Today, three years after home care nurses began using laptop computers to record patient information at the point of care and after years of testing technology such as cell phone cameras, Partners is equipping the nurses with a telemedicine wound care application that pairs standard digital cameras with the nurses' laptops. Yet Partners continues to evaluate more efficient options.
The story of remote wound care at Partners is a typical one in the world of telemedicine, and provider organizations should be prepared for the challenges as well as the benefits of such projects, Partners executives say.
"This is a great example of a specific way telemedicine technology can add value to the practice of medicine," says Joseph C. Kvedar, M.D., director at Partners Telemedicine and a dermatologist. But it also represents a trial-and-error approach that is common in new technology ventures, he says. "We have tried a number of different ways to move it forward, and we have run into the classic adoption challenges. Sometimes it is a technological issue, and more often it is that people are reluctant to change."
What's key is that Partners didn't give up, says Bob Waters, executive director at the Home Care Technology Association of America, a Washington-based advocacy group. "It's important that people stay at it, because we really don't have any other choice. We need to find ways to improve quality of care, make it more timely, and make it more cost effective."
From the beginning, the wound care project has been a joint effort between two Partners divisions, Partners Telemedicine and Partners Home Care. Partners Telemedicine is a research and development group charged with leveraging telecommunications technologies to improve care. Partners Home Care, which has about 3,500 patients under its care, admits 70 to 80 patients per week with wounds. Just six of its nurses have specialty training in caring for wounds.
"We had a classic problem," says Doug McClure, corporate manager at Partners Telemedicine. "Wound care nurses are specialists, and they are in short supply. So we said, 'Is there a way we can move images around instead of the nurses?'"
The telemedicine staff at Partners began tackling the wound care project in earnest about five years ago. Studies demonstrated that a specialist nurse could review the wounds of about 30 patients a day remotely. Specialist nurses also felt confident that looking at images would enable them to evaluate the effectiveness of current treatment plans and help make new plans if necessary, says Kathy Duckett, director of clinical programs at Partners Home Care. "We wanted to maximize their time."
In the first pilot test, home care nurses received off-the-shelf digital cameras and were asked to take pictures of wounds. Nurses used digital image storage chips in the cameras, one per patient, and placed each chip into an envelope after taking the photos. When they returned to their office, they turned the chips in with their paperwork and then waited to hear back via telephone from the specialists.
"We ended up moving at a 'sneaker-net' pace, meaning that these chips and the paperwork had to be walked around until they could be loaded into the application," McClure says. "We were running into an issue of time. Taking the pictures, driving them back to a central office where the information could be loaded up into a workflow system, and having the specialist nurse look at them took about three days."
Time lag
That first try yielded excellent digital images but an unacceptable time delay, Duckett says. "Wound care nurses did not want anything that was more than 24 hours old."
Cell phones with cameras seemed to be an obvious solution, McClure says. "We needed to marry the image capture process with a transport mechanism that was connected to a network."
To work with cell phones, staff members at Partners Telemedicine knew they had to have high-quality images, find a way to encrypt the data stream to transmit the images securely, and write an application that would manage the image transfer process so that nurses did not have to watch the phones to make sure each image went through. "If a nurse had to sit there and transfer files over a cell phone, we were going to lose any productivity gains," McClure says.
Working with Claricode Inc., a Waltham, Mass.-based firm that specializes in customizing software for health care clients, Partners built a prototype on the Windows Mobile operating system-from Redmond, Wash.-based Microsoft Corp.-that demonstrated they could move images around securely and quickly.
"The bad news was image quality just wasn't there," McClure says. "That was more than two-and-a-half years ago, and there just wasn't enough pixels in the cameras."
Says Kvedar: "When the nurses looked at their images, their gut reaction was, 'This is not ready for prime time.'"
An image problem
Research suggests that the nurses may have been being overly cautious, but the telemedicine division, which has been working hand-in-glove with the home care division on this effort, chose not to fight their decision, in part because the nurses had legitimate technology concerns.
"Cell phone cameras have two megapixels now, so people say, 'What's the hold up?'" McClure says. "The answer is that a two-megapixel cell phone camera is not the same quality as a two-megapixel camera. The reason is that the lenses that are used and the image processing that is done to the image once it is captured are quite different in a cell phone than in a digital camera. So the two megapixels you are capturing with a cell phone is the same number of pixels, same number of data, but each bit of data is poorer quality."
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