October 19, 2010 (Washington, DC) — An online wound (OW) electronic medical record (EMR) can contribute significantly to a decrease in amputation rates in patients with diabetes and lower extremity wounds, according to a study presented here at the American College of Surgeons 96th Annual Clinical Congress.

Dr. Jason Maggi

Senior author Jason Maggi, MD, from the Department of Surgery at the New York University Langone Medical Center in New York City, said that because of the number of people involved in the care of patients with diabetic foot ulcers (DFUs), a centralized EMR is needed to coordinate patient care.
Such a system allows caregivers to quickly access patient data and to identify pertinent information. In addition, it can be set up to flag information and notify caregivers of a nonhealing wound. “Effective management of this information and analysis of data in a timely fashion can mean the difference between limb salvage and amputation,” Dr. Maggi said.
Previous work by Harald Brem, MD, and colleagues determined factors associated with the healing of DFUs (Wound Repair Regen. 2009;17:657-665). Updated data showed that of 274 patients with DFUs, 27 patients underwent 30 minor and 16 major amputations. Patients had multiple pathogens on deep tissue culture, and only 3 did not have evidence of osteomyelitis or peripheral arterial disease.
For his study, Dr. Maggi entered data on all patients with diabetes and lower extremity wounds and at least 2 documented entries in the OWEMR over a 6-month period; there were as many as 137 patient variables for each record. The investigators performed a retrospective review of the outcomes of the DFUs. Included in the record were patient demographics, medical history (including specific comorbidities and condition of the wound), laboratory values, wound characteristics, digital imaging, and tracking of the wound over time. Also included were vascular assessment variables (including noninvasive testing and radiographic imaging) and all culture and pathology results.
The investigators identified 34 consecutive patients with a total of 46 diabetic wounds, 4 (8.7%) of which progressed to amputation, all at the level of the toe. “All amputees had evidence of osteomyelitis on pathology [compared with] 21% of the nonamputees,” Dr. Maggi reported. There were no significant differences upon presentation in age, sex, serum albumin, glycated hemoglobin, or white blood cell count between the patients who proceeded to amputation and those who did not.
An online database of EMRs “can contribute greatly to decreasing amputation rates in these patients,” Dr. Maggi concluded. “The significance of this EMR is that it integrates quantitative measures [such as] healing rates and other relevant clinical data in real time. This is currently done with an automated alert system to all clinicians involved in a patient’s care, through . . . email alerts and Blackberries, of any change in a patient’s status — [from] radiology reports, culture reports, and vascular testing.”
Such a system provides an objective quantitative evaluation of the wound, with sequential measurements and digital photography over time to determine the effectiveness of therapy. “It’s a single-screen summary . . . with the push of 1 button to centralize all the information,” Dr. Maggi said.
He referred to previous literature describing the advantages of such systems as decreasing cognitive load, decreasing the time needed to review multiple sources of information by consolidating data onto a single page, and presenting visual data and trends that are easier to retain. He showed an example of a 1-page OWEMR report that contained a list of medications, medical history, significant laboratory results, culture, radiology, vascular testing, pathology reports, and digital photos of a wound over time to illustrate the trend.
For the future, Dr. Maggi said the idea will be to provide clinicians with evidence-based treatment options in addition to the clinical changes. If the clinician wants to follow another path, he or she can enter it into the record (and track outcomes) to expand the database into an expert system.
The investigators are planning a randomized controlled 12-site clinical trial to assess the OWEMR with a clinical alert system as a clinical intervention tool to prevent amputations resulting from DFUs. They have funding from 3 federal sources and the goal to develop an online informatics tool to coordinate protocol-based treatment and to provide evidence-based clinical decision support to decrease amputation rates.
Session moderator Danielle Katz, MD, associate professor of orthopedic surgery at SUNY Upstate Medical University in Syracuse, New York, commended the study, and said: “This could be the future of medicine. . . . I think more and more there will be a push to have applicable practice guidelines [and] methods for tracking outcomes, and I think this really demonstrates a very potentially useful tool.” She said she awaits the results of the prospective study to see if it changes outcomes, and added that “this is a really important area of research for us to be involved in before things get dictated to us in terms of how we practice medicine.”
Dr. Maggi and Dr. Katz have disclosed no relevant financial relationships.
American College of Surgeons (ACS) 96th Annual Clinical Congress: Abstract SF-10. Presented October 5, 2010
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