3.5.2 Additional suppositions Patients often prefer this form of visit to a face-to-face (physical) visit CMS and private insurers are covering such visits Getting the complete picture of the patient is hard Need for more patient education in general What are best practices?

The WHO defines telemedicine as the provision of remote health care via communication and information technologies.61 There is ample Levels 4 and 5 evidence that telemedicine drastically increased at the beginning of the SARS-CoV-2 pandemic in March 2020. Telemedicine has been used during the pandemic for diagnosis, triage, treatment, surveillance and follow-up care, rehabilitation, and to successfully mitigate the risk of SARS-CoV-2 infection.21, 27, 37, 60, 62-65 With wound care declared nonessential at the pandemic start, virtual visits were quickly organized via telephone calls and video calls, and remote care and monitoring has largely been augmented by the use of artificial intelligence and portable technology to monitor blood pressure, glucose, foot temperatures, and other vital signs relevant to the population with CLTI. The NYU Langone Health system reported that daily telemedicine visits increased from 102 to 801 between 2 March and 14 April 2020. Within 10 days, 70% of ambulatory visits (over 7000 visits) were video visits.67 A 22,900% increase in virtual visits (from 0 to 220) for diabetic foot was reported after just 1 week of implementing telemedicine.37 Among 535 vascular surgeons responding to a national survey of the Society for Vascular Surgery Wellness Task Force in April 2020, 81.3% reported performing virtual ambulatory visits.27 Among 100 plastic surgeons responding to a survey conducted by the American Academy of Facial and Plastic Reconstructive Surgery, 91% reported using telemedicine.63 However, in an international survey of 465 vascular surgeons in 53 countries by the Vascular and Endovascular Research Network, only 29.0% cancelled outpatient visits and only 14.9% reported using telemedicine.65 The marked differences in telemedicine usage among surgeons is likely a reflection of the ‘digital divide’ in health care.60, 66-70 Nearly 40% of all patients in the United Kingdom did not have access to online consultations in 2019 and additional patients were unfamiliar with the technology.69 Elderly, immigrant, and lower-income populations are traditionally considered to have a disadvantage to accessing telemedicine.60, 65, 67-70 The limited availability of broadband and its high costs in some regions are major barriers for the patient population, as well as an inadequate infrastructure for information technology. However, low-to-middle income countries, such as Iran and China, found that the widespread use of smartphones facilitated remote care via social media apps such as WhatsApp, Facetime, and Skype to communicate with their providers.64, 70, 72

Patients are very satisfied with telemedicine, which they perceive as improved care, and it is much more convenient to them as a time-savings alternative to in-person visits and (in many areas) more affordable. They prefer remote care and monitoring due to the major benefit that they do not have to risk exposure to SARS-CoV-2 at a hospital or health centre. Among 3962 patients receiving telemedicine in a large, private academic health network in Santiago, Chile, they reported even greater access to care compared to in-person visits in 2019 (p < 0.001), although access was similar to in-person visits in 2020.73 In Tuscany, Italy, patients with diabetic foot reported on a scale from 0 to 5 that telephone monitoring was useful (mean 4.35), including for the future (mean 4.34).58 In Saudi Arabia, only 6.9% of patients with diabetes thought the quality of telemedicine was less than in-person care.74 Privacy concerns was a major factor in accepting telemedicine in Korea p < 0.001), and data protection must be ensured.67

The coverage and reimbursement of telemedicine visits by CMS, national health systems in the United Kingdom, France, China, and Chile, and private insurers across the globe has greatly facilitated the increased use of telemedicine.21, 73, 75-77 In March 2020, CMS announced that ‘telehealth visits’ are reimbursed at the same rate as in-person visits to further incentivize provider use.21 CMS also reimburses ‘virtual check-ins’, which are brief communications (including text messages) to avoid unnecessary office visits, and ‘e-visits’, which a patient initiates using an on-line patient portal. Private insurers such as BlueCross Blue Shield, Humana, UnitedHealthcare, Cigna, and Aetna are expanding telemedicine coverage.76

The principal barrier to adopting telemedicine among providers is physician unwillingness. In the American Academy of Facial Plastic and Reconstructive Surgery survey, 69.2% of providers identified physical examination as the main difficulty to using telemedicine.63 In wound care, where the physical examination is particularly crucial, providers are concerned that it is very challenging to comprehensively assess the wound using telemedicine if they cannot smell the wound or touch the wound for temperature differences.21, 60 Assessing the wound for edema, depth, undermining, and tunnelling is also difficult using telemedicine. Patients who live alone need assistance with photographing wounds in difficult locations, such as the sacrum.21, 60, 78 It has been suggested that initial wound assessment and complex, ischemia, and/or deteriorating wounds should be seen in-person. However, the evidence supports that assessment via videos and photographs are comparable to in-person assessments and can be used successfully to detect infection and produce good outcomes.21, 68, 79 A standard protocol detailing instructions on how to photograph or video the wound should be provided to the patient, caregiver, or remote provider to ensure appropriate lighting, background for contrast, distancing, ruler positioning, and visual field positioning to optimize the remote wound assessment. A French, Level 2 RCT carried out in 2011 was published during the pandemic that demonstrated that video consultations in wound care had similar healing rates to wound care provided at a wound centre and via home care.79 The 6-month healing rates were 68.5% (61/89; mean 66.8 days) for telemedicine, 64.4% (38/59; mean 69.3 days) for wound home health care, and 62.9% (22/35; mean 55.8 days) for the wound centre. The authors felt the video visit provided an adequate assessment to determine wound management. For difficult and complex cases, CMS reimburses for simultaneous visits during which a wound care provider provides a virtual visit to a home health provider to provide a clear and accurate wound assessment.21 In two case reports, remote consultation between wound care providers and other providers ensured the continuity of care among critical care patients and patients with multiple comorbidities who require hospitalization for reasons beyond wound care.68

Traditionally, the goal of wound care was wound closure.21 During the pandemic, this goal has shifted to wound management to provide good wound care at home, control associated pain, prevent wound deterioration and hospitalizations, reduce emergency department visits, and minimize exposure to the virus by limiting unnecessary in-person visits.21, 37 This means that a healed wound is not the expected outcome, and longer healing times have to be accepted. Before the pandemic, there were no established or comparative best practices in telemedicine in wound care. Over the past year, authors have multiple published triage and treatment algorithms and telemedicine recommendations based primarily on Levels 4 and 5 literature reviews or case reports of their wound centre's overnight experience of shifting to telemedicine.21, 37, 38, 55-58, 60, 80-82 The WCWW model is a geographically fluid telemedicine model that shifts care from the hospital to the outpatient clinic to the physician's office to the home, depending on whether the wound is stable or has complications and/or shows deteriorations.21 In this model and other wound care telemedicine models, there are commonalities reported from which emerges a potential best practice hybrid model that uses triage to integrate telemedicine with home care and clinic/hospital visits. An example of a remote wound care consultation provided by a wound care physician to a home healthcare nurse is depicted in Figure 1. Stable wounds, including uncomplicated venous ulcers, stable PIs, recently healed foot ulcers, and healed amputations should be treated at home via telemedicine, home care, and patient self-care (as appropriate), using culturally appropriate and privacy compliant technology, remote monitoring devices, and home delivery of dressings, medications, and other necessary supplies. If the patient is undergoing self-care at home, with or without the help of a household member, it is important to consider the appropriate offloading device. A removable offloading device is recommended to be used whenever possible in a patient that is highly compliant,57 although total contact casts can be applied by wound care specialists during home visits to ensure optimal offloading.21, 80

A wound care physician provides a remote wound care consultation to a home healthcare nurse. On the computer screen on the right, a digital photograph of the wound was sent by the nurse to the physician to assess. On the computer screen on the left, the nurse, wearing personal protective equipment (a N95 mask) is seen in the patient's bedroom dressing the patient's wound, while the physician guides her through the standard of care process

High-risk, unstable wounds, including those with ischemia, moderate-to-severe infection, and increasing wound size and pain (especially in patients with diabetes), should be treated in-person by a wound care specialist.21, 37, 38, 56-58, 60, 80-82 Limb- or life-threatening infection, especially with diabetes, must be attended to as a surgical emergency. Patients with PAD can participate in telemedicine, but should they develop CLTI, they must be referred to a vascular specialist for in-person care.27, 33 Urgent intervention is required for CLTI; procedures may be postponed for a short time, in patients with peripheral vascular disease with rest pain or tissue loss. Patient hospitalized for wound infections and/or other complications should be discharged as soon as their wound is stable.21, 37, 38, 56-58, 60, 80-82

Because patients with CLTI and/or diabetes are at greater risk of hospitalization due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), this hybrid model also introduces a new opportunity for wound care to be provided via remote consultation between a wound care specialist and the patient's provider to ensure the continuity of wound care during SARS-CoV-2 infection.21, 37, 60, 68 Providers also face ongoing risk of SARS-CoV-2 infection, and so, organizing teams of providers that rotate between in-person contact and remote care is recommended.37 Given the risk providers have to be quarantined at home, the coordination of teams needs to also be fluid. Those who are quarantined without suspected SARS-CoV-2 could still provide remote care from their homes.

For telemedicine to be successful, it is imperative that all patient data are documented in the electronic medical record (EMR) system.37, 68, 72, 74, 76 This will be a challenge where EMRs are not used; more increased coordination between all providers and caregivers will be necessary. Protection of patient data must be guaranteed, and before any remote consultation begins, it is necessary to first confirm the patient's identity and obtain patient (or their caregiver's) consent.37, 67, 68, 72, 74, 76 Upon obtaining patient consent, a remote wound consultation during the pandemic should involve21, 37, 38, 56-58, 60, 80-82: Documentation of medical history (check for neuropathy and ischemia) Patient counselling and education on hygiene and SARS-CoV-2 prevention

Comprehensive wound assessment involving digital wound photographs using a standardized protocol, videos (if appropriate), and importantly ask if the wound has any odour or local heat

All patient data should be documented in their EMR Supervision of wound dressing and cleansing (as appropriate) Identification of high-risk patients requiring immediate referral to a wound centre or hospital for surgery Wound education, especially on wound surveillance, and referral information for the patient in case the wound deteriorates before the next telemedicine visit Identification of SARS-CoV-2 infection or suspected infection; confirm patient has been tested for SARS-CoV-2 or direct patient to nearest testing facility. Remote wound care should be provided until the patient is confirmed to be free of infection; limb-saving surgeries should be carried out using personal protection equipment and strict SARS-CoV-2 protocols.

With patients and/or their caregivers becoming more involved with their care through telemedicine, more patient education is needed. Patient awareness and lack of knowledge of diabetic foot disease was an issue prior to the pandemic, with patients accustomed to surrendering their foot to care at their regular visits with their primary care physician or podiatrist. With the onus now on patients and/or their caregivers at home to take on board advice and regularly look after their feet, a proactive attitude and engagement with the process is required to achieve positive outcomes.21, 37, 38, 56-58, 60, 80-82 Most importantly, it cannot be reiterated enough that patients need to be provided with adequate information on who they can contact if their symptoms are deteriorating, as often urgent intervention may be required, to make telemedicine successful.60, 66-70

Authors have reported that their telemedicine models resulted in reduced hospitalizations and comparable outcomes to in-person visits or before the pandemic.37, 75, 79 However, authors acknowledge that, due to the short-term time horizon of these studies, the long-term consequences of minimizing in-person visits could mean a future increase in incidence of amputations and major surgeries as well as increased mortality. Access of care and quality of care has been restricted by the pandemic, especially among new referrals. New diabetic foot referrals decreased by a worrisome 34.8% at one institutuion.37 While in the postpandemic future, telemedicine may be used with in-person care to improve patient care and engagement; in the context of the pandemic, it must be understood that it is never going to replace in-person care and serves as an urgent alternative care delivery system to ensure that minimal standard of care is provided and prevent serious complications and hospitalizations, whenever possible.

Thus, the drastic increase in telemedicine is confirmed by Levels 4 and 5 evidence, with patients largely preferring virtual visits during the pandemic and private insurers and governments reimbursing these services. While it can be difficult to get the complete picture of the patient, telemedicine can comprehensively assess patients and their wounds. More patient education is still needed. An emerging best practice confirmed by mostly Levels 4 and 5 evidence (and a prepandemic, Level 2 RCT) is a fluid, hybrid telemedicine and home care model that uses triage to provide good care at home whenever possible, while serious cases such as CLTI are treated in-person.