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Abstract title: Accuracy of Web-Based Telemedicine System for Monitoring Ulcers

Author(s):
JC Lowery - VA Center for Practice Management and Outcomes Research, Ann Arbor, MI
HM Kim - VA Center for Practice Management and Outcomes Research, Ann Arbor, MI
EG Wilkins - VA Center for Practice Management and Outcomes Research, Ann Arbor, MI
JB Hamill - VA Center for Practice Management and Outcomes Research, Ann Arbor, MI

Objectives: The objective of this study was to evaluate the accuracy of a store-and-forward telemedicine system for monitoring ulcers. Digital photos and other patient and wound data were collected by a nurse using a laptop and transmitted via the Internet to a database, which organized the data and posted them onto a Web page for access by a telemedicine physician.

Methods: Two VA medical centers and two specialties participated in the study: Ann Arbor (plastic surgery) and Augusta (plastic surgery, physical medicine and rehabilitation). Study patients included inpatients and outpatients with pressure ulcers of stage II, III, or IV, plus outpatients with diabetic foot ulcers or venous stasis ulcers. All patients were assessed both in-person (the “gold standard”) and with the telemedicine system according to yes/no responses and to five-point scale responses, respectively, to four diagnostic questions concerning wound healing and infection, based on AHCPR guidelines.

Results: A total of 70 patients were enrolled, with data collected on 411 visits. Percent agreement for all visits ranged from 67.9 for “not healing” to 88.8 for “cellulitis present”. Sensitivity ranged from .26 for cellulitis to .64 for necrosis; and specificity ranged from .81 for necrosis to .91 for cellulitis. Area under the receiving operator characteristic curve (AUROC) ranged from .69 for cellulitis to .81 for necrosis. A link to a demonstration Web site of the system can be found under “Telemedicine Projects” at: http://www.hsrd.ann-arbor.med.va.gov/.

Conclusions: The agreement rates between telemedicine and inperson assessments in our study were not as high as those reported in other studies assessing the accuracy of digital photos for diagnosing clinical conditions. However, feedback from the participating physicians indicates that the telemedicine system could be very useful for patients who are not currently receiving routine monitoring by qualified nurses or physicians—e.g., spinal cord injury patients residing at home. The sensitivity and specificity data (often not reported in other studies) are important for understanding limitations of the system.

Impact statement: A relatively inexpensive, store-and-forward telemedicine system for monitoring the status of ulcers has the potential to improve access to specialty care for spinal cord injury patients.