Contactless care

3 November 2021

The pandemic has been a challenge for health systems globally, including the dilemma of how to continue meeting the needs of patients with underlying conditions while ensuring safety. Chronic wounds require constant management and in-person treatment, raising the question: what has been the impact of Covid-19 on this essential service? Mae Losasso speaks to Dr Ammar Al Rubaiay, foot and ankle surgeon at North Shore Foot & Ankle Associates; Dr Alisha Oropallo, medical director of the Comprehensive Wound Healing Center and Hyperbarics at Northwell Health; and Kevin Keenahan, co-founder and CEO of Tissue Analytics, to find out about the telemedicine-based strategies that are changing the future of wound care.

The term ‘misnomer’ describes a word that inaccurately names or designates something else. For example, ‘starfish’ is a common misnomer, since the star-shaped echinoderm isn’t a fish at all. The term ‘telehealth’ is also a misnomer – or at the very least misleading – since the prefix ‘tele’, in a modern communications context, refers to something that has changed beyond recognition over the last 20 years: the phone.

If the word ‘telephone’ brings to mind a household object, plugged into a wall, with a spiral cord, then the term ‘mobile phone’ probably makes you think of a portable device from the 2000s, furnished with flip top and antenna. Both are fast falling into the annals of technological antiquity, made increasingly obsolete by the smartphone. Of course, this is what telehealth – or ‘telemedicine’, as it is sometimes called – refers to: not the old-fashioned telephone consultation, but the development and use of app-based technologies and video conferencing platforms across a range of healthcare contexts. 

Over the past few years, tech developers and clinicians have been working on a spectrum of digital platforms designed to make healthcare more accurate, objective and contactless. It’s this last condition – the ability to move health services out of the clinic and into the virtual realm – that has changed the rules of the telemedicine game in the wake of the pandemic.

As Dr Ammar Al Rubaiay, foot and ankle surgeon at North Shore Foot & Ankle Associates in Chicago, explains: “Covid-19 has had a significant impact on essential wound care services. Most patients with chronic wounds have underlying medical conditions that put them in the very high-risk category for severe Covid complications, so there is general hesitancy in going to frequent doctor visits, which are normally required in wound care patients.”

In other words, wound care patients suffering from chronic conditions are among those most at risk of catching Covid-19 – but also those most in need of clinical attention. Legitimate fears, not to mention government limitations, have kept these patients at home, when frequent visits were, quite literally, what the doctor was ordering.

Touching base without touching the patient

Dr Alisha Oropallo, medical director of the Comprehensive Wound Healing Center and Hyperbarics at Northwell Health, also stresses the importance of wound care consultations. “About 20% of our patients come back from the hospital to the wound centre,” she says. “But what we found was that, of 500 patients that we analysed, those that actually came to the wound centre reduced their readmission rate and mortality from 40% to 9%. So, we made strong impact at reducing mortality if we just were able to touch base with the patient afterwards.”

Just touching base is precisely what these telemedicine solutions allow for. Throughout the pandemic, clinicians like Oropallo and Al Rubaiay were able to monitor their patients remotely. As Al Rubaiay recalls, “I had a number of cases where patients were afraid to present for in-person evaluation and were concerned about the condition of their wound.” Using video platforms such as Doximity, Zoom, FaceTime and Zocdoc, Al Rubaiay could “set up a telemedicine visit and, through that, […] recognise soft tissue infections in patients” and then “send [them] antibiotics and advise [them] to go to the hospital for proper management of the condition in severe cases”.

Meanwhile, over at Northwell, New York’s largest healthcare provider, Oropallo and her team were able to fit in same-day telemedicine appointments for critical patients on three-week hospital waiting lists. As Oropallo comments, “I think that [telehealth] could change the way that we practice medicine. I think it already has. For the better.”

Similar examples have been widespread over the past 12 months across all aspects of medical care, as doctors have seen increasing numbers of patients via remote video conferencing apps. But when it comes to wound care, such measures are often insufficient on their own. “There are still a lot of limitations to doing something over the phone versus clinically evaluating somebody,” Oropallo admits. “Mainly being able to touch them. When we talk to the patients, we ask them to do the physical examination that we would normally do. For example: ‘Please touch there. Do you have pain there? Is there swelling? Does it feel hard?’ So, we’re asking the patients to do the physical examination that we would normally do without them even noticing.” Al Rubaiay, too, emphasises the limits of these technologies, noting that “telemedicine is best used as an adjunct tool to [supplement] the standard practice of seeing patients in the office. But a proper physical exam cannot be replaced with a telehealth visit”.

“Covid-19 has had a significant impact on essential wound care services. Most patients with chronic wounds have underlying medical conditions that put them in the very high-risk category for severe Covid complications.”

Dr Ammar Al Rubaiay, North Shore Foot & Ankle Associates

Yet, while in-person consultations remain essential in some cases, telemedicine technologies are continually adapting to suit a more virtual world, offering ever more advanced possibilities for remote healthcare. One such example is Tissue Analytics, a smartphone app developed to simplify wound tracking and documentation. Established in 2014, the company’s founders – a team of biomedical engineers at Johns Hopkins University – set out to help tackle what they diagnosed as the two biggest problems facing hospital-based wound care.

The first, as Kevin Keenahan, co-founder and CEO, explains, “is that clinicians use rulers to measure wounds, and that introduces a lot of error when looking at outcomes”. And the second is that “those outcomes […] are communicated between different electronic medical record systems that don’t talk to each other, or that don’t make it easy to share outcomes or care plans. So wound care tends to exist in these silos”.

So, Tissue Analytics was born: a user-friendly app that allows both clinicians and patients to accurately measure wounds and render the data captured legible across a range of electronic medical record (EMR) systems. Unsurprisingly, perhaps, the pandemic has brought about a spike in the use of such technologies. “During the Covid pandemic, [the situation] was rather challenging and many wound centres shut down in the US,” Oropallo says. In order to stay open for patients, many staff at these centres had to work remotely, using telehealth to bridge the physical gap.

“Tissue Analytics was a company that we [had been] entertaining for a while, but in a large corporation like this […] it wasn’t deployed yet. During Covid we were able to accelerate the wishlist,” she explains. Using Tissue Analytics – in conjunction with telehealth service provider Avizia (which merged with Amwell in 2018) and EMR system Allscripts – Oropallo was able to keep Northwell’s vital wound care centre open throughout the pandemic.

Yet she also recognises that there are significant limits to the widespread adoption of the technology. “The biggest challenge is that not all patients have good accessibility to smartphones, nor do they know how to use them. Some of the companies like Tissue Analytics were not equipped to really understand the intricacies of the difficulties of patients understanding how to do this. I mean, the majority of our patients are over 70.”

Breaking barriers

To help combat these obstacles, Northwell has rolled out an initiative to inspire younger and more tech savvy family members to participate in care. This is a refreshing example of technology building a bridge, not a wall, between generations – helping to facilitate, rather than erode, face-to-face interactions.

For every obstacle that telehealth presents, another door, it seems, opens under its far-reaching remit. As Oropallo points out, telehealth has granted clinicians access to previously unseen aspects of patients’ lives. “We only get one picture: their picture,” she comments. “But [with telemedicine] we would really have a full understanding and comprehensive view of the patient. So, [their] economic status, where they live, their food source. Many times we may treat them, but they go back home and their social environment might be difficult [and then they have to] come back to the wound centre because they’ve had another traumatic injury. So I see the technology of the future as one in which the wound care physician will have those other aspects to think about, besides just managing the wound.”

“The cat’s not out of the bag yet, but I would advise somebody who’s going into this area of telehealth to embrace it. This is really going to be the future.”

Dr Alisha Oropallo, Northwell Health

Will telehealth continue to expand after the pandemic? For Oropallo, Al Rubaiay and Keenahan, there’s no question that the future of healthcare lies in telemedicine – but the balance for best practice remains to be determined. “We’re working on a best practice [paper] to try to evaluate our telehealth right now,” Oropallo explains. “We’re looking back over the past year [to see] how many times we made the right judgement over the phone, talking with the patients, and how many we didn’t […] and they ended up at the hospital. So the cat’s not out of the bag yet, but I would advise somebody who’s going into this area of telehealth to embrace it. This is really going to be the future.”

With all the caveats and cautions, there’s no question that telemedicine will be playing a key role in the roadmap of the future – but somebody should probably do something about that old-fashioned name. This is so much bigger than the telephone.

Is telehealth the future?

Early in the Covid-19 pandemic, telehealth usage surged as consumers and providers sought ways to safely access and deliver healthcare. According to data collected by McKinsey & Company, overall telehealth utilisation for office visits and outpatient care in the US was 78 times higher in April 2020 than in February.

The spike came at a time in which many healthcare professionals were using telehealth as their first line of care, only seeing patients in person if it was absolutely. McKinsey conducted a review of this research in July 2021 and reported that although these levels stabilised, telehealth utilisation was still 38 times higher than before the pandemic. In a consumer survey, it also found that 40% of respondents were willing to use telehealth services – a dramatic increase on 11% prior to the outbreak of Covid-19.

McKinsey also looked at doctor’s attitudes to telehealth and found that 58% viewed the modality more positively than they had before the pandemic.

Telehealth platforms have helped clinicians to contact wound patients who have difficulties attending an in-person evaluation.

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