The information reflects information available as of June 2, 2020. We encourage monitoring subsequent regulation updates pertaining to telehealth in wound care

1. Copyright © 2020 Healthy.io Ltd. All rights reserved
Transforming Best Practice
in Wound Care
Telehealth
Beyond
COVID-19
Sponsored by

2. Copyright © 2020 Healthy.io Ltd. All rights reserved
Turning the
smartphone into
a medical device
Shifting testing from the clinic to the
home with no quality compromise.

3. CE-marked and FDA-registered
Digitizing wound
management
Creating a flexible, smartphone enabled product to
support documentation and create new data
based insights
The new standard in care and analysis

4. Elaine H. Song
MD, PhD, MBA
Co-Founder,
WoundReference
Tiffany Hamm
BSN, ACHRN, CWS
Co-Founder,
WoundReference
TELEHEALTH BEYOND COVID-19:
Transforming Best Practice in
Wound Care
Catherine T. Milne
APRN, MSN, ANP/ACNS-BC, CWOCN-AP
Co-owner, Connecticut Clinical Nursing Associates
Clinical Advisor, WoundReference
Webinar sponsored by:

5. Disclaimer
 The information in this webinar reflects the best understanding of
the information available as of June 2, 2020.
 We encourage webinar participants to monitor regulation
updates pertaining to telehealth in wound care that occur after
June 2, 2020.

6. The Transformation of Wound Care
as a Result of COVID-19

7. What is “telehealth”? The basics
eHealth
•Not only remote
Telehealth
• Remote
• Curative,
preventative
Telemedicine
•Curative
CMS telehealth
CMS communication-based
technology services (CTBS)
AHRQ. The Evidence Base for Telehealth: Reassurance in the Face of Rapid Expansion During the COVID-19 Pandemic, 2020
Van Dyk L. A review of telehealth service implementation frameworks. Int J Environ Res Public Health. 2014 Jan 23;11(2):1279-98
Song E.. What is new in 2019 for Telehealth and Telemedicine?, 2019

8. What is “telehealth”? The basics
Telehealth
•Remote
•Curative, preventative
Telemedicine
• Curative, remote
Medicare
telehealth
AHRQ. The Evidence Base for Telehealth: Reassurance in the Face of Rapid Expansion During the COVID-19 Pandemic, 2020
Van Dyk L. A review of telehealth service implementation frameworks. Int J Environ Res Public Health. 2014 Jan 23;11(2):1279-98
Advisory Board . How COVID-19 is transforming telehealth—now and in the future , 2020
Song E.. What is new in 2019 for Telehealth and Telemedicine?, 2019
E-consults
Real-time
virtual
communication
Remote patient
monitoring
Asynchronous
store-and-forward
Telehealth
modalities
Patient-to-
provider use cases
Provider-to-
provider use cases
Televisits
Wearables,
home exams
Secure
messaging
E-consults
Wound
measurement
Mobile health
(mHealth)
General
education
Medicare
communication-
based technology
services (CTBS)

9. Medicare reimbursements for telehealth
Type of Medicare-covered Service Description of the service HCPCS
Medicare Telehealth Visits CMS Telehealth. A visit with a provider that uses
telecommunication systems between a provider and
a patient
Commonly used CPT codes include 99201-99215
"Office or other outpatient visits" and others; see
https://www.cms.gov/Medicare/Medicare-General-
Information/Telehealth/Telehealth-Codes
Brief communication technology-based service
(e.g. virtual check-in)
CTBS. Virtual check-in by physician or other QHP,
provided to an established patient
HCPCS code G2012
Remote evaluation of recorded video and/or images
submitted by an established patient
(e.g. store and forward)
CTBS. Patient submits a video/pictures to provider,
who provides interpretation with follow-up with the
patient within 24 business hours
HCPCS code G2010
E-Visits: Online digital evaluation and management
services or e-Visits for an established patient
CTBS. Communication between patient and provider
through an online portal
CPT 99421-99423 and G2061-G2063 or CPT 98970-
98972 for some commercial payers
Interprofessional internet consultation
(e.g. e-consults)
Provider to provider communication involving
assessment and management of a specific patient
CPT codes 99446, 99447, 99448, 99449, 99451,
99452
Remote monitoring Chronic care remote physiologic monitoring
(e.g, weight, blood pressure, pulse oximetry,
respiratory flow rate)
CPT codes 99453, 99454, 99457
Shaum K. COVID-19 Reimbursement Depends on What Was Performed: Telehealth or Communication Technology-Based Service? Today’s Wound Clinic, June 3 2020
Song. E. Reimbursement for Telemedicine Services in Wound Care. May 12 2020
CMS Fact Sheet. Medicare Telemedicine Health Care Provider Fact Sheet. March 17 2020
Federal Register. Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency. April 6 2020
CTBS: Communication Technology-Based Services (CTBS)

10. The rapid shift towards telehealth
Healthcare Dive. Medicare members using telehealth grew 120 times in early weeks of COVID-19 as regulations eased, May 27, 2020
AHRQ, The Evidence Base for Telehealth: Reassurance in the Face of Rapid Expansion During the COVID-19 Pandemic, May 14, 2020
Forrester Research. Healthcare Predictions 2020: Virtual Care Visits Will Soar To More Than 1 Billion In The US,”, March 16, 2020
Temporary
waivers
New rules
CMS’ rapid legislative and
regulatory changes to
payment and privacy
requirements
Broadened access and
payment for a wider range of
telehealth services
11,000
1,300,000
March 7th 2020 April 18th 2020
Number of
Medicare
beneficiaries
receiving
telehealth
services
Estimated number of
total U.S. telehealth
visits in 2020
1 billion
11,718%

11. Medicare drops barriers to telehealth
Weigel G. Opportunities and Barriers for Telemedicine in the U.S. During the COVID-19 Emergency and Beyond. KFF, May 11 2020
Updates in privacy, patient and provider eligibility
Privacy
regulations
Audio-only
visits
possible
Access
services
from home
New and
established
patients
Practice
across
state lines
Widespread coverage and reimbursement
Technological developments
Healthcare workforce training

12. What are patients thinking about telehealth?
Sage Growth Partners. As The Country Reopens, Safety Concerns Rise,, May 11 2020
Most patients in the U.S. who tried telehealth are satisfied
(Sage consumer survey, May ’20)

13. Pre-COVID evidence supports telehealth
AHRQ . The Evidence Base for Telehealth: Reassurance in the Face of Rapid Expansion During the COVID-19 Pandemic, May 14, 2020
Huang Z et al. Efficacy of Telemedicine for Patients with Chronic Wounds: A Meta-Analysis of Randomized Controlled Trials, Advances in Wound Care, May 20 2020
Telehealth is as good or better than usual care
Evidence is concentrated in specific uses
Beneficial for chronic wounds
* Telehealth: televisits combined with in person visits, remote wound expert consultation using store and forward with picture and measurements

14. Crisis brings opportunities
• Opportunities to better generate evidence and understand:
o How to do telehealth in wound care rather than whether
to do it
o How digital solutions can facilitate clinicians’ and patients’
transition to the new normal
 Televisits
 Wound assessment & measurement
 Point-of-care decision support
 Automated documentation

15. The Impact of Telehealth in Wound Care
Challenges and Opportunities

16. Pre-COVID wound management challenges
Acute Care Long Term Acute Care (LTAC)Primary Care/ Urgent Care/
Community Health Centers
Home Health SNF/Short-term Rehab

17. Common themes across settings
Different techniques, lack of
standardization
Wound measurements are inconsistent
Wound descriptions often subjective
Variable documentation among providers
Pressure injury staging incorrect
Is wound better or worse?
What interventions have been
employed?
May not have efficient “look-back” processes
in place
Lack of coordination in and between
settings

18. The New Paradigm addresses the challenges
 Save transportation costs
 Early and right intervention – cost
impact?
 Specialty beds, compression,
offloading
 Less supply waste
 Improved patient adherence
 Improved local care
 Earlier referral to experts
 Targeted visits
 Improved documentation
Potential telehealth benefits

19. Telehealth addresses these issues expediently
• Between settings
• Provider to provider
• Provider to patient
Quick evaluation
of wound
• Identify challenges each other did not know
existed
• Provides Teaching opportunities
• Assists in Quality improvement
Fosters
relationships
between
providers and
organizations
• COVID-19
• Non-pandemic situations
Triages
appropriately

20. Best Practices for Successfully
Adopting Telehealth

21. Pandemic challenges
• Equipment
• Processes
• Uncertainty and rapidly shifting environment
• Staffing changes
Rapidity of Lockdown left wound management unprepared

22. Overcoming pandemic challenges
• Organization
• Payors
• Liability company
• State Practice Acts
Know the rules
• Work within and between
each setting to determine
process
• Write it down!!
• Train, train, train!!
• It must be workable in the
workflow
Establish processes Identify barriers early1 2 3

23. For Provider to Provider
• Consider this like a patient visit – set date
and time
• Expect a learning curve
• Get as much information up front
• Do you need a Business Associate
Agreement?
• Keep it HIPPA compliant
• Document as if you were planning on an
audit
BEST PRACTICES AND TIPS

24. For Patients and Caregivers
• Train early and often
• Expect a learning curve
• Determine technology comfort and identify
point person
o Is patient comfortable with this?
o Is point person comfortable?
o Can you use an intermediary provider?
• Expect increased time and technical
difficulties
• Above all set the expectations up
front… and its limitations
BEST PRACTICES AND TIPS

25. If “outside” the organization…
• Run a few test locations within the
collaborating organization if needed
• Develop your relationships first…
• Know what’s available to you
o Staff, dressings, adjunctive therapies, etc.
• Try a few with the other site in full PPE
BEST PRACTICES AND TIPS

26. Selecting the right patient
• Determine the telehealth goal….
o Are you worried about the patient/wound?
o Feel the need to “trust but verify”?
o“Survey says?”
o Urgent but quick intervention?
o Patient/family initiated?
 Patient doesn’t want face-to-face visit
 Patient concerned
 Worried well patient/family member
oTriage?
oSatisfy paperwork requirements?
• Efficient for you?
BEST PRACTICES AND TIPS

27. Lessons learned
• Some people are early adopters, some out of necessity, some not at all
• For most part, you will not save time early in process
• You will get the information you need to make decisions…and sometimes
more!
• Telemedicine visits do not substitute for all visits
• You will have to teach wound assessment and dressing change techniques
• You will become a better provider….
• Expect the unexpected……

28. Case example
• 58 yo female admitted in January to SNF with Stage
4 ischial pressure ulcer and co-morbidity of
multiple sclerosis
Pre-pandemic picture at second MRI

29. Case example
Outcomes
• Improved communication
• Care coordination
• Time efficient for providers
• Staff education
• Expedient care for patient
New wound on right leg

30. Implementing telehealth in the outpatient setting
• Telemedicine process implemented at an outpatient wound clinic
• Patient volumes dropped by half due to COVID-19
• Delivering care in a completely different manner
• Approval from hospital administration
• Overcoming obstacles

31. Provider workflow: design and implementation
• Involvement of the
hospital billing and coding
department and
management
• Multiple training
sessions were completed
with providers to ensure
seamless and efficient
experience
o Sequence of steps
on how to conduct
televisits
• Providers’ feedback was incorporated in
documentation templates
o Ease of use
o Reimbursement requirements
o Coding the encounter
o Integration

32. Provider challenges and solutions
 Solution: repetition/training
Memorizing steps of the new televisit
workflow
 Use telehealth solution that
automatically keeps track of time
spent and guides the selection of
the CPT code
Getting used to time-based codes
 Diagnosis, description
 Practice with patient or enlist caregiver
 Submit pictures before televisit
 Have patient utilize wound
assessment/measurement app if possible
Unable to objectively assess/measure wounds
Technical obstacles
 Perform pre-call test
 Check connectivity in the hospital
 Check devices, browsers, operating systems
 Understand communication technology
limitations

33. Televisit workflow: nursing
• Offering televisit
• Scheduling
• Vetting the patient
• Sending the invite
• Preparing the patient encounter
• Integrating with the wound clinic scheduling
• “Rooming” the
patient in the
provider’s video visit
room at the
patient’s scheduled
appointment time
• Helping provider with
documentation
Before the televisit During the televisit After the televisit

34. Lessons learned: clinicians training and support
• Providers became stressed if the patient was having difficulty
• Educate clinicians
• Educate patient and caregivers

35. Lessons learned: technical challenges and solutions
• Pre-appointment:
oPatient factors
oExperience with technology
oEquipment
oConnectivity
• During the video call:
o Capturing the image
o A new experience

36. Lessons learned: patient experience
• We had been focusing on the provider and staff
• We didn’t think about the patient’s problems from the onset.
• The patient experience is the number one priority. If patients
are happy, clinicians will be happy.

37. The Future of Wound Care in a
Post-COVID-19 World
Where Do Clinicians Go From Here?

38. Telehealth to become “table stakes” in wound
care
Gadzinski AJ, and Chad E. “Telehealth in urology after the COVID-19 pandemic.” Nature reviews. Urology, 1–2. 13 May. 2020
Brain, David et al. “Cost-effectiveness analysis of an innovative model of care for chronic wounds patients.” PloS one vol. 14,3 e0212366. 6 Mar. 2019
Advisory Board . How COVID-19 is transforming telehealth—now and in the future, 2020
• Ideal for simple follow-up care
• Ideal for televisits between clinicians, to treat patients who
cannot come in
Virtual-care-first model
• Pent up demand: need physical
examination, procedures,
diagnostic test
Increased in-person visits
States reopening

39. The new normal in wound care: follow up for
non-complex cases
Communication
• Remote follow-up
via televisits
Remote monitoring
• Wound assessment
and measurement
• First encounters
in-person
• Patient education:
dressing change,
compression
• Wound care
instructions via
online patient portal
• Monitoring of
wound healing
Simple venous
ulcer
Outpatient
Gadzinski AJ, and Chad E. “Telehealth in urology after the COVID-19 pandemic.” Nature reviews. Urology, 1–2. 13 May. 2020
Rasmussen BS et al. A Randomized Controlled Trial Comparing Telemedical and Standard Outpatient Monitoring of Diabetic Foot Ulcers. Diabetes Care.;38(9):1723‐1729, 2015
Santamaria N et al. The effectiveness of digital imaging and remote wound consultation on healing rates in chronic lower leg ulcers in the Kimberley region of Western Australia. Prim Intention, 2004

40. The new normal in wound care: streamlining
wound care and documentation
Diabetic foot ulcer
Skilled nursing
facility
Standardized
documentation for SNF
• Audit-ready
• Supports diagnoses
• Maximizes SNF per
diem rate
Increased efficiency for
wound consultant
• Data collected prior to
encounter
SNF Clinician
• Clinical decision
support tools
oAlgorithms
oWound-specific
recommendations
oVirtual panel
Time is tissue
SNF Clinician
• Submits intake form,
images, automatic
wound measures
Wound consultant
• Televisit with SNF RN
• Uses templates to
document E/M
• Tele-wound rounds
Tele-wound care
Purcell L. An invited commentary on “Impact of the Coronavirus (COVID-19) pandemic on surgical practice-part 1”. Impact of the Coronavirus (COVID-19) pandemic on surgical practice: Time to embrace telehealth in surgery. Int. J. of Surgery, May 2020

41. Are you ready to launch telehealth?
Partner with your patient1
• Actively promote virtual visit
options
• Encourage patients to
conduct a virtual visit before
coming onsite
• Support patients while using
telehealth technology
Ensure right technology is
working properly
2
• Ensure digital solutions that
integrate with your workflow
are in place
• Check bandwidth, connectivity,
hardware
Support your clinicians3
• Assess licensure status
• Offer training
• Provide real-time support
for issues that arise during
a virtual visit
Get the legal team involved
Providers’ licensure and employment
agreements ok?
Identify the unmet need, form your team then follow these 3 steps
Song E et al. Telemedicine/ Televisit Implementation Playbook – Parts 1 and 2. 2020
Advisory Board . How COVID-19 is transforming telehealth—now and in the future, 2020

42. Start off on the right foot
• Likely the first restriction to be restored
1 Non-HIPAA compliant solutions
Select HIPAA compliant solutions
• Secure, permanent
2
• No specific documentation
• Does not fit workflow
Non-wound care-specific solutions
Select wound care-specific solutions
• Workflow integration, decision support,
easy to implement
Common pitfalls and suggested solutions
• Steep learning curve
• Barriers to adoption
3 Non-patient friendly solutions
Select patient friendly solutions
• Easy to use, meets specific needs

43. Incorporate telehealth into your strategy
“There is no going back” Seema Verma, CMS Administrator
Telehealth implementation and re-evaluation questions
1. What is your unmet need?
2. Who should be part of the implementation team?
Leadership, clinicians, staff, billing, coding, legal?
3. Which digital solutions can meet this need? Are they HIPAA
compliant, wound care-specific and patient-centered?
4. How can clinicians and patients be trained/educated on the
telehealth processes and solutions?
5. How can progress be measured? Access to care, patient
satisfaction, clinical effectiveness, cost savings?
CHECKLIST
Generating data to support
reimbursement parity
• Demonstrate how
telehealth can help meet
payers’ objectives such as:
o Budget neutrality
o Cost-effectiveness
o Improved clinical
outcomes, access to
care, patient
satisfaction
Song E et al. Telemedicine/ Televisit Implementation Playbook – Parts 1 and 2. 2020
The Wall Street Journal. The Doctor Will Zoom You Now, April 2020
Advisory Board . How COVID-19 is transforming telehealth—now and in the future , 2020
FUTURE ACTIONS

44. Thank you!
Questions?
Webinar sponsored by: