the history and treatment plan that I designed. Then I would have to fill out by hand a piece of paper that [an accrediting organization] required that included all of the patients’ medical conditions, surgeries, and their medications,” she explains. “So I would have just done the same thing, basically, three times.”
The paperwork didn’t end there. In order to be reimbursed for wound care services, physicians have a long, complicated list of items that they must document. And to help patients and families carry out her recommendations appropriately, Fife provides them with a written summary of what has taken place during their consultation and a clear outline of what they need to do to take care of their wounds at home.
It dawned on Fife that there must be a more efficient way to complete these overlapping tasks. “By and large, we only have five diagnoses that we treat, and we do the same kinds of things moment after moment, and the documentation is so repetitive that there was really no excuse for not developing some sort of framework for it,” says Fife.
From paper documents to an EMR
This realization ultimately lead in 1998 to the first version of Fife’s clinical documentation system for wound care, an approach that streamlined all of the required pieces of documentation so the clinician did not have to keep entering the same information into different formats. “You could then just pull pieces like cut and paste, only the computer was doing the cut and paste,” says Fife. “I could then automatically generate a letter to the referring physician and give the patient a copy as he [or she] left my office.”
Although the early versions of Fife’s software offered significant dividends in productivity and efficiency, she eventually decided to get away from paper documents. At this point, she partnered with David Walker, CHT, to create the Intellicure Clinical Documentation Software program, an electronic medical record (EMR) designed specifically for wound care.
With the new system, documentation begins when the patient enters the clinic and registers at the front desk. Typically, the front-office staff will enter the patient’s demographic and insurance information as well as contact information about the referring physician and any other providers involved with the patient’s care.
The EMR is then further enhanced when the patient is taken to the exam room and seen by the nurse. In most wound centers, the nurse will record vital signs, go through what medicines the patient is taking, and perhaps review symptoms and medical history, documenting each item in the software system using a computer in the exam room.
The system will automatically populate appropriate data entry points based on information that the nurse has entered. For example, if the nurse enters a medication used to treat diabetes—a critical diagnosis in wound care—the software system will automatically document that the patient has diabetes and introduce a series of questions to guide the nurse toward accurate diagnoses and ICD-9 coding.
Likewise, the system will automatically select appropriate documentation, depending on what type of wound the clinician designates. For example, if the clinician indicates that the patient has a diabetic foot ulcer, the system will pull up the Wagner grading system—the most commonly used classification system for foot ulcers.
Alternatively, in the case of a pressure ulcer, the system will pull up the staging system recommended by the National Pressure Ulcer Advisory Panel.
In many clinics, the nurse will also measure and photograph the wound using a digital camera attached by cable to the computer. “The picture is archived in relation to the place where the nurse indicates the wound is, so if she said it was on the left lateral ankle, the picture will always relate to [that specific location], and whenever a clinician clicks on ‘left lateral ankle’ that picture will show up,” says Fife.
This feature is critical because many clinics don’t document their wound photographs until the end of the day or the next day, Fife says. “A lot of people end up with completely worthless photographs because they later can’t identify either who the patient was or what part of the body it was taken on,” she says. To further complicate matters, it is common for Fife to see patients presenting with as many as 10 wounds.
Prompts streamline patient evaluation
By the beginning of the physical exam, the patient’s record is often already populated with all of the basic information, but the physician will continue to enhance or amend these findings as appropriate. Further, the system will provide additional prompts sothe physician can quickly
When the physician clicks the print button, the system automatically generates the patient’s history and physical, referrals, orders, prescriptions, and any other materials that the physician has selected, thereby bypassing the need for additional paperwork.
Although improvements in efficiency have been easy to document with the Intellicure system, developers have not yet studied the approach’s effect on wound healing rates. However, such evaluations are planned when the next iteration of the software is unveiled, as it will include an array of clinical suggestions for the provider based on nationally accepted clinical guidelines.
In addition to providing decision support functions, providers will be able to find the basis or research behind each clinical suggestion, Fife says. “The clinician will be able to go through the recommendations, click on the ones that are appropriate, and then they will populate the appropriate fields for orders, labs, and testing. Further, physicians will receive report cards indicating the frequency with which they have followed the clinical suggestions, she adds.
Another feature that will be added to the software alerts clinicians when wounds they are treating have not healed as quickly as they should. This feature is possible because of the wealth of data that Intellicure has collected thus far on wound healing trajectories. Fife believes that the warnings are important because they offer the clinician a timely reminder that he or she is not meeting the target, and that it may be time to try revascularization or another treatment modality.
It will not be easy to measure the precise clinical impact of the new decision support functions. However, they may well shorten healing times by decreasing time delays for critical tests and procedures, Fife says. “We would like to think that the clinical suggestions will front-load all of the important tests and then push people through to whatever their management plan should be at a quicker pace.”
Consistency is a problem
Recognizing that elderly diabetic patients are particularly susceptible to wounds and related complications, Hollywood, FL–based Wound Technology Network (WTN) has devised a system that combines telemedicine support with in-person consultation for every patient encounter. This approach makes it easier to treat patients who have difficulty getting around, as well as those who reside in nursing homes or assisted living facilities. The company maintains that it has been able to drastically reduce patient care costs for the health plans with which it works.
WTN was established in 1999 by Jeffrey Galitz, MD, its current chief medical officer and CEO. At the time, Galitz had other business interests that included providing podiatric services to patients in nursing homes, and he was frustrated with the level of care that the clinicians were providing. “We were having issues concerning getting the doctors and the clinicians to do what was proper in a consistent manner,” he says. “Even with sophisticated documentation systems, we still weren’t achieving the levels of care that we wanted to.”
Galitz concluded that a system that incorporated telemedicine, artificial intelligence, and in-person care would be able to deliver the kind of consistency he wanted to see. And he believes that is exactly what he achieved with WTN. “Now, we are able to ensure that wherever the patient is—in a nursing home, assisted living facility, home health, or in a clinic setting—he [or she] is provided the same level care [as every other patient], based on evidence-based guidelines,” he says, noting that the system is equipped with triple redundancy. “Every single visit is a consultation involving two people and a computer system figuring out the best way to treat this person.”
Computer-based algorithms guide care
When a patient is referred to WTN for care, a patient care coordinator immediately begins gathering data and making arrangements for the first patient visit, which can take place in a clinic setting or in the patient’s residence. WTN’s field clinicians are typically nurse practitioners, physicians, or physician assistants who have been certified in wound care.
When the field clinician arrives for the patient encounter, he or she uses a portable computer to set up a live encounter with another specialist at WTN’s call center. At this point, the call center specialist will go through the long series of questions required in wound care, entering the answers into a sophisticated computer database. Additionally, the in-person clinician will photograph the wound using a camera that is attached to the computer. “The computer system will instantly generate a report with charts, graphs, and an individual photograph that is instantly faxed to the PCP’s office,” says Galitz. “If the PCP has any questions, he [or she] can contact the clinician while still at the patient’s bedside.”
The plan of care—as stipulated in the computer-generated report—can then be carried out through subsequent encounters and in consultation with the PCP. Galitz emphasizes that WTN clinicians will continue treating the patient until the wound heals. “On a weekly basis, we are recording 250,000 points of wound care data,” he says. “On average we lower costs by 80%, and we reduce hospitalizations by 95%.”
As with Intellicure’s system, WTN’s computerized data collection process facilitates the tracking of utilization and costs. Consequently, WTN can provide its health plan customers with quarterly reports outlining its performance on a range of clinical and financial measures. “We sit on the world’s largest wound care database right now, and are able to get a lot more data than we ever thought we would,” says Galitz. “It gives us the ability to analyze why people are healing and why they are not healing. It gives us, really, total control.”
In fact, Galitz believes his “triple redundancy” approach has the potential to also improve care consistency, and adherence to evidence-based care for other chronic diseases as well. Consequently, the company is in the process of rolling out new programs focused on hypertension, diabetes, and CHF, and there may be additional programs to follow. “We are saving money, we have improved outcomes, and our patients are happier,” says Galitz.