Wound care, especially the management of chronic wounds is a costly affair. It is estimated that for every 1000 patients, 3.5 have a wound (Shepherd & Nixon, 2013). This implies that considerable resources are spent in the management of wounds. For instance, in the US, $2.8 billion is spent annually in the management of about 3-5 million chronic wounds. Chronic wounds negatively impact on the quality of life of affected patients since they affect their comfort, mobility, emotional well-being, life satisfaction, create caregiver burden, and time is spent seeking medical care (Buckley, Adelson, & Agazio, 2009). The implementation of prospective payment systems has forced health care providers and organizations to look for ways of capping the increasing costs of wound care (Jelinek, Prinz, & Wild, 2013). This is because this payment system has reduced reimbursements to hospitals and other health care organizations. The paradigm shift to evidence-based practice has, on the other hand, created a need for institutions and health workers to demonstrate patient progress through accurate and consistent documentation so as to receive appropriate reimbursement from payers for services provided (Buckley, Adelson, & Agazio, 2009). In addition, factors such as minimal utilization of advanced wound care products and lack of standardized wound assessment techniques have been identified as contributing to lower wound healing rates, prolonged healing times, increased home health visits, and frequent hospitalizations due to complications (Buckley, Adelson, & Agazio, 2009). Digital assessments and documentation of wounds has been proposed as an innovative approach for addressing the identified gaps in wound care. This paper will explore the background of digital documentation of wounds and its impact on health care, nursing care, consumers, and health care providers. It will also provide a succinct personal position on digital documentation.
Background
The goals of wound management are to ensure optimal outcomes whilst mitigating costs. Accurate and consistent documentation of wound care is crucial in ensuring optimal outcomes. Nursing documentation is in particular fundamental to care delivery. Its design needs to support continuity of patient care because other nurses and health care providers also rely on nursing notes. Accurate documentation in this case facilitates fruitful communication between health care practitioners to promote optimal care. It also allows monitoring of the progress of healing, and effectiveness of treatment interventions (Shepherd & Nixon, 2013). Studies have revealed gaps in wound assessment and variability in wound documentation practices (Jelinek, Prinz, & Wild, 2013). These variations include differences in wound assessment techniques and methods, time lapses in between assessments, methods of documentation, and practices used in deciding whether patients need a specialist review. Often, wound assessments are limited to narrow medical history, limited measurements with a ruler, and minimal diagnostic documentation. Objective assessments of the condition of the wound bed, granulation, fibrin/slough, and necrosis are usually not performed. Studies have demonstrated that lack of adequate information on wound bed conditions and dimensions often leads to under treatment (Shepherd & Nixon, 2013). Consistency in these parameters is particularly essential in community settings where various health care practitioners rely on available information to plan patient care due to a shortage of health staffs. Consequently, the cited gaps in wound care practices have led to increased calls for standardization of wound assessment and documentation. For instance, Fletcher et al. (2008 as cited in Shepherd & Nixon, 2013) argues that irrespective of the health care context, health staffs should strive to standardize wound care practices specifically in terms of clear, evidence-based objectives, regular reviews, assessment and documentation procedures, and specialist referrals. He contends that standardization of practice enhances patient’s chances of optimal wound healing. Digital documentation and assessments of wounds has been proposed as the solution to the cited problems.
Impact of Digital documentation of Wounds on Health Care, Nursing Care, Consumers, and Health care Providers
Digital imaging of wounds can be used as an assessment tool. When used in this manner, they should be obtained routinely and consistently. Additionally, they should supplement and not replace written documentation. Similar to other imaging modalities like X-ray and MRI, every image needs to be accompanied by text explaining the observable features of the photograph. A series of wound photographs permit institution of more informed and efficient interventions (Shepherd & Nixon, 2013). This is because digital imaging allows objective assessment of the condition, tissue composition, and dimensions of the wound bed. Color modeling can be used to distinguish different tissues: fibrin/slough appears yellow and dry, granulation tissue red, and necrotic tissue black or dark. Infected necrosis appears soft with shades of yellow. Green color in a wound is usually due to overgrowth of bacteria for instance pseudomonas while blue color is due to topical medications. The wound healing analyzing tool (WHAT) software is an example of a digital documentation tool found useful for assessment as well as documentation purposes in clinical trials and daily clinical practice. This system was tested in settings that permitted comparisons between wound tracings and digital images by trained clinicians (Jelinek, Prinz, & Wild, 2013).
In relation to assessment of wound size, digital imaging when combined with computer software is more effective and safer than traditional tools used for the same purpose. Assessments of wound size are traditionally done by overlaying of wounds with plastic films following which the border of the wound is traced. Digital retracing of the original tracing is then done to provide the circumference and area of the wound. This method is costly and time-consuming. It is also risky because microorganisms can be introduced to the wound and new granulation tissues may be damaged during the removal of the film (Jelinek, Prinz, & Wild, 2013).
Digital imaging improves the efficacy of ongoing remote consultations. For instance, in a study by Buckley, Adelson, & Agazio (2009), WOC nurses acting as consultants for home care nurses were able to conduct remote assessments of wounds via digital images sent via email. Compared to verbal reports, digital images were found to be more effective. They provide an objective view of patients, for example in this study, close-up and distant photos were essential in providing information. The distant photos in particular helped provide information that would have otherwise been missed. The WOC nurses also reported that the digital photos enabled them to utilize more than one sense when evaluating wounds remotely. Additionally, the WOC nurse reported that the digital photos allowed comprehensive review of the patient’s environmental factors. This is essential because these factors influence management and wound healing and may not be effectively captured in verbal reports due to variations in the levels of competencies and experience of nurses providing home-based wound care. In addition, digital images were found to permit detection of subtle features that may be missed on direct visual inspection. This is because digital images can be magnified via computer software tools. Another advantage of the use of digital images for remote consultations is that they are more cost-effective than other modalities such as telehealth. They only equipments required are a digital camera and a computer with an internet connection. Most importantly though and in relation to monitoring and reimbursements, digital images in such contexts permit visualization of wound changes over time.
Overall, digital imaging enhances the effectiveness of evaluation of wounds, prompts quicker actions, and ensures that ritualistic practice is avoided (Jelinek, Prinz, & Wild, 2013). For instance, the WHAT tool was found to support holistic assessments and clinical judgments, to initiate consistent and regulated practice, and to ensure regular evaluations. This in-turn helps to improve the quality of wound care, patient outcomes, and concomitantly, the quality of patient’s lives. For example, consistency in wound care practices enables timely identification of patients with non-healing wounds and their early referral to appropriate specialists. This mitigates the risks for complications that may result in adverse consequences such as amputations. Digital documentation also provides accurate records that enhance team interactions and communications.
The last several decades have witnessed a paradigm shift towards evidence-based practice where increased emphasis is being placed on the demonstration of the efficacy of interventions for remuneration purposes. Digital images provide accurate and consistent documentation of wound care and can be utilized to show patient progress and for quality assurance purposes. This is because a series of images obtained regularly help to objectify the wound volume changes during the wound healing process. A study by Zeller (2011) that examined the consistency of wound care documentation practices in a small home healthcare agency concluded that digital imaging fostered consistency and accuracy in documentation.
Personal Position
I support the use of digital documentation of wound care for reimbursements. This is because it helps to standardize wound care, can be used as both an assessment and documentation tool, forms a basis for monitoring of wound healing, and facilitates early institution of remedial actions for non-healing wounds.
Conclusion
In summary, the shift to digital documentation of wound care for reimbursement is driven by paucities in current wound care practices. Digital images of wounds can be used as diagnostic and documentation tools. They help to standardize care, in the monitoring of the progress of wound healing, and in ensuring consistency and accuracy in documentation. In light of these considerations, I strongly support the use of digital documentation in wound care.
References
Buckley, K. M., Adelson, L. K., & Agazio, J. G. (2009). Reducing the risks of wound consultation: Adding digital images to verbal reports. Journal of Wound, Ostomy, and Continence in Nursing, 36(2), 163-170.
Jelinek, H. F., Prinz, M., & Wild, T. (2013). A digital assessment and documentation tool evaluated for daily podiatric wound practice. Wounds, 25(1), 1-6.
Shepherd, S. & Nixon, M. (2013). Standardizing wound care documentation in clinical practice: The wound healing assessment and monitoring (WHAM) tool. Research and Audit, 9(1), 62-67.
Zeller, L. (2011). The impact of consistent and accurate wound care documentation on home health care outcomes and appropriate reimbursement. Retrieved from http://digitalcommons.hope.edu/curcp_10/93/
