Lehigh Valley Hospital, Allentown, PA, USA.
PURPOSE: Telemedicine has been used for remote management of many medical problems, including congestive heart failure, diabetes, and trauma. Quality care and practice efficiency may be enhanced by telemedicine. The utility and reliability of this modality in reconstructive medicine has not been documented. This study was explored the reliability of wound assessment from a distant site, using computer transmitted digital imagery compared to traditional bedside evaluation.
METHODS: Two physicians independently evaluated extremity or torso wounds. A digital photograph was taken by the resident. Attending and resident physicians completed a wound assessment tool at the bedside documenting whether the image accurately represented the actual physical exam. Quantitative evaluation of variables including eschar, exposed bone, cellulitis, purulence, swelling, granulation tissue and color, and depth of wound was provided. The image was transmitted via CD to a third physician who evaluated it on a standard PC screen and completed the same wound assessment tool. Kappa statistics were used to correlate findings between the onsite resident and attending physician and between onsite and remote physicians.
RESULTS: Two study phases: Phase 1, 50 wounds were evaluated. Five vascular surgeons, two plastic surgeons, and a PGY3 resident were involved. Kappa statistics, computed for all variables, showed poor agreement with raters. Phase 2, 56 wounds were evaluated. Two vascular surgeons, one plastic surgeon, and the resident (now PGY6) participated. After training on exact definition of assessment tool variables, Kappa values consistently showed high degrees of observer agreement: eschar: 0.988095, exp. bone: 0.976190, cellulitis: 0.988095, purulence: 0.988095, swelling: 0.940476, granulation tissue: 0.845238, granulation color: 0.916667, depth: 0.699405.
CONCLUSION: Remote assessment of torso and extremity wounds using digital images and a standard database, given appropriate training, is equivalent to an actual physical examination and is an acceptable standard of care.