Telemedicine and The treatment of Diabetic Foot Wounds: A Perfect Marriage.

Last week we talked to Dr. Howard Umansky DPM, founder of the Diabetes Rural Outreach Project (DROP), a telemedicine program designed to remotely monitor diabetes patients in rural areas. All with the goal of eliminating amputations.
Here’s a transcript of our conversation.

 
mhealth360: Explain DROP and its goals. How did you get the program started?
Dr. Umansky: DROP is a privately funded program designed to identify, monitor and treat diabetes patients in rural areas who are at risk for gangrene and lower extremity amputation. The program grew as an adjunct to a mobile service I started 25 years ago to provide doctors to homebound patients in underserved areas.
Specifically, it started when one of our bed-bound patients with a decubitus ulcer on her heel was referred to the emergency room by a visiting nurse.  We had managed to close the ulcer twice but it had reopened and was infected. She was transported to the hospital by ambulance and her leg was amputated. She was 29 years old at the time. I have no doubt that the ulcer would have been treated successfully but we weren’t able to monitor her closely enough.  DROP started very shortly after that to insure that there wouldn’t be another case like that one. Many of our patients were 80 miles or more from the closest doctor or service area and I felt we needed better communication and more frequent monitoring.  We had a large diabetic population to contend with so we had to create a better system.
We started by identifying the patients who were at greatest risk for ulcers and amputation.  We then put monitoring systems into their homes.  If they had Internet access, we would use web cams.  If they didn’t, we would use videophones that worked off the standard phone line.  A nurse would then go out to the patient’s home to explain how to use the equipment.  In most cases, we were able to explain the equipment to the patients themselves.  In situations where that was not possible, we would use a surrogate – a relative or neighbor, someone we could count on at a specific time to help us monitor the patient.  This allowed us to keep potential ulcers, open wounds or infections under a close watch.  The results have been excellent and I am very pleased with the program.
mhealth360: Can you tell us how many patients you started with, how it’s grown, and if you plan to see it grow any further?
Dr. Umansky: DROP has approximately 1,000 diabetics being monitored at the present time.  We started five years ago with about 65 patients being monitored and have grown from there. We draw most of our patients from Mobile Health, which provides doctors for home visits.  Mobile has a patient load of about 20,000 in the southeastern U.S. so we are continuing to grow.  We are also expanding our monitoring program outside the United States to coordinate with our wound care center in Barbados and we will be opening a diabetes wound center in central China at the end of this year. The technology will allow us to monitor any of our patients from anywhere.  I would like to be able to use our service as a resource for any physician with at-risk diabetic patients.
mhealth360: Did you see any barriers with people not getting the technology or understanding it?
Dr. Umansky: The first problem we had was that we were using web cams. We needed Internet access, which was problematic in the beginning due to lack of Internet connectivity in some rural locations. We then fixed that with videophones that worked on a standard phone line. Once we did that we really had no other problems. Our nurses were very thorough in training the patients and the surrogates in how to use the equipment.
mhealth360: How did the patients react to the program?
Dr. Umansky: The patients were very happy when we approached them with the idea of putting a monitoring system in their homes.  I think they were relieved, knowing that someone would be checking on them more frequently. Many of the patients were intimidated by the equipment initially, but we made sure that they were comfortable with using it and we would frequently re-train them at the beginning until we were confident that they could use the system. Allowing them to be an active partner in their treatment I think was also beneficial psychologically.
mhealth360: Are you measuring outcomes for this?
Dr. Umansky: Yes. As a little background, about 60-70 percent of diabetic patients will experience some form of neuropathy, which is a loss in sensation. When they do that they’re more prone to developing a wound. Once they develop a wound it’s a slippery slope, which can lead to amputation. So generally you can expect that you are going to have some percentage of patients that will end up with an amputation. Since 2005 when we started, we’ve had no amputations at all.
And all of that I think is due to the fact that we respond very quickly and we keep our patients monitored very closely. I think that this program, not only the DROP program, but telemedicine in general, is a model for outcome-based medicine.  The physician has better communication and consequently, far more control over patient outcomes.
Beyond the outcome-based medicine, there’s also the cost-benefit. A lower extremity amputation in the life span of a patient can cost almost a million dollars when you factor in surgery, rehabilitation, prosthetics, medication, and that’s not taking into account the financial consequence of disability and loss of independence. For the patient, a diabetic with a lower extremity amputation has a 50% chance of losing the other limb within two years and the five-year mortality rate after amputation is just under 50%.  This mortality rate is actually higher than many types of cancer. If you can prevent amputation, you are saving an enormous amount of money. If I look at our patient load alone, eliminating two amputations saves $2 million. The cost of treating an amputation is too high in comparison to the cost of preventing it.
mhealth360: From what we understand there really is no reimbursement infrastructure for telemedicine or remote doctor visits. Are things changing and are you seeing reimbursement for these models?
Dr. Umansky: Reimbursement is probably the biggest barrier. The people I know who are doing telemedicine are doing it with the idea that they will be able to show insurance companies, Medicare, Medicaid, that this is really saving money.  So right now it’s a goodwill thing, but I think that shortly people will start to realize that telemedicine can save both time and money while providing a better result, and for essentially a very small start-up cost when you consider the cost of disability.
mhealth360: What is your biggest obstacle in this program?
Dr. Umansky: The largest obstacle, I think, is the start-up cost in terms of the hardware, especially since we’re dealing with a lot of patients who are poor and we know we’re not getting reimbursed. So we need to consider, what’s the bottom line and what can we use to get as many monitors out there and do this while keeping costs down. We expect to do that at a fairly low cost and we’ve been successful, but it means reallocating dollars from other places to cover the cost.
For a lot of hospital-based telemedicine practices the equipment they use is more sophisticated than what we have and more costly. I think that may be one of the reasons fewer people are going into it. They’re looking at costs and saying, “Well I’m not sure. I’m not getting reimbursed for this and I don’t know if I want to put out that kind of money just yet.” So right now it will be on the shoulders of the people who are doing it to say the outcomes are well worth it.
mhealth360: Have you used telemedicine for any other diseases or areas?
Dr. Umansky: Actually, we haven’t because this program is aimed at preventing amputations. The first people who I knew that did it were two doctors in Denmark at Aarhus University named Larsen and Clemenson. They monitored foot problems using telemedicine and had great success with it.  In Hong Kong, Prince of Wales Hospital did likewise a few years ago with good results.  In Madrid, a nephrology practice was monitoring home dialysis patients and I have read articles in which telemedicine is being used for cardiology, dermatology, primary care, mental health, post-op follow-ups, the list goes on and on.
mhealth360: Is it a challenge for doctors to balance their time between clinic patients and telemedicine patients? Especially when it comes to reimbursement?
Dr. Umansky: I think that once there’s reimbursement for telemedicine, that’s not going to be a problem. We also use wound care nurses to do a lot of the basic monitoring for us.  If there is a problem developing, the nurses can get that information to us so that appropriate treatment is started immediately. I don’t think it would be possible to devote an inordinate amount of time to monitoring, but the nurses triage the cases and give us the opportunity to treat a problem before it turns into something that needs more radical intervention.
This requires a bit of time management, but once it starts getting reimbursed that will become less of a problem. But for right now it’s setting aside some un-reimbursable time and that is a problem. From the outcome-based standpoint, I think any doctor that is using telemedicine understands how worthwhile it is.
mhealth360: Why do you believe telemedicine hasn’t become more adopted than it is now?
Dr. Umansky: Lack of reimbursement, the cost of implementation, and the time needed to adapt to a different system.  All of those things make it unappealing to someone whose hours are already completely spoken for. From the insurance side, reimbursement will be a thorny issue at a time of exploding health care costs. But if I can go back to our patient who’s leg was amputated, more money was spent on the ambulance ride and the initial ER visit than would have been spent treating that wound for 6 months, assuming we needed that long to close it.
Once it is understood that technology will allow for better care, better outcomes and far better communication between doctor and patient, and at a lower cost, it will also be understood that there is really no down side to it.
mhealth360: What about patient engagement? Does this help with that?
Dr. Umansky: Yes, particularly when you’re talking about people who don’t have access to the healthcare system. This does engage them and makes them part of the system again. We’ve heard from so many people that, “I don’t know how to get in… It’s seventy miles to the nearest doctor… I’m going to have to ask my neighbor.” They don’t have to do that now. We know you’re bedbound and that’s ok, you’re still connected to us and we’re still connected to you. And I think that makes an enormous difference. Not only in outcomes, but also in how patients feel about their care. And how involved they are and I think that’s really important also.
mhealth360: Where do you see the future of this movement going? What about the intersection of mobile health and telemedicine?
Dr. Umansky: Telemedicine is the future of medical care. It is also the gateway to preventive care, which will help screen patients, catch disease processes earlier, allow more immediate implementation of treatment, and save time and money while doing it.  For patients intimidated by doctors and hospitals, it allows a consultation while in familiar surroundings. For caregivers, the transportation burden is lifted. And for people in remote areas, geography becomes far less of a problem.
Will traditional medicine be replaced? No, but it will be transformed as more delivery systems will be developed to bring medicine directly to the patient.  Some of the traditional barriers between doctor and patient will be changed but to the benefit of both. It is an exciting time.
For more about DROP, visit http://www.dropinternational.org/.