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A Picture of I.T. Progress
Health Data Management Magazine, February 2007
No one knew then how long it would take to realize that vision.
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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."
To deploy the system, Partners decided to go back to giving nurses digital cameras, and Claricode rewrote the image transfer application for the laptops the nurses carry in the field.
The new application is easy to use, Duckett says. A nurse takes the photos, plugs the camera into the laptop and then uses a scroll-down menu to indicate which part of the body the images are related to. The application captures the patient's identification number from the home care software used by Partners, from Patient Care Technologies in Atlanta. The nurse can then click and drag photos into folders that categorize the images: front view of the wound, 45-degree angle of the wound, where the wound is in relation to other parts of the body, and miscellaneous views.
"Once the nurse saves the photos into the application, all of the pictures in the camera are deleted so there's no chance they will be confused with the next patient," Duckett says.
Nurses use the laptop to connect to the Internet at the end of the day, transferring all of the patient data they have collected back to the main home care system. The images, however, are automatically sent to a Web site where they can be reviewed the next day by wound care specialists.
The wound care application, which is being rolled out to about 60 home care nurses this year, "will not completely replace the need for wound care specialists to go out into the field," Duckett says. "It is meant to be an adjunct to the care they provide."
Still going
Partners Telemedicine has not kept a running tally on the investment it has made in the wound care project, but Kvedar says the development process is not over yet. "We will work on the cell phone platform until the cameras are more mature. We know that in Asia now, they have five-megapixel cameras on cell phones, so it won't be long before we can cross that technical barrier in the United States."
The benefit, he and other Partners executives say, will be that home care nurses - who already carry cell phones - will not have to lug around the digital cameras. Plus, the image-based second opinions Partners has been seeking will finally be only a phone call away.
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