In light of telehealth services taking on an increasingly prominent role in the health-care community, our panelists share their varied experiences, discuss the benefits and pitfalls of this evolving system, and expound upon the future role of telemedicine in podiatric practice.
How have you incorporated telemedicine services into your practice in light of COVID-19? What kind of results have you seen? What kind of reactions have you seen from patients as well as insurance payers regarding the integration of telemedicine, specifically as it relates to wound care treatment plans?
Anthony Tickner, DPM, FACCWS, FAPWCA, FAPWH has utilized telemedicine for a variety of patients, mostly patients with diabetes and/or wounds. He says telemedicine is a great tool to screen patients who may need an earlier appointment or reaffirm that patients can wait until a scheduled appointment.
During the first peak of the COVID-19 pandemic, Paul Kim, DPM, FACFAS relates seeing 50 percent of patients through telehealth and now has current in-person visits at about 90 percent of pre-COVID-19 numbers. Dr. Kim says his goal is to maintain approximately 10 to 15 percent telehealth visits post-pandemic.
He also explains that patients like this platform because it saves them a trip to the clinic and insurance companies are waiving copays. However, Dr. Kim points out that there are significant limitations in providing wound care through telehealth including technology challenges for patients.
“For the providers, it often feels like treating patients without ‘putting your hands on them’ limits your assessment and treatment options,” acknowledges Dr. Kim. “If you can’t see a patient weekly or every couple of weeks, you create more simplified plans. It feels like we are in a period of wound maintenance, not wound healing.”
Kazu Suzuki, DPM, CWS has not yet incorporated telemedicine services as billable visits. However, he notes he has practiced similar services to some extent by communicating with patients via emailing pictures and videos.
“Needless to say, I cannot debride or wrap my patients over the phone,” says Dr. Suzuki. “My service would be limited to prescribing antibiotics, pain management and answering general questions regarding dressing changes, edema control, etc.”
Conversely, Dr. Suzuki shares that many internal medicine colleagues in his area have used telehealth visits exclusively for the past few months in an effort to minimize travel and mitigate the spread of the COVID-19 virus.
What role do you feel telemedicine plays in triaging wound care patients into the most appropriate and safest treatment location?
Dr. Kim points out that triaging patients through telehealth poses challenges for both the patient and provider.
“You cannot perform a thorough assessment via a 2-D image on a screen,” explains Dr. Kim. “The visuals can be misleading due to lighting and camera fidelity. Furthermore, you have to rely on the patient and caregiver to provide accurate information, which is difficult for some.”
Dr. Kim says one can’t fully assess for perfusion or biomechanical faults through telemedicine. He emphasizing that the most concerning aspect is determining the presence of infection. When in doubt, he feels the best course of action is to ultimately ask the patient to come in for a face-to-face visit.
While he has not extensively incorporated telehealth into his practice since the COVID-19 pandemic began in the United States, Dr. Suzuki feels that keeping patients out of the hospital is a primary goal over avoiding office visits.
“Our wound clinic never closed our doors. Our service is essential to our patients,” maintains Dr. Suzuki. “I do not regret my choice of keeping our clinic open even though our clinic patient volume was down by 50 percent compared to the same month last year.”
Dr. Tickner does feel that telemedicine is a great tool for triaging and categorizing patients into levels of urgency. He shares that this option tremendously helps his office to determine who needs a visit in what time frame and in what care setting. He points out, though, that his office also sees patients in their homes, which removes some burden of travel and mitigates risk.
How is telemedicine helping you communicate with others in the care team such as home health, physical therapy or patient caregivers?
Dr. Suzuki relates he has always communicated well with other health professionals via email, phone calls or texts. However, he does hope, especially in light of increased use of electronic communication, that electronic medical records systems will resolve software integration and information sharing issues. Dr. Suzuki says, in his experience, that these systems do not “talk to each other” and notes still needing to send some orders by fax despite technological advances.
“Telemedicine has great potential to increase communication, awareness and adaptation of care plans involving multiple practitioners,” says Dr. Tickner. “It is much easier to coordinate and implement instructions while a patient is receiving visiting nurse home services for wound care dressings or have a Zoom meeting with a physical therapist while he or she is in the patient’s home.It helps preserve and strengthen continuity of care.”
Dr. Kim shares that he relies more heavily on home health to assess patient wounds. He states he finds himself communicating more directly with home health nurses instead of the majority of communication being between those nurses and the nurses in his clinic. Dr. Kim says he also tries to coordinate his telehealth visit to coincide with the home health visit.
Can you share an experience that stands out with respect to rendering care via telemedicine for wound care patients? How do you see telemedicine impacting the future of wound care?
Dr. Tickner relates overall great success with involving patients, family members and even children in telehealth visits.
“We had one case in particular with a wound care patient whose young daughter was tech savvy and able to take pictures of the patient’s wound, and bandage the area,” recalls Dr. Tickner. “She was also able to optimize all lighting and filters on the video meeting, resulting in great teamwork and reduction of stress for the patient.”
“Virtual visits will not go away after the COVID-19 crisis abates,” maintains Dr. Kim. “There will always be a subset of patients that can be managed in this way.”
He shares his hope that technology will advance to a point where providers can perform a more comprehensive wound assessment through telehealth with additional tools that allow for assessment of perfusion and infection.
Dr. Suzuki point out that some rural parts of the world, including major parts of Australia, have a robust telehealth infrastructure and regulations.
“We are not there yet but I do believe the COVID-19 lockdown was a wake-up call in many ways to provide low-cost and quality health care to our patients collectively,” maintains Dr. Suzuki. n
Dr. Kim is the Medical Director of the Wound Program at the William P. Clements Jr. University Hospital in Dallas. He is a Professor in the Departments of Plastic Surgery and Orthopaedic Surgery at the University Of Texas Southwestern. Dr. Kim is a Fellow of the American College of Foot and Ankle Surgeons.
Dr. Tickner is the Medical Director of the Saint Vincent Hospital/RestorixHealth Wound Healing Center in Worcester, Mass. He is a global wound care consultant and is involved in podiatric wound care education at Saint Vincent Hospital.
Dr. Suzuki is the Medical Director of the Apex Wound Care Clinic in Los Angeles. He is also a member of the attending staff of Cedars-Sinai Medical Center in Los Angeles. He can be reached at Kazu.Suzuki@ cshs.org.