Definitions

• eHealth: eHealth is a broad term that refers to the utilization of technology as a tool to enhance individual health states.[6][7] Both telehealth and telemedicine fall under eHealth [1], which often employs electronic health records, patient administration systems, and data collection.[6][7] See Figure 1.
• Telehealth: According to the Agency for Healthcare and Research Quality (AHRQ), telehealth encompasses remotely-delivered health care services that are “preventative, promotive and curative.”[1] Telehealth consultations focus on “prevention, assessment, diagnosis, and/or clinical management of acute or chronic conditions.” While the patient may or may not be involved in the consultation, the consultation is required to be related to a specific patient or group of patients in order to differentiate this activity from training or education.[8]
• Telemedicine: According to the AHRQ, telemedicine is the process of delivering curative care remotely, and is part of telehealth. Examples include teledermatology, and teleradiology.[1] 
• Centers for Medicare and Medicaid Services (CMS)-billable telehealth services: CMS defines “Telehealth Services” as remote visits between a provider and patient using “interactive audio and video telecommunications systems that permit real-time communication.” Covered healthcare services include preventative and curative services.[9]
  Figure 1. Relationship among eHealth, telehealth, telemedicine [10][11]

Relevance

The use of telehealth in wound care offers health and economic benefits for patients, providers, and institutions (Figure 2): 

• With respect to clinical outcomes, the use of telehealth services in specific cases has been shown to result in faster healing rates [12][13],[14], fewer adverse events [13], and decreased risk of amputation.[15][16] 
• From the patient perspective, telehealth offers the benefits of reduced wait times [8], greater access to specialty care [8], and facilitated delivery of education materials. A study found that a 12-week educational intervention improved foot self-care behavior among patients with diabetic retinopathy.[17][18] 
• From the provider and institutional perspective, the use of telehealth presents important additional advantages: 
• • Greater scheduling flexibility for providers: providers can conduct virtual visits from home, which opens up possibilities for scheduling virtual visits on evenings or weekends.[19][20]
  • Ability for clinicians to more easily provide follow-up care to patients
  • Opportunity to fulfill CMS quality measures requirements (e.g. expanded practice access and better care coordination). See section ‘CMS Quality Measures’ below
  • Telehealth can help providers ensure continuity of care and avoid lost income when an in-person encounter is not possible or recommended (e.g., lack of transportation to the clinic, immunocompromised patients amidst a pandemic, etc), 
  • A hybrid approach that employs a combination of in-person care and adjunctive telehealth may translate into 30% cost savings to the institution when compared to an in-person only model.[21]

The U.S. healthcare spending is projected to continue to shift towards telehealth post-COVID [22], which affords wound care patients and clinicians the opportunity to realize these health and economic benefits moving forward (Figure 2). 

Figure 2. Telehealth adoption, benefits and growth [23][13][12][21][22]

Telehealth Modalities

Telehealth modalities are generally classified as [24][25][26] :

• Store-and-forward (asynchronous): e.g. digital photographs and clinical data sent over the internet to a wound care specialist, who analyzes the data, and sends back written recommendations
• Real-time televideo conferencing (synchronous): e.g. live interaction/communication with a wound care specialist via a webcam
• Remote monitoring: e.g. a provider continually monitors vital signs, glucose, etc. of a patient who is at home or remote care facility
• Mobile health (mHealth): health care and public health information provided through mobile device applications with the goal of improving health services and outcomes [27] 

Types of Telehealth According to CMS and Private Insurers

In the U.S., CMS and private insurers generally classify virtual services as [28][29]: 

• CMS Telehealth Visits
• Brief communication technology-based service (e.g. virtual check-in),
• Remote evaluation of recorded video and/or images (e.g. store-and-forward)
• Interprofessional internet consultation 
• Remote monitoring

Table 1 below summarizes the telehealth modalities covered by CMS.

Indications and Contraindications for Telehealth

Not all patients are suitable for telehealth consultations. Therefore, it is important to develop and implement a wound care triage system to identify which patients are candidates for virtual services, which patients require in-person evaluation, or which patients would benefit from a combination of services. 

Two examples of telehealth triaging models are: 

• Virtual-First Triaging [31]: NHS England and NHS Improvement developed the “Total Digital Triage” model in order to reduce avoidable risk of infection for both patients and providers during the COVID-19 pandemic. In this model, institutions utilize an online consultation system to asynchronously collect a patient’s history, symptoms, and relevant images. A patient calls or submits an inquiry through the practice website, administrative staff filters and directs queries to an appropriate clinician, and the clinician responds to the patient using the most suitable method for their needs (i.e. online, phone, video, or face-to-face). 

Figure 3. Total Digital Triage model [31]

• Status-Dependent Triaging Preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes. | Rogers LC, Lavery LA, Joseph WS, Armstrong DG et al. | 2020" target="_blank">[32]: Rogers’ “Pandemic Diabetic Foot Triage System” recommends that providers determine appropriateness of telehealth based on the classification of patients’ conditions as critical, serious, guarded, or stable (Figure 4). Specifically: 

Indications

Potential uses of telehealth include [2]:

• Delivery of wound care advice from a remote wound specialist to a non-wound care clinician treating a patient with chronic wound in the community, post acute facility or at the patient’s home
• Wound care specialist seeking evaluation by other specialists (e.g. infectious disease, endocrinology, etc)
• Wound care specialist providing virtual follow up care to patients who are not allowed to complete an in-person visit (e.g. to minimize the spread of infectious diseases)
• Virtual triage of any new or existing patients, to direct patient to the appropriate clinician and avoid unnecessary referrals 
• Virtual follow up of a established patient who is going out of town for vacation, or for an established patient who is out of town and needs urgent advice
• Provision of specialized wound care for patients with COVID-19 in the hospital/intensive care unit from outside the patient’s room, limiting healthcare workers’ exposure to the virus

Situations in which telehealth is not appropriate

Potential limitations of telehealth include [2]:

• Technological barriers (e.g., lack of internet or cell phone reception, lack of devices that are capable of televisits)
• Patients with suspected critical or severe conditions should receive a thorough evaluation in-person
• Patients or clinicians who are unwilling or unable to conduct a virtual visit
• Other factors that may eliminate the telehealth option. See section ‘How to Determine if Telehealth is Suitable for a Patient’
• Patient requiring procedures (i.e debridement, skin substitutes etc ) 

EVIDENCE AND RECOMMENDATIONS

Telehealth Services Between Wound Care Specialists and Non-Wound Care Clinicians

• 2BFor patients with chronic wounds under in-person care of non-wound care clinicians, we suggest that non-wound care clinicians consider receiving advice from a remote wound care specialist via telehealth, in order to improve wound healing outcomes and decrease amputation rates.(Grade 2B).
• • Rationale: Expert advice delivered to non-wound care clinicians via telehealth (i.e., store-and-forward and/or real time video conferencing) has been shown to improve wound healing outcomes (i.e, wound healing rate, amputation rate) compared to care by non-wound care clinicians alone, as evidenced by moderate certainty evidence derived from several randomized controlled trials (RCTs).[8][12][13][14][15]
  • So far, evidence is concentrated on telehealth between a remote expert clinician and a non-wound care clinician treating a patient (for instance, a treating clinician submits clinical information along with images of a patient’s wounds to a remote wound care specialist, who in turn provides wound care recommendations to the treating clinician). Current literature lacks RCTs that focus solely on direct telehealth services between clinicians and patients. 
  • From a patient perspective, patients have reported appreciation for the greater access to specialized care and savings in time, costs, and time off work that traveling for care would require.[8]
  • Use of resources: compared to in-person visits, studies report lower costs with telehealth. In most cases, savings are attributable to reductions in transfers or less transportation.[8] 

• 2BFor patients with lower extremity ulcers (e.g. DFUs) in guarded or stable conditions, who live far from a wound clinic or for whom an in-person visit is not recommended, wound care specialists might opt to provide follow-up care via telehealth as an alternative to the standard of care (i.e. in-person visits at the wound clinic) (Grade 2B). 
• • Rationale: There is moderate certainty evidence supporting follow up of patients with more superficial DFUs in the community, where community clinicians provide care under weekly supervision of a remote wound care specialist. It has been shown that such an arrangement leads to similar healing outcomes and quality of life as the standard of care, in which patients are followed up directly by wound specialists at a wound clinic.[33][16][34]
  • This option is particularly attractive to patients who live far from wound clinics, or for whom in-person visits to the clinic/hospital are not recommended or convenient. Furthermore, studies have shown that telemedicine may significantly improve patient engagement and quality of care.[34] 

Telehealth Services Between Wound Care Specialists and Patients 

• 2CFor patients with chronic wounds in guarded or stable conditions, we suggest a hybrid model of telehealth combined with in-person visits to promote wound healing and detect potential complications, as opposed to in-person visits only (Grade 2C).
• • Rationale: Current literature lacks RCTs assessing telehealth interventions between wound care clinicians and patients at home; so far RCTs have focused on telehealth between treating non-wound care clinicians and remote wound care specialists. However, the COVID-19 pandemic created the need for wound clinicians to schedule virtual visits directly with patients at their homes, in an effort to minimize spread of the virus. As a result, several recent cases reported successful management of chronic wounds via telehealth between providers and patients.[35][36]
  • It is important for clinicians to identify what constitutes a good balance between in-person and telehealth care. Factors contributing to successful virtual visits include patient selection (not all are good candidates for telehealth), availability of family members or caregivers to assist with dressing changes, wound measurement, technical and connectivity difficulties, etc, and ease of use of the telehealth platform.[35][36][37]
  • From a patient’s perspective, studies have reported a high level of satisfaction with telehealth interventions, due to convenience, increased access to care, decreased transportation costs.[37] 
  • Use of resources: CMS and many private insurers continue to provide widespread coverage to telehealth services during the pandemic. Several telehealth modalities will continue to be covered after the public health emergency ends. See topic “Reimbursement for Telemedicine Services in Wound Care”. A cost analysis study indicated that a hybrid model with a combination of in-person and telehealth visits can be less costly to the wound care institution when compared to an in-person only model.[21]

BEST PRACTICES AND TIPS 

The best practices and tips in this section are specific to telehealth in wound care and were compiled from multiple sources, including publications, webinars, and expert opinions (See Infographic)

How to Get Started with Telehealth

• Ensure that your malpractice insurance covers telehealth services, especially across state lines, and provide your carrier with an effective date.Preventing hospitalizations in an overburdened healthcare system, reducing amputation and death in people with diabetes. | Rogers LC, Lavery LA, Joseph WS, Armstrong DG et al. | 2020" target="_blank" style="background-color: rgb(255, 255, 255);">[32][38][39]
• Review State Practice Acts.[38]
• Conduct an early meeting with your team to identify:
• • Potential barriers [38]
  • Patient demographic limitations (e.g., communication barriers, access to technology) [19][38]
  • Ways to cultivate a positive patient experience, which should be a top priority when considering telehealth implementation [38]
  • Nursing staff needs [19]
  • Insurers’ coverage determinations related to telehealth; documentation and billing requirements 
  • Coding updates in the chargemaster, needed for proper billing of telehealth services 
  • Information technology (IT) needs (e.g., technology risk assessment, minimum requirements, etc) 
  • Telehealth modalities that will meet your needs. See the “How to Choose and Tailor Telehealth Modalities to your Needs” section below.
• Understand your electronic health record system (EHR) workflow and how telehealth can be integrated into the existing EHR workflow
• • Some EHRs have telehealth capabilities. Generic EHR telehealth solutions may be sufficient for clinicians who do not need to evaluate patients with wounds. Specialized solutions might be desirable for specific needs. For a list of telehealth capabilities that are ideal for patients with wounds see the “How to Choose a Telehealth Software” section.
• If you choose to utilize an external vendor, execute a Business Associate Agreement (BAA) and obtain evaluation of your contract.[39]
• Prepare for implementation: 
• • Identify workflows tailored to the practice’s needs.[39] See workflows in the “Telehealth Modalities” section above.
  • Create professional remote visit templates with smart phrases to standardize documentation for patient care and billing.[35]
  • Incorporate a triage pathway to determine which patients are appropriate for telehealth.[39]
• Begin training sessions:
• • Prior to beginning training sessions, ensure that workflow integration is in place.[38]
  • To ensure a seamless experience and assist in workflow memorization, conduct multiple training sessions, manually rehearse steps, and incorporate clinician feedback.[38]

Figure 5. Summarizes the points above.

How to Choose and Tailor Telehealth Modalities to Your Needs 

• Telehealth modalities include real-time audio and video, store-and-forward, remote monitoring, etc. See the “Telehealth Modalities” section above.
• To identify the telehealth modalities that fit your needs, refer to the “The Wound Telemedicine Wizard” algorithm.

How to Choose a Telehealth Software for Wound Care

• Key characteristics of an optimal telehealth software may include:
• • Secure, encrypted, and HIPAA-compliant [35][39][40]
  • Easy-to-use [35][40]
  • Interoperable [40]
  • Cost-efficient [40]
  • Accessible from desktop computers, tablets, and smartphones [35]
  • Patient-centered [41]
  • • This is essential for individualization, fostering greater autonomy in the healing process, and promoting telehealth adoption.[41]
    • Compliant with the Open Notes Provision of the 21st Century Cures Act [41]
• Key features of an optimal telehealth software may include:
• • Ability for mobile device users to switch from the front to the rear-facing camera in order to show their wound to a remote provider during a video visit [41]
  • A portal that allows patients to request consultations, submit photos, access medical history, and receive educational materials [41]
  • Ability for patients/requesting clinicians to receive video visit links via SMS and/or email [41]
  • Provision of real-time instructional materials for patients (e.g., how-to video tours) [41]
  • Integration with clinic scheduling software [38]
  • Documentation capabilities: 
  • • Photo and wound documentation [40]
    • Automatic time-tracking for CPT code selection [38]
    • Smart/dot phrases with predefined, modifiable snippets, which allow for standardization and time saving [35]
    • EMR workflow integration, which enables clinicians to link patients’ photos in the hospital information system and encourages providers to utilize the technology [19][40]
    • Patient progress management to view patient’s development over time [40]
    • Ability to obtain a second opinion from a colleague [40]

Figure 6 summarizes the points above.

How to Determine if Telehealth is Suitable for a Patient 

• Screen patients during in-person appointments and identify patient-level factors that may eliminate the telehealth option.[38] 
• • Does the patient have a smartphone, computer, or tablet? [38]
  • Does the patient have a strong Internet connection? [38]
  • Does the patient have someone to assist you during the visit? [38]
  • Does the patient have experience using technology? [38][40]
  • Does the patient have visual or hearing impairment? [38]
  • Does the patient have difficulty with manual dexterity? [38]
  • Does the patient display a favorable attitude toward technology and telehealth visits? [38][40]
  • Is the patient concerned about their condition? [38]
  • Do you have a positive working relationship with the patient? [38]
• Establish the goal of each visit and identify clinical factors that may eliminate the telehealth option.
• • Do you need to communicate bad news or test results? [38]
  • Do you need to obtain diagnostics (e.g., collect wound culture)? [38]
  • Are you or a family member worried about the patient? [38]
  • Does the complexity of the patient’s condition necessitate an in-person appointment? [38]
  • • For example, while some pressure ulcers and injuries are suitable to be treated via telehealth, complex and deep wounds such as a Wagner 3 diabetic foot ulcer require in-person assessment.[38]
  • Do you feel the need to “trust but verify” to ensure that the patient is telling the truth? [38]
  • Will a telehealth visit satisfy your paperwork requirements? [38]

Figure 7 summarizes the points above.

How to Prepare for a Successful Virtual Encounter

• Nursing/administrative staff perspective

• Provider's perspective 

• Facilitating clinician perspective
• In home health settings (Figure 10):
• Ensure that telehealth visits are on the patient’s schedule.[41]
• Arrive early to measure the wound, upload images, and take vital signs.[41]
• Ask a family member or aide to assist with positioning the phone and working with the patient.[41]

Figure 10. How to Prepare for a Successful Virtual Encounter - Facilitating Clinician's Perspective

• Patient perspective

How to Assess and Measure Wounds

• Ask the patient to place a device with measurements in centimeters near the wound to provide dimension.[19] Alternatively, if available, may consider an automated app to track wound assessment and measurement.[38]
• Refer to images of the wound submitted in advance or captured during the visit. 
• • TIP: The presence of a technically-proficient family member or aide is helpful in both uploading images and stabilizing the mobile device during the visit.[38]
  • TIP: Capturing a quality image is a team effort requiring collaboration and patience from both the provider and patient.[38]
• If assessment of the wound is challenging due to blurred video/photo, use terms such as “appears to” when documenting characteristics of the wound, as it may be difficult to discern details with confidence (other than if the wound is of partial or full thickness).[38]

Figure 12 illustrates the points above.

How to Overcome Technical Obstacles

• Implement checklists to identify potential limitations and ensure Internet connectivity is stable.[38]
• Troubleshoot in advance and conduct pre-call tests with collaborating organizations to ensure that operating systems, browsers, and mobile devices are suitable.[38]

Figure 13 illustrates the points above.

Figure 13. How to Overcome Technical Obstacles

How to Meet Documentation Requirements

• Ensure that documentation meets specific payor requirements.[38]
• Document as if you are being audited.[38]
• Recognize that the documentation requirement for telehealth is the same as for in-person visits.[39]
• To streamline telehealth visits in home health settings, develop a checklist of essential, EMR-specific information for the nurse to collect.[41]

Figure 14 illustrates the points above.

PATIENT EDUCATION

• The delivery of patient education materials is a critical component in the provision of telehealth services, as it empowers patients to achieve greater involvement in their care plan and independently navigate telehealth technology. To view examples of patient handouts on subjects such as preparing for a successful visit and completing a self wound check, reference the “Patient Education - Successful TeleVisits for People with Wounds” topic.

CODING, COVERAGE AND REIMBURSEMENT

• Reference the “Reimbursement for Telemedicine Services in Wound Care” blog post for detailed information on CMS coding, coverage and reimbursement for telehealth services relevant to wound care. 

CMS QUALITY MEASURES

• The implementation of telehealth services offers practices a unique opportunity to fulfill CMS quality measures requirements. Improvement Activities is one of four categories comprising CMS's Merit-based Incentive Payment System (MIPS), and completion is required for all MIPS-eligible providers who bill Medicare Part B. Telehealth can satisfy 2020 Improvement Activities requirements in two ways: 
• • Use of Telehealth Services that Expand Practice Access (IA_EPA_2): Use of telehealth services that expand practice access and analysis of data for quality improvement, such as participation in remote specialty care consults or teleaudiology pilots that assess ability to still deliver quality care to patients
  • Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop (IA_CC_1): Use of specialist reports back to referring clinician/group to close a referral loop
• For more information, reference the “MIPS in Wound Care and Hyperbaric Medicine - Improvement Activities” blog post. 

APPENDIX

Summary of Evidence (SOE)