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“Wound photography" communicates a universal language that can easily translate across the continuum of care and to the stakeholders involved (patient, family/carers, healthcare professionals and the agencies funding treatment)” (Estocado & Black, 2019).

Images of wounds provide a timeline for monitoring the status of a wound over a period of time. For healthcare providers, it is important to document a wound accurately, descriptively, and timely. The new redesigned workflow process aims to create value for healthcare providers engaging in wound care efficiency.

With the new workflow process, the goal is the elimination of time-processing wound photography with the use of a mobile device with software capability to allow automatic electronic uploading of a wound into the EHR, instead of the current paper documentation process.

The use of wound photography in the EHR will increase the accuracy of documentation and improve the workflow process.

Without the burden of physical documentation to write patients' identification data on paper rulers and fill out information on a wound care document, errors such as image mislabeling or uploading data into the wrong patient’s chart are significantly reduced.

Transition from paper documentation to electronic uploading of wound care photos will save time, prevent errors, and preserve resources thereby, comprehensively improving the overall quality and continuity of patients' wound care.

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The team identified that this facility uses a traditional digital camera to take pics of patients who come to the hospital's emergency department or wound care clinics. This process requires the RN/ARNP/MD to take a photo with a camera, print the image, attach it to the wound care documentation form, place the physical copy in the patient's chart and then upload medical records into the patient chart.

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The new workflow redesign process will significantly improve this by utilizing the healthcare organization's preferred mobile device (iPhone, iPad, Etc.), which can be equipped with software that allows a healthcare provider to take a picture of a wound. Once the picture is taken, it will automatically upload the picture directly into the patient's EHR.

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Faster provider response with ordering medications, consultations, and treatments etc. thus allowing for the care provided by nurses and wound care specialists to be as quick and efficient as possible

Reduced error and improved accuracy in wound care documentation and compliance

Improved patient portal access and added telehealth benefit for patients to upload their own wound care photos online vs coming in person to assess skin breakdown and wounds

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Currently, more than eight million Americans are living with a chronic wound (Onuch et at., 2022). For nurses and physicians, it is important to accurately and descriptively document the wound. The use of photography in electronic health records (EHR) will increase the accuracy of documentation and improve the workflow. The new redesigned workflow process of wound care documentation and use of photos in the electronic health record (EHR) will be improved.

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By creating this workflow, wounds can be regularly photographed and monitored. Closer monitoring produces better outcomes. Patients who have chronic wounds will have the added advantage of watching the progression of their wound both in and out of the hospital.

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The Board of  Directors: for approval of workflow process, authorization of HIPPA regulated mobile devices, and financial support to make the new redesign process feasible.

IT department: for pilot testing and go-live.

EHR team: for software development and support and also help with the transition and integration from paper to electronic documentation with the use of approved mobile devices.

Research department: to help conduct and analyze pre and post workflow implementation surveys.

Pharmacy department: will be important to include as they are involved in medication management and antibiotics administration reports.

Billing and Finance department: will be responsible for reviewing billings related to wound infections.

Health Information Management Systems (HIMS) department: will be responsible for ensuring records are safely maintained, including understanding of wound care digital use in EHR.

Dietary team: Dieticians are subject matter experts when it comes to diet and wound management.

Quality Management department: will be responsible for maintaining and running reports related to hospital acquired infections (HAIs).

Nurses, Wound care specialists, and Doctors: to gather their opinion on the existing workflow and re-designed workflow.

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The Wound Care Camera Project Team (WCC) in collaboration with the Nurse Informaticists team, aligned on a phased approach to implementing wound photography with end-users.

Rollout should begin early fall/winter and complete by the end of year 2022. End-users will start using wound photography based on their primary console view in their current EHR system.

This approach will give end-users a general idea of when they should expect their training dates and go-live dates.

Depending on the end-user role and access to EHR training is expected to last under an hour to accommodate questions and or concerns. (See Appendix D for rollout plan).

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1. The importance of gathering data to measure the results and benefits of the project was considered by the team responsible for the design, development, and execution of the project prior to presentation to the board for approval.

2. An essential piece of data that was revealed, was the time taken to take the wound photograph with a digital camera, print it out, attach it to the paper form, and file it in the chart after copies were made to send to medical records to be scanned later.

3. This tedious documentation process can take approximately 30 to 45 minutes to allow time for a provider to see the wound picture in person, and up to 2 days to be uploaded into the EHR.

4. All of these factors were more than enough to involve staff and administration with the collaboration of IT/HIT to support the project.

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Aldaz, G., Shluzas, L. A., Pickham, D., Eris, O., Sadler, J., Joshi, S., & Leifer, L. (2015). Hands-Free Image Capture, Data Tagging and Transfer Using Google Glass: A Pilot Study for Improved Wound Care Management. PLoS ONE, 10(4), 1–21. https://doi-org.ju.idm.oclc.org/10.1371/journal.pone.0121179

Bail, K. (2020). Documenting patient risk and nursing interventions: record audit. Australian Journal of Advanced Nursing, 38(1), 36–44. https://doi-org.ju.idm.oclc.org/10.37464/2020.381.167

Bansiewicz, T., El-Nogoomi, I., & Swanson, T. (2022). The role of VR technology in wound management and education. Wounds International, 13(2), 42–45.

Billing and Coding: Wound Care (A55818). (2022). Centers for Medicare & Medicaid Services (CMS). Retrieved from https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=55818

Estocado, N., & Black, J. (2019). Ten top tips: wound photo documentation. Wounds International, 10(3), 8–12. https://flickread.com/edition/html/index.php?pdf=5d88c770f0ec6#1

How do I use a rapid-cycle improvement strategy? | HealthIT.gov. (n.d.). Retrieved from https://www.healthit.gov/faq/how-do-i-use-rapid-cycle-improvement-strategy

Jacob, C., Sanchez-Vazquez, A., & Ivory, C. (2020). Factors impacting clinicians’ adoption of a clinical photo documentation app and its implications for clinical workflows and quality of care: Qualitative case study. JMIR MHealth and UHealth, 8(9). https://doi-org.ju.idm.oclc.org/10.2196/20203

Level Up RN. (2019, December 18). Introduction to Wound Care, Skin Assessment on Admission - Wound Care for Nurses | @Level Up RN [Video]. YouTube. https://www.youtube.com/watch?v=CxtEtMbMPXs

McBride, S., & Tietze, M. (2023). Nursing Informatics for the advanced practice nurse: Patient safety, quality, outcomes, and interprofessionalism (3rd ed.). Springer Publishing Company. Kindle edition.

Michigan Medicine. (2015, July 22). How to take helpful clinical photos [Video]. YouTube. https://www.youtube.com/watch?v=Ggh7JhKkntc

Milne, J. (2021). Establishing the benefits of digital consultation pathways in wound care. Wounds UK, 17(4), 68–75.

Mohammed, H. T., Bartlett, R. L., Babb, D., Fraser, R. D. J., & Mannion, D. (2022). A time motion study of manual versus artificial intelligence methods for wound assessment. PLoS ONE, 17(7), 1–14. https://doi-org.ju.idm.oclc.org/10.1371/journal.pone.0271742

Nair, H. K. R. (2018). Increasing productivity with smartphone digital imagery wound measurements and analysis. Journal of Wound Care, 27(sup9a), S12–S19. https://doi-org.ju.idm.oclc.org/10.12968/jowc.2018.27.Sup9a.S12

Onuh, O. C., Brydges, H. T., Nasr, H., Savage, E., Gorenstein, S., & Chiu, E. (2022). Capturing Essentials in Wound Photography Past, Present, and Future: A Proposed Algorithm for Standardization. Advances in Skin & Wound Care, 35(9), 483–492. https://doi-org.ju.idm.oclc.org/10.1097/01.ASW.0000852564.21370.a4

Peters, J. A., & Stamler, J. (2020). How to Transform Your Ambulatory Surgery Strategy for Value-Based Care. Physician Leadership Journal, 7(4), 42–46.

Rose, A. J., Kamil, A., Roberts, E., Hopson, A., & Tehan, P. E. (2022). eHealth interventions for the prevention of pressure injuries: a scoping review protocol. Wound Practice & Research, 30(3), 179–184. https://doi-org.ju.idm.oclc.org/10.33235/wpr.30.3.179-184

Smith, I., Hicks, C., & McGovern, T. (2020). Adapting Lean methods to facilitate stakeholder engagement and co-design in healthcare. Bmj, 368. doi: https://doi.org/10.1136/bmj.m35

WoundRounds. (2015, April 17). WoundRounds Webinar:  Wound Photography for Risk Management [Video]. YouTube. https://www.youtube.com/watch?v=3WDO2fW_Q_o

Wound Photography 101. (2021, November 22). Swift. https://swiftmedical.com/wound-photography-101/

Wynn, M., & Clark, M. (2022). Attitudes of UK based wound specialists towards the use of mobile applications in wound care delivery: a cross-sectional survey. Part 1: quantitative findings. Wounds UK, 18(2), 20–28.

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Current: Current time spent processing and uploading paper wound care form and  photos into EHR can take up to 2 days.

Goal: To reduce wound care photo processing time into EHR from up to 2 days to 1 to 3 minutes via electronic mobile device,  to upload wound care pictures into the EHR.

Improvement %: 100 % improvement rate.

Units: Time; Minutes

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Metric 2: Nursing documentation deficit.

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Metric 2: Nursing documentation deficit.

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Current: Absent or incomplete wound care photo/documentation in patient chart due to paper process

Goal: Improved wound care photo/ documentation compliance due to new electronic process

Improvement %:  90% improvement in compliance rate.

Units: Percent of compliance.

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Current: Staff satisfaction with the paper process is <50%.

Goal: Staff satisfaction with the new electronic process will be >50%.

Improvement %: >50% increase in staff satisfaction rate.

Units: Percent of satisfaction.

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A picture of a wound would provide more information than a written description of the wound. Written descriptions of wounds may not describe the wound accurately, or may unintentionally eliminate characteristics of the wound. Pictures minimize confusion and discrepancies between providers.
This improved workflow will improve care for patients with wounds and may decrease morbidities and mortalities related to wounds. Patients will want to seek care for wounds at a facility that provides great wound care, which will also increase revenue for the facility.

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Healthcare staff benefits from the improved workflow. Wound photography has been shown to save nurses time documenting (Nair, 2018). Once the workflow is efficient, nurses will be able to allocate their time to additional patient care. The added benefit of the visual photos increases the accuracy and understanding of the written documentation.

The provider responsible for prescribing the treatment plan will also have the added benefit of observing the patients wound progress, and make any medication adjustments, if necessary. With the use of photographs in the patients EHR, the provider will also be able to view the wound without removing the dressing, thus decreasing the risk for infection.

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External Customer: The Healthcare Entity

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External Customer: The Healthcare Entity

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Hospital costs will be reduced with faster wound healing. Without the ability to visually compare photos and make necessary adjustments, non healing wounds can cause an increased length in hospitalization.

Taking pictures of the wound area upon hospital admission gives the staff a visual confirmation distinguishing between a preexisting chronic wound and hospital acquired wound. This is important because hospital acquired wounds are not eligible for reimbursement from Medicare or Medicaid (CMS, 2022).

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There will be two ‘real time’ support staff to answer questions for end-users in real time and during business hours.

Outside of business hours end-users will contact their current IT department via EHR Help Request form provided to them.

Using the WCC email provided, end-users will include a detailed description of the issue and any relevant screenshots to make the triage process easier and ensure issues are resolved in a timely fashion.

As a last resort, users will revert to the WCC to report issues by following two steps (Milne, 2021).

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The process aims to create value for healthcare providers engaging in wound care efficiency. In this process, the goal is to eliminate time-processing wound photography. Therefore, the process requires a learning team that aims to identify the needs and wants of the clients while eliminating limitations (Smith et al., 2020).

A qualitative study done by Jacob et al. (2020), found that the use of mobile health tools for clinical photos and wound documentation provides numerous benefits, such as time-saving and efficacy, better patient safety and quality of care, enhanced data security and validation, better collaboration and accessibility, promising potential improvement in wound documentation that is clear and may enhance clinical workflow and quality of care.

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The process eliminates medical professionals from having to write excessive patient data to describe the wound. Instead, the process tags the patients' former wound photographs, who also can upload the pics through the portal application access, to their providers to compare the healing progress and effectiveness of the treatment prescribed. The process aims to reduce crucial errors associated with mislabeling or uploading images to the wrong data chart. In addition, the process will facilitate the transmission of the correct information to the electronic medical records that verifies the identity of the patients through the providers and patients' access portal who used the proper credentials to upload the pics.

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An existing workflow mapping diagram was drafted to analyze and identify the issues and needs that can be modified or updated to improve.

The team identified the best approach is adding an interface or application using smartphones or smart tablet devices that, through an interface/software, can upload pics into the EHR to be added to the e-template for wound documentation.

The process will facilitate the transmission of barcode information to the electronic medical records that verify the identity of the patients (Aldaz et al., 2015).

The process tags the patients' former wound photographs. It aims to reduce crucial errors associated with mislabeling or uploading images to the wrong data chart.

A new workflow mapping design was created involving the team project and staff. The facility’s policy and procedures and the staff responsible for the current tasks were observed.

The staff, who are the first-line providers, were invited to validate the current state flow to avoid overlooking the real needs and obtain feedback for any modifications (Aldaz et al., 2015).

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1. We will test our new workflow process by having the nurses and wound care specialists on the chosen Med-surg floor and ICU, complete a questionnaire regarding their opinion on the existing workflow. This feedback will be collected and analyzed by the research department, and considered and utilized in the new redesigned workflow.
2. With the help of the IT department, we will have a data analyst conduct an analysis of our redesigned workflow to ensure it is ready to be pilot tested in the chosen ICU and Med-surg unit. This will be done to identify the limitations of the new workflow and highlight areas for modification prior to a systemwide go-live among all acute care and critical care floors in the hospital.
3. Once modifications are identified and implemented, we will go-live with the guidance of the EHR support team.
4. Approximately one month after go-live, we will conduct a post-implementation assessment with the same group of nurses and wound care specialists via questionnaires and direct observation of the redesigned workflow in practice and make any necessary changes.

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A nurse educator, IT personnel, and the group team members provide training and support to handle any obstacles during the testing phase.

Since using the device to take the pics, the proper technique to capture the wound under light and from different angles, the uploading process into the EHR, and the appropriate verification of it attached to the patient record.

The provider was observed and supported while retrieving the system's photography to complete the treatment and prescriptions orders to the staff, expediting the process. Therefore, this testing phase can be achieved, and the results accomplished in a reasonable time frame according to the facility requirements stated during the discussion of the redesign project.

A general recorded training will be available. In addition, there will be 5-6 live questions and answers (Q&A) and demo sessions and 1-2 sessions for overnight shifts.

Super users are expected to attend and contribute to these sessions. Pre-and post-LIVE coordination on tasks, readiness, and issue triage will be communicated via email chain provided by the WCC project team.

Daily emails, reminders, tips and tricks, issue communication and links to resources will be available to end-users on go-live date.  This will also include ‘how to’ video links for quick find solutions.

Final user published guide with tips and tricks will be made available on live date. This user guide will be stored at a specific organization SharePoint for all end-users' to access in the future. There will be ample training and documentation available for end-users to adjust at their own pace.

A monthly newsletter will be available and more frequent newsletters and communications as we begin rollout in earnest. In addition, a trained superuser group will be formed  to provide information to their divisions and teams and assist with baselining project metrics (Bail, 2020).

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The group team project members proposed the recommendation to the scheduling department in consensus with providers to decrease patient load during this period.

Those trained during the testing phase were called "superusers" and requested to be assigned to areas to coach users and guide those who can encounter difficulties operating the camera, table, and phone with the installed software.

IT, nurse educators, and nurses informaticist who collaborated with the team were present, making rounds to help to overcome any difficulties.

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The team project will start discussions, monitor areas where the new workflow is used, and gather data and feedback from first-line nurses and providers. This step is crucial to identify deficiencies, gaps, and physical, technical, or human barriers that can impact the workflow process having a lower or negative outcome. After its identification, this analysis will allow the team project to fix or redesign the specific issue, optimizing patient care delivery, which was its initial goal.

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1. What is the current process of wound care photography at your workplace? Do you prefer that process or would you prefer our new redesigned process? Explain why.

2. What recommendations would you suggest that could improve our new workflow process?

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WoundRounds Webinar:  Wound Photography for Risk Management

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Using Wound Photos to Enhance Your Documentation

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Using Wound Photos to Enhance Your Documentation

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Wound photo documentation captures a visual reference and helps provide a timeline for healing status for the patient's medical record. Pictures in wound care can be used to ensure accuracy of measurements, to encourage objective assessments, to reduce the risk of misinterpreting the cause of the wound, as a teaching resource to both patients and new clinicians, and to encourage the use of evidence-based practices. In providing wound care from a distance such as through telewound services, wound photos are taken to help in diagnosis and treatment. The quality of the photo may vary depending on the person taking the photo (clinician, caregiver, patient). However, the emphasis is on using the photo in conjunction with the patient's clinical wound descriptions and medical history, thereby evaluating the wound, treatment plan, and healing progress. ¹⁻³ Clinical documentation is a legal, moral, economic, and professional responsibility. ⁴ Wound photos supplement the written record but should never replace it. ⁵ Despite the value of wound photography, not all health care settings provide wound photo documentation software or include this as a part of their wound care policies and procedures. The facility or agency should always discuss this issue with the risk manager or legal counsel because each state has its own rules on the use of images. ⁶

Photos in Wound Care

Wound photos are valuable for various reasons, including assisting dressing selection, validating healing status, correcting wound classification, and planning care. Wound photographic documentation provides a faster method for injury discovery on admission and date of onset and for reporting progression or regression of wound status. ⁷ Patients are normally asked on admission for consent to photography (photo identification, wound, etc.).

In the past, clinicians took pictures of the wound with Polaroid cameras and would then tape the photo to the patient's chart. Polaroid images did not always have proper lighting, and there was always the risk that the image would become detached from the chart and lost. Additionally, dates and notes on the image would need to be written down in the chart, or possibly on the image itself. Camera technology has evolved into a more streamlined method that helps to facilitate mapping of wound status timelines from admission to discharge. Photos may now be taken with a digital camera and uploaded to the patient's electronic medical record (EMR) or with a smartphone that connects directly to the EMR. ⁷ These methods often automatically record the date the image was taken, and most modern cameras have automatic methods of correcting light exposure to ensure a more accurate picture of the wound.

Tips for Taking Photos of Wounds

Clinicians should be trained effectively in providing consistent photographs. ¹ The policy and procedure for taking wound images during wound assessment should include a systematic process in how to take the best-quality and correct image (lighting, distance), how to label the image, and how to attach the image to the EMR. Duplicated photos, poor-quality photos, and photos not labeled with patient identification should be deleted. ⁷

Wound care photos can be used to help strengthen various areas of a practice for providers and clinicians. Communication between providers and nurses during wound deterioration or changes in wound status can be utilized, but we always need to consider HIPAA compliance. Taking photos has now become part of everyday practice in many facilities (depending on policies) for inclusion in the patient's EMR.

Wound photos help with numerous assessment components, including:

Wound size

Wound depth

Wound tissue and amount (granulation, slough, eschar, epithelial)

Quality of wound edges and the periwound area (maceration, epibole, shape)

Pre- and post-debridement wound status, to validate effectiveness

Using Photos to Create a Timeline of Wound Healing

Photos are a good way to create a timeline and can help identify issues. For example, if a patient under your care with a stage 2 pressure injury is transferred to the hospital and then returns with a stage 3 pressure injury, the wound photos may validate where the pressure injury worsened and may thus allow for further investigation into the quality of care received at the time of wound deterioration. Also, if a nurse documents the stage 2 pressure injury before the patient was transferred and the photo clearly identifies granulation in the wound, the wound should have been documented as a stage 3 pressure injury. Having the photographic evidence of the wound's status would allow for a correction to be made to the documentation and prevent potential accusations of improper care.

If your patient had a previous admission with the same wound, these photos can be helpful in identifying the correct cause of the wound, the date of onset, and progression and regression in healing status. To ensure usable data, the following criteria should be met:

All photos should be attached to a progress note or report.

Take photos before and after debridement.

Number wounds for better tracking.

Take photos of the wound from the same position or angle.

Consider taking images during the following timeframes ⁷:

Admission, the initial head-to-toe skin assessment: Images should be taken within 24 hours to validate when the wound was identified. Consent for photos should be part of the admission process.

New wound: Photos should be taken within 24 hours of wound discovery. Always follow your facility protocol in reporting a new wound.

Weekly wound assessment: Weekly wound assessments should preferably occur on the same day each week, with images of the wound taken at each assessment. Compare wound images to evaluate healing progress.

Discharge: Take wound images before discharge to provide a record of skin and wound status.

Why Photo Documentation is Important in Wound Care

Images should be reviewed for inaccuracies such as inconsistent color, out-of-focus images, and inconsistent orientation. Wound photos will not always be perfect, but they can be used to justify the course of care from a quality of care and reimbursement standpoint, so it is critical to try to take clear and consistent images. The Centers for Medicare & Medicaid Services are known to audit regularly, and wound photos provide supporting evidence.

More than 17,000 lawsuits are related to pressure injuries annually in the United States. It is the second most common claim after wrongful death.8 Proper documentation proving quality of care will help prevent potential legal issues. Wound photography can be used in helping defend medical malpractice cases. Especially in patients with pressure injuries, malpractice lawsuits are most common, and wound photos can assist in validating quality of care, can help protect facilities from legal implications, and ultimately are used as a tool to record the wound location, date, and time validating wound status. ⁹

Always explain to patients the importance of photos as part of their medical record. Explain that photos are used to track their wound progress and support better care. Involve your patients in their wound care when possible and offer to review their wound report and images with them. Use these times as an educational opportunity and to keep patients hopeful by showing them how their wound has progressed toward healing. Discuss healthy tissue versus dead tissue, measurements, and treatment, and strive for positive feedback in adherence to the care plan. Using images may also help the patient and family understand the serious nature of the wound and assist in making choices. ³

When reviewing wound images in a timeline, the provider or clinician can determine whether there is wound healing progress, no advancement toward closure, declination, changes in tissue types and percentages, and changes in periwound health. Some wound assessment and monitoring systems that can be downloaded to the EMR have the capability to compare wound progression data, flag stagnation of wounds, and track healing progress over time. These systems can be used to help evaluate data and streamline the documentation creation process.

Conclusion

Wound photos are paramount in enriching documentation and encouraging better overall patient care. Creating a consistent timeline of wound images enhances identification of issues while providing a way to involve patients in their care. Showing patients their wound progress can lead to better adherence to the care plan and can provide encouragement to patients.

References
1. Bradshaw L, Gregar M, Hooko G. Collaboration in wound photography competency development: a unique approach. Adv Skin Wound Care. 2011;24: 85-92.
2. Hamilton A, Fielder K. Digital Photography in Wound Management. WoundsWest IT Solution - MMeX pilot 2010. University of Western Australia.
3. Wang SC, Anderson JA, Jones DV, Evans R. Patient perception of wound photography. Int Wound J. 2016;13(3):326-330.
4. Applegate MI. Ethics. In: Black JM, Matassarin-Jacobs E, eds. Luckmann and Sorensen's Medical-Surgical Nursing: A Psychophysiologic Approach. 4th ed. Philadelphia, PA: WB Saunders; 2000.
5. Pasqualone GA. The role of photography in the emergency room: an ER nurse's perspective. Polaroid. http://www.polaroid.com/instantevidence/instantevidence_12_02_hc.html. Accessed January 6, 2020.
9. Calianno CA, Martin-Boyan A. When is it appropriate to photograph a patient's wound? Adv Skin Wound Care. 2006;19(7):304-306.
6. Langemo D, Hanson D, Anderson J, Thompson P, Hunter S. Digital wound photography: points to practice. Adv Skin Wound Care.2006;19(7):386-387.
7. Estocado N, Black J. Clinical Practice. Ten top tips: wound photo documentation. Wounds Int. 2019;10(3).
8. Berlowitz D, Parker V, Niederhauser A, et al. Are we ready for this change? In: Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care. Rockville, MD: Agency for Healthcare Research and Quality; 2012; last reviewed 2014. https://www.ahrq.gov/patient-safety/settings/hospital/resource/pressureu.... Accessed January 22, 2021.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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Using Wound Photos to Enhance Your Documentation

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Wound photo documentation captures a visual reference and helps provide a timeline for healing status for the patient's medical record. Pictures in wound care can be used to ensure accuracy of measurements, to encourage objective assessments, to reduce the risk of misinterpreting the cause of the wound, as a teaching resource to both patients and new clinicians, and to encourage the use of evidence-based practices.

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(Michigan Medicine, 2015)

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(Level Up RN, 2019)

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Introduction to Wound Care, Skin Assessment on Admission - Wound Care for Nurses | @LevelUpRN

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NURSE 585-Wound Care Photo Integration Rollout Plan

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Manual Vs Artificial intelligence Methods for Wound Assessment

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Manual Vs Artificial intelligence Methods for Wound Assessment

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Heba Tallah Mohammed,

Robert L. Bartlett,

Deborah Babb,

Robert D. J. Fraser,

David Mannion

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Abstract

Objectives

This time-motion study explored the amount of time clinicians spent on wound assessments in a real-world environment using wound assessment digital application utilizing Artificial Intelligence (AI) vs. manual methods. The study also aimed at comparing the proportion of captured quality wound images on the first attempt by the assessment method.

Methods

Clinicians practicing at Valley Wound Center who agreed to join the study were asked to record the time needed to complete wound assessment activities for patients with active wounds referred for a routine evaluation on the follow-up days at the clinic. Assessment activities included: labelling wounds, capturing images, measuring wounds, calculating surface areas, and transferring data into the patient's record.

Results

A total of 91 patients with 115 wounds were assessed. The average time to capture and access wound image with the AI digital tool was significantly faster than a standard digital camera with an average of 62 seconds (P<0.001). The digital application was significantly faster by 77% at accurately measuring and calculating the wound surface area with an average of 45.05 seconds (P<0.001). Overall, the average time to complete a wound assessment using Swift was significantly faster by 79%. Using the AI application, the staff completed all steps in about half of the time (54%) normally spent on manual wound evaluation activities. Moreover, acquiring acceptable wound image was significantly more likely to be achieved the first time using the digital tool than the manual methods (92.2% vs. 75.7%, P<0.004).

Conclusions

Using the digital assessment tool saved significant time for clinicians in assessing wounds. It also successfully captured quality wound images at the first attempt.

Citation: Mohammed HT, Bartlett RL, Babb D, Fraser RDJ, Mannion D (2022) A time motion study of manual versus artificial intelligence methods for wound assessment. PLoS ONE 17(7): e0271742. https://doi.org/10.1371/journal.pone.0271742

Editor: Kanhaiya Singh, Indiana University Purdue University at Indianapolis, UNITED STATES

Received: April 13, 2022; Accepted: July 6, 2022; Published: July 28, 2022

Copyright: © 2022 Mohammed et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant data are within the manuscript and its Supporting Information files.

Funding: The author(s) received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Chronic wounds are a highly prevalent condition that can significantly diminish patients' quality of life and impose a financial burden on patients and the health care system [ 1]. The ubiquity and impact of chronic wounds has led to them being called the "silent epidemic," affecting a large population in North America, and globally [ 1]. Evidence shows that careful assessment and continuous measurements of a wound using valid and reliable quantitative measurement methods are fundamental to wound care management [ 2- 4]. Various factors such as discoloration, swelling, shape irregularity, and location can impact the ability to define and accurately measure wounds' margins and depth [ 5, 6]. Wound assessment largely depends on evaluating the visual elements of the wound, such as the amount of surrounding erythema, the presence and color of granulation tissue, wound drainage, and accurately measuring the key dimensions of the wound to calculate the wound area and volume. These processes are typically accomplished by traditional methods, such as a photographic image of the wound using a digital camera, a paper-ruler, and a depth probe to determine the key measurements of the wounds [ 7]. However, using these traditional methods in daily practices is not ideal [ 8], especially when measuring irregular wound boundaries [ 9, 10], or unequal distances from the edge of the wound [ 11]. A growing evidence base considers these methods invasive, inaccurate, and time-consuming [ 12, 13].

Swift is a non-invasive digital tool utilizing artificial intelligence (AI) to provide standardized wound assessments. The Swift app uses an FDA-registered fiducial marker to capture scientifically color calibrated images and uses intelligent features to automatically identify wound boundaries, record measurements, accurately calculate surface area, depth and immediately upload and document all this information in patients' charts. Swift's proprietary fiducial marker (HealX) provides true color imaging by compensating for ambient lighting bias. HealX is a small blue adhesive fiducial sticker placed beside the wounds as a point of reference upon evaluation of a wound.

The precision-manufactured HealX design elements help the software calibrate the wound photo for color, lighting and size-all in real time on a smart device. Next, the software automatically and accurately traces the wound and calculates clinically validated measurements. HealX is foundational to ensuring the high accuracy and consistency of these wound image and wound measurements. It helps clinicians capture accurate consistent wound images regardless of the different lighting, body position, or camera setting ( Fig 1).

Swift software with fiducial marker (on the left) vs. traditional methods (right).

Assessing wound areas in different illumination conditions and angles may exhibit color bias leading to incorrect assessments [ 21, 22]. The bias can range from too red (tungsten) suggesting infection, to blue hues (LED) suggesting ischemia, to green hues (fluorescent lighting) suggesting pseudomonas infection [ 23]. The FDA registered Swift fiducial marker compensates for bias and provides a registered distance perspective for comparable image sizing.

The app is designed to capture accurate surface area measurements even for irregular wounds, which cannot be accomplished using the traditional methods. Traditional length and width measurements assume all wounds have rectilinear geometry-which is not the reality.

Swift application provides equitable access to an AI standardized technology that can be used to assess wounds in large and small clinics in both urban and rural settings. Once downloaded, the Swift application does not require the internet to operate. The platform is interoperable with many healthcare systems and can be easily customized and adapt to the clinics' workflow.

Despite the positive perception of integrating with a digital evaluation, published literature on the time saved is limited. Au and colleagues found in their pilot study that Swift technology is faster for measuring than manual methods [ 24]. For clinicians to actively adopt digital technology, these tools must fit within their existing workflows and provide time savings for measuring and charting wounds.

This research project was built on the pilot project conducted by Au and colleagues [ 24]. The study's primary objective was to investigate the amount of time healthcare providers spent on wound assessments in a real-world environment. Specific activities required for wound assessments include labeling wounds, capturing images, measuring wounds, calculating surface areas, and transferring data into the patient's record. A comparison was made using Swift Skin and Wound application vs. manual methods. The study also aimed at comparing the proportion of captured quality wound images on the first attempt by the assessment method.

Material and methods

Study design and setting

The quality improvement time and motion study was conducted at Valley Wound Healing Center (VWHC) in Modesto, California, US to study staff time and resource utilization. VWHC collected data on the time required for nurses to complete a wound assessment on chronic wound patients using manual methods vs. Swift. VWHC has operated since 1990 with over 50 years combined wound experience among their medical staff. VWHC is a self-standing outpatient wound clinic that accepts all types of wounds, including diabetic, venous stasis, arterial, pressure ulcers, surgical wounds, trauma wounds, skin tears, blisters, burns, etc. The centre receives an average of 130 wound patients per day, referred from other specialists, primary care providers, hospitals, and on occasion, self-referrals.

Study participants and data sources

VWHC has seven medical assistants (MAs) and three licensed vocational nurses (LVNs). From a list of all nurses practicing at the VWHC, clinicians meeting the eligibility criteria were invited to join the study. The eligibility criteria allowed licensed clinicians of any age, gender and years of practice who can provide direct wound care and evaluation to patients using both methods during the weekly follow-up evaluation days at the center to participate in the study. Participation was voluntary.

Four MAs and one LVN met the inclusion criteria and agreed to join the study. They were asked to record the time needed to complete a wound evaluation for patients referred for routine wound evaluation on the weekly follow-up days at the clinic. Clinicians implied consent to participate in the study was established when they recorded their time on the data collection sheet provided to them and submitted to researchers. Clinicians were asked to include assessment time of wounds for patients 18 years of age or older with chronic active wounds, including diabetic, venous stasis, arterial, pressure ulcers, surgical wounds, skin tears, abscesses, blisters, and burns. A total of 115 wounds referred to the center on the follow-up days during the study period met the inclusion criteria and were assessed using both manual and digital methods. Wound assessments were carried out over a period of two weeks starting Jan 24, 2022.

No wound measurement data was collected. Patients were informed that the clinicians would document the time they spent assessing their wounds and inform researchers of the time spent, wound type, patient age, and gender. Clinicians only proceeded to document their time if the patient consented verbally and was comfortable with sharing the unidentifiable information.

To maintain confidentiality, each wound assessed in this study was assigned a study ID number by the nurses at VWHC. The study-medical record number (MRN) key was not shared at any point with the research team, leaving no possibility for the researchers to identify the patients. Assessment of wounds was part of the routine care provided at the weekly follow-up days at the clinic. Tracking time did not involve any particular intervention or preparation and did not impact the standard care provided to patients. The institutional board director approved the study protocol.

Data collection process

Clinicians participating in the study were supplied with two data collection Excel TM spreadsheets that included all-wound assessment-related activities necessary to evaluate a wound using the manual methods and the Swift digital application downloaded on tablet or smartphone. The MAs used the spreadsheet to record time for each of the listed activities. In general, the clinicians used the stopwatch application on their phones to time each activity and then they recorded the time in the spreadsheet.

For the manual method, an administrator first prepared the labels necessary to register and assess patients manually. The labels contained the patient's initials, wound number, and date of image. The labels were placed in the camera's field of view. The LVN then recorded the time to complete the labelling process for each patient on the data collection spreadsheet.

For the visual assessment, the MAs used a traditional digital camera to capture images. The recorded time to capture an acceptable image started when the camera was touched and stopped when the image was captured, and the camera was placed back on the counter. The MAs also recorded how many pictures were taken before a clear, acceptable image was captured.

The LVN also recorded the time to transfer the camera SIM card to the computer, the time to review SIM card files, and the time to transfer files to the EMR. The time it took the MAs to measure the wound length and width using the manual paper-ruler method and the time to transfer the measurements to the system and to calculate wound surface area was also timed and recorded by the LVN.

Using Swift for the wound visual assessment, the MAs used the built-in digital camera guided by the HealX adhesive sticker placed beside the wound to capture images. The recorded time started when the iPad was touched and the HealX sticker was placed. Recording the time stopped when an image was captured, and the iPad was placed back on the counter. The MAs also recorded how many pictures were taken before a clear, acceptable image was captured using Swift. For the measurements, the staff recorded the time it took to confirm the measurements and wound surface area automatically calculated by the application. Then the time to transfer the information from the Swift application to VWHC's EMR was recorded ( Fig 2).

To ensure consistency, a sample of eligible ten patients with 14 chronic wounds was selected at random, and each nurse was asked to evaluate the same 14 wounds independently and record the time for each activity needed for the wound assessment using both manual and digital methods. The level of inter-rater agreement on the time required to assess patients by methods was measured. The nurse's total time was compared to ensure uniformity.

Statistical analysis

Data was analyzed using the Statistical Package for Social Sciences (SPSS) (SPSS, IBM Corp, Armonk, NY. Version 28; 2022). The descriptive analysis generated from the numeric age variable and categorical gender, and type of wounds variables were calculated and displayed as frequencies, mean and standard deviations.

An intraclass correlation coefficient (ICC) test was used to determine if there was an agreement between the clinicians' recorded time of different wound assessment activities using manual and digital methods for the 14 wounds. ICC was interpreted based on the Koo and Li, 2016 guidelines where measurements below 0.50 are poor, between 0.50 and 0.75 are considered moderate, between 0.75 and 0.90 are good, and above 0.90 are excellent [ 25].

Additionally, bivariate analyses were conducted, and Paired samples t-test was used to examine whether there was a mean difference in the time to evaluate wounds using a traditional manual method versus Swift's digital application.

The Chi-square and Fisher Exact tests were used to examine whether there was a statistically significant difference in pictures taken once or more to get a clear, acceptable image in the relation to the method of evaluation (manual vs. Swift) per the type of wound. A two-way repeated measure ANOVA was computed to determine the effect of the type of wound on the time required to evaluate the wound using different assessment methods. A 2-sided P-value of <0.05 was considered statistically significant.

Results

Overall characteristics of clinicians participated in the study and inter-rater reliability

Recording the time needed to assess patients' wounds was conducted by four MAs and one LVN. All clinicians were females and their years of practice ranged from 3 to 10 years, with a mean of 5.9 years.

ICC demonstrated a good agreement between clinicians in their recorded time of manually capturing images, ICC = 0.868, (95% CI, 0.76-0.96), P<0.001 and manually measuring wounds ICC = 0.834, (95% CI, 0.78-0.94), P<0.001.

Moreover, ICC demonstrated a moderate agreement between clinicians in their recorded time of capturing images using Swift, ICC = 0.552, (95% CI, 0.52-0.73), P<0.001 and measuring wounds using Swift, ICC = 0.581, (95% CI, 0.53-0.75), P<0.001.

Overall characteristics of patients included for wound assessment at VWHC

A total of 91 patients were assessed for the study. 49 (53.8%) were females and 42 (46.2%) were males. The age of patients ranged from 18 to 90 years, with a mean of 62.8 years.

A total of 115 wounds were identified with a wide range of wound types. Of this total, 32 (27.8%) were venous, 28 (24.3%) were diabetic, 19 (16.5%) were surgical ( Fig 3).

Number of attempts needed to acquire a clear wound image using manual and Swift methods

Overall, acquiring a clear acceptable wound image was significantly more likely to be achieved the first-time using Swift compared to the manual methods (92.2% vs. 75.7%, P<0.004).

The proportion of captured wound images on the first attempt is consistently higher with Swift compared to the manual methods for the different types of wounds. All pressure ulcers (100.0%) were captured with the first picture using Swift compared to only 73.3% using manual methods. However, no significant differences were detected in relation to the evaluation method for the different types of wounds ( Table 1).

Clinician time to complete different activities necessary to evaluate wounds using manual and Swift methods

The average time needed to complete each activity necessary to successfully assess a wound is presented in Table 2. Overall, the average time to capture and access the wound image with Swift was significantly faster by 78% with an average of 62 seconds (P<0.001).

The average time to measure a wound's length and width was similar for the manual and Swift methods, with both taking an average of 25-26 seconds. However, with Swift calculating the surface area automatically, the digital method was significantly faster by 77% at accurately measuring and calculating the wound surface area with an average of 45.05 seconds (P<0.001).

Overall, the average time to complete a wound assessment using Swift was significantly faster by 79% with an average of 2.39 minutes than manual methods (0.54.44 vs. 2.53.15, P<0.001).

In total, slightly more than half of the clinicians' time (54%) was saved assessing 115 wounds using Swift with 2:44:20 hours spent on wound evaluation vs. 5:31:21 hours spent using manual methods.

Time to complete different activities necessary to evaluate wounds using manual and Swift methods by wound type

Table 3 summarizes the average time needed to complete each activity to effectively complete a wound assessment by the type of wound. Overall, the average time to capture and access images with Swift was significantly faster for all types of wounds compared to the manual method (P<0.001). The reduction in average time to complete a visual assessment using Swift was the highest for pressure ulcers with an average saving of 1.10.04 minutes. The time to assess surgical wounds was 1.03.32, venous ulcers was 1.03.12 and diabetic ulcers was 1.00.11 minutes.

The average time to capture wound measurements and calculate wound surface area was significantly faster with Swift for all the wound types (P<0.001).

Overall, the average time to complete a wound assessment using Swift was significantly faster than using manual methods, resulting in an average savings of 2 minutes of clinicians' time per wound across all wound types.

A two-ways repeated measures ANOVA test was computed to determine the effect of wound etiology on the time required to assess wounds using different assessment methods. No statistically significant differences were detected for the two-way interaction between assessment methods for different types of wounds, P = 0.061. However, testing the main effect of assessment methods only showed a statistically significant difference in the time spent assessing wounds between the manual vs. the Swift methods, F = 82.46, P<0.001. Therefore, the time it took clinicians to assess wounds was most likely impacted by the assessment method only even if the type of wounds being assessed changed.

Discussion

The study's primary aim was to quantify the time clinicians saved completing wound assessments using the Swift application vs. manual methods in a real-world clinical setting. The study also compared the need to repeat the capture of wound images in order to get a clear, acceptable picture of the wound by the assessment method. Our findings showed that the AI- based assessment tool was twice as fast. Using Swift automation, the staff completed all steps in about half of the time (54%) normally spent on wound manual evaluation activities. These activities include capturing wound images, transferring to EMR, measuring and calculating wounds.

When designing a digital health tool in healthcare, the technology must meet the user's needs for better utilization and performance impact. Human factors such as visual perception, color discrimination, luminous and contrast discrimination, motor grips, etc., are important contextual factors to efficient device interface and usability characteristics [ 29]. According to the American National Standards Institute and Association for the Advancement of Medical Instrumentation, human factors are the elements that impact physical, sensory, emotional and intellectual capabilities [ 30]. Growing evidence substantiates the importance of ease of use, professional satisfaction, and technology interoperability in optimizing efficiency [ 31]. Swift surveyed clinicians across the US and Canada and assessed their level of satisfaction with Swift workflows and features. Of the 245 responses, 81% were satisfied with the technology, 79% would recommend it to others, and 77% believed Swift meets their clinical needs (unpublished data).

Furthermore, Swift provides an automated approach that improves time to assess wounds while facilitating quality photographic evidence of the wounds healing progress. Our findings showed that clinicians successfully captured quality images of the wounds on the first attempt, 16.5% more often with Swift than manual methods. Evidence shows that quality images are essential to accurately measuring the wound area and tracking wound progress [ 7], an attribute that can support successful pre-authorization claims [ 32].

Unlike Swift's application, using standard digital cameras to capture wound images can present challenges in capturing quality images due to a lack of image calibration that accounts for variable lighting conditions, skin tones and distance the picture is taken from the wound. Altered colours and suboptimal images data common with the standard digital cameras reduces their reliability in supporting effective wound evaluation [ 21, 33- 35].

Pre-authorization of coverage claims, especially for chronic non-healing wounds, can be challenging and differences in processing focus on the clinical criteria of the rendered wound service [ 32]. However, clinicians at VWHC stated that Swift's quality wound images supported claims for insurance payments, with fewer or no denials for reauthorization requests. Langemo and colleagues attested that wound documentation is critical to tracking patients' progress and demonstrating medical necessity [ 36]. They stated that wound images are complementary to written reports. Therefore, quality photographic documentation of wounds assists healthcare facilities in accurately measuring wounds, determining wound stage, assessing progress, selecting treatment, verifying the facility's adherence to assessment best practices and supporting reimbursement processes [ 36].

Reliable wound analytics and documented data are essential to wound assessment practice [ 19]. They provide clinicians with a holistic view of a patient's health status and determine a wound healing trajectory required to develop a quality treatment plan [ 19]. Accurate assessment of the wound healing trajectory is important in determining efficacy of advanced therapies [ 41]. AI-powered technology uses a more standardized format, contents and plan, making it more reliable, accurate, and objective [ 42].

While Swift has established integrations with many Electronic Health Records (EHR) systems, the VWHC EHR and the Swift app were not integrated at the time of the study. Without integration, clinicians had to manually search for their patients in Swift before beginning an assessment and then manually type their notes into the EHR at the end of the assessment. Even without an integration between the Swift app and VWHC's EHR, our finding still demonstrated a 40% faster workflow with an average of 1.38 minutes savings for the total evaluation process with Swift.

Enhancing the documentation process is complex and requires a robust solution to achieve superior outcomes [ 19]. Interoperability of technology can reinforce the benefits of quality technology and maximize its efficiency. Swift is designed as an Application Program Interface (API) which allows for integration into electronic medical records in the hospital, home health and community setting enabling automatic registration of patients and direct data sharing (e.g. PDF reports, discrete data) to be embedded into the patient records.

Limitations

This study provides an insight into the time savings clinicians' have experienced evaluating wounds using Swift-digital AI-powered wound assessment tool compared to the traditional manual methods. The study included 115 different types of wounds and assessed the impact on the same patients using both methods. However, the data set is still limited to wounds evaluated at one ambulatory outpatient clinical setting in the US, limiting the generalizability of our findings. It is worth noting that the number of wound referrals per day to this establishment is large, and the workflow is comparable to other wound care organizations. However, our population could differ from a more complex and mobility-restricted inpatient population.

Our conclusions are drawn from recording the time clinicians spent assessing wounds by the method. The study recruited clinicians who have been assessing wounds for 3-10 years and are quite professional in using the digital methods at their practice. The level of experience and knowledge of using the digital tools might differ at each practice, impacting the estimated time to assess wounds.

Our study used a within-subject design where the same wounds were evaluated using manual and Swift digital tools. Four independent clinicians conducted this approach. However, due to the clinic workflow, the same wounds were sometimes assessed by different clinicians rather than the same one. However, as the concordance on time spent on evaluating patients had little variability among the clinicians, we do not anticipate it affected our recorded time.

Conclusions

Many clinicians' have moved towards using digital tools within their practice settings to improve workflow and capacity. Using Swift saved significant time for clinicians in assessing wounds. It also facilitated a successful capture of quality images of the wounds at the first attempt. Our findings showed modest savings in clinicians' time with Swift when transferring and charting wound files were considered. This highlights the necessity of following a model where digital tools are fully integrated within the healthcare system for more observed savings in clinicians' time and improved capacity. As more clinicians use Swift as the assessment tool to evaluate wounds, more research focusing on time saved to measure and calculate the depth and volume of wounds would provide a broader vision of the capabilities of the tool's enhanced features in evaluating wounds.

Acknowledgments

We would like to thank Taylor Sisk- VWHC human resources for supervising data collection, creating personal labels, reviewing SIM files and transferring the files to systems. A special thanks to Laurie Mauldin, Kassandra Lopez, Lorena Green, Jennifer Spears and Angelica Acedo for capturing wound images, time measurements and recording time needed for the different activities. Thanks also to Dr. Jose L Ramirez-GarciaLuna for his valuable input on the study protocol.

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A time motion study of manual versus artificial intelligence methods for wound assessment

# data[].attributes.attachment_link.description
Objectives This time-motion study explored the amount of time clinicians spent on wound assessments in a real-world environment using wound assessment digital application utilizing Artificial Intelligence (AI) vs. manual methods. The study also aimed at comparing the proportion of captured quality wound images on the first attempt by the assessment method.