A smartphone-based teleconsultation system for the

management of chronic pressure injuries

Changsik Pak, MD1; Ji In Jeon, MD1; Hyeonwoo Kim, MD1; Jungyoon Kim, RN, PhD1; Suyeon Park, RN1;
Ki-hwan Ahn, PhD2; Yeon-joo Son, BS2; Sooyoung Yoo, PhD3; Rong-Min Baek, MD, PhD4;
Jae Hoon Jeong, MD, PhD1 and Chan Yeong Heo, MD, PhD4*
1. Department of Plastic and Reconstructive Surgery, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea,
2. Department of Technology Development, KT R&D Center, Seoul, Republic of Korea,
3. Center for Medical Informatics, Seoul National University Bundang Hospital, Gyeonggi, Republic of Korea,
4. Department of Plastic and Reconstructive Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea

Reprint requests:
Chan Yeong Heo, Department of Plastic
and Reconstructive Surgery, Seoul National
University College of Medicine,
103 Daehak-ro (Yeongeon-dong), Jongno-
gu, Seoul 03080, Republic of Korea.
Tel: +(82) 31-787-7222;
Fax: +(82) 31-787-4055;
Email: lionheo@snu.ac.kr
Manuscript received: April 3, 2017
Accepted in final form: August 27, 2018
DOI:10.1111/wrr.2
Jae Hoon Jeong and Chan Yeong Heo
contributed equally to this article as
corresponding authors.
ABSTRACT
We investigated the accuracy of pressure injury evaluation using tele-devices and
examined the concordance between automatically generated recommendations and
primary manual recommendations. Caregivers took photos and videos of pressure
injuries using smartphones with built-in cameras and uploaded the media to the
application. The wound team evaluated the wound using a specially modified ver-
sion of the Pressure Sore Status Tool. This was compared with the Pressure Sore
Status Tool score assessed during the actual examination of the patient. We devel-
oped an automatic algorithm for dressing based on the Pressure Sore Status Tool
score, checking for consistency between this and the primary manual recommenda-
tion. A total of 60 patients diagnosed with pressure injuries were included. The κ
coefficients indicated substantial agreement for wound size and total score, and
excellent for all other items. We found that the overall concordance rates were sta-
tistically significant for all items (p < 0.001). For the primary dressing, the κ coeffi-
cient for the concordance rate of automatic algorithm and manual recommendation
was 0.771, while that of teleconsultation system and manual recommendation was
0.971. For the secondary dressing, the figures were 0.798 and 0.989, respectively.
All values were statistically significant (p < 0.001). We presented strong evidence
documenting the utilization of a smartphone, patient-driven system, and demon-
strated that the measurements obtained were comparable to the ones obtained by a
trained, on-site, wound team. Furthermore, we confirmed agreement between auto-
matically generated recommendations and primary manual recommendations.

INTRODUCTION chronic diseases. Generally, these patients require continuous,

In the past, there were various attempts at teleconsultation of
patients using the telephone. More recently, there have been
great advancements in teleconsultation due to the widespread
use of the World Wide Web.1 It is now possible to aggregate
and transmit medical information via the Internet, using plat-
form infrastructure and smartphone applications that can col-
lect and manage an enormous amount of data. Moreover,
efforts are ongoing to develop smartphone applications for
efficient diagnoses and treatments,2–4 which have allowed
both physicians and patients to more effectively manage med-
ical information.5 U-health (ubiquitous health), m-health
(mobile health), and teleconsultation are efficient tools for
patient evaluation, diagnosis, and treatment. They are also
effective in reducing medical expenses.6,7
Recently, there has been growing interest in geriatric and
chronic diseases, with efforts made to minimize the cost and
time associated with treating patients with chronic diseases,
particularly the elderly. A complete cure is typically infeasi-
ble based only on short-term treatment for patients with
meticulous monitoring of their clinical course. We believe
that teleconsultations may contribute to improving quality of
life and shortening the length of hospital stay and treatment
period of patients with chronic disease, thereby proving to be
a useful tool for the health care industry.8 Although there are
studies on teleconsultation for some diseases, there have not
been substantial efforts to make smartphone applications
commercially available for chronic wound management.6,9–13
We found some reports on the effectiveness of smartphone
application-based teleconsultation for the diagnosis of injuries
and wounds, based on assessments of the concordance rate
with traditional in-person examinations.6,14 However, most
reports focused on the degree of patient satisfaction.
Patients with pressure injuries, and especially chronic
wounds, are vulnerable to severe symptoms, which may
API Application programming interface
PSST Pressure Sore Status Tool
WOC Wound, ostomy, and continence

Wound Rep Reg (2018) 26 S19–S26 © 2018 by the Wound Healing Society S19
Teleconsultation of chronic wound management Pak et al.

result in poor quality of life for both patients and their care-
givers. It is therefore crucial to treat patients with pressure
injuries appropriately.15 When monitoring the clinical course
of patients with chronic pressure injuries, it is important to
achieve prompt recovery from symptoms, thereby minimiz-
ing the need for in-hospital intervention.
Consequently, we developed chronic pressure injury tele-
consultation methods based on a smartphone store-and-
forward system. Using information that patients and care-
givers sent, a doctor would make a diagnosis remotely. In
addition, the system was capable of automatically recom-
mending a diagnosis-based treatment. We investigated the
accuracy of the pressure injury evaluation via tele-device, and
examined the agreement between the automatically generated
recommendation and the primary manual recommendation.
METHODS
Study population
Patients undergoing outpatient treatment were selected from
a group of patients diagnosed with pressure injuries in the
plastic surgery clinic. Only patients who were 21 years of
age or older with a wound less than 100 cm2 were included.
The following patients were excluded: patients diagnosed
with osteomyelitis who had not yet been treated, patients
with fistulae, patients who had participated in other drug
studies within a month of this study, and patients considered
by the researchers to present difficulties for participation in a
clinical trial.
addition, we chose the iPhone, which offered the best secu-
rity available at the time, and designed the system to delete
the data from the mobile device following transmission.
Data were collected, monitored, and analyzed, and feed-
back was obtained in accordance with the standards of the
National Pressure Ulcer Advisory Panel and its Korean
equivalent, the Bundang Pressure Ulcer Advisory Panel. The
feasibility of the system was assessed through the collabora-
tion of a Wound, Ostomy, and Continence (WOC) nurse, a
plastic surgeon, and a researcher.
Data collection (mobile device)
Pressure injuries are commonly diagnosed through a gross
examination, for which the data can be collected simply by
using the built-in camera of a smartphone. For the current
study, we used the standard touch screen user interface and
camera installed in the iPhone 3GS and iPhone 4, with iOS
3.0 and iOS 5.0 operating systems, respectively.
(1) Measurement of pressure injury size
Caregivers of patients were instructed to remove the
wound dressings and expose the wound sites for photo-
graphs. At this time, attempts were made to examine the
amount of exudate at the wound sites. Caregivers were then

Study oversight
This study was a single-institution trial to test the accuracy
of pressure injury evaluation via tele-device, and to examine
the agreement between the automatically generated recom-
mendation and the primary manual recommendation. Each
patient visited a hospital once a week for 4 weeks; a total of
four evaluations were made per patient. The current study
was approved by the Institutional Review Board (IRB) of
Seoul National University Bundang Hospital (IRB # E-
1006-050-001, E-1106/063–005, and E-1206/158–001), and
all patients and legal guardians provided written informed
consent to participate.

Study design
System protocol
Our system followed a design-implementation-evaluation
developmental cycle. Design and implementation were
based on data collection, monitoring, analysis, and feed-
back.16 The system was designed to measure and process
biometric data, and to detect changes in biological markers
associated with the health status of patients, using a smart-
phone interface. In addition, it alerted patients to changes in
their health status and transmitted relevant information to
physicians (Figure 1). This study linked the electronic medi-
cal records of Seoul National University Bundang Hospital
network, and the information was stored on the hospital’s
servers. As a result, the data received the same level of pro-
tection as the other medical records. Not only did we
enhance the security of the application itself, but also we
prevented developers from accessing patient information. In
Figure 1. System diagram. The staff portal/ OS terminal on
the first line is the cyber space where the users upload infor-
mation. In the second telemedicine server, the API layer
serves to receive user-uploaded information. The control layer
analyzes and processes user-uploaded information. The data
access layer allows the processed information to be stored in
the data center. The third database is a space where various
data are stored. OS, operating system; HTTPS, hypertext
transfer protocol over secure socket layer; XML, extensible
markup language; API, application programming interface;
WAS, web application server; DBC, database connectivity.

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Pak et al. Teleconsultation of chronic wound management

instructed to transmit the photographs. The size of the pres-
sure injuries was automatically measured using a 1 cm × 1 cm
indicator on the screen. Automatic size measurement was
performed by touching the screen and dragging or dropping
the indicator, thereby modifying its movement and eventu-
ally adjusting the recorded size of the pressure injury
(Figure 2a). The resolution of the iPhone 3GS camera sen-
sors was set to 3,000,000, while the resolution of the iPhone
4 camera sensors was set to 5,000,000 pixels.
(2) Videography
It is impossible to grossly examine the depth and direction
of wounds using two-dimensional images, and difficult to suf-
ficiently examine a pressure injury using a single still image.
Clean swabs were therefore used to sweep around the edges
of the deepest point of the pressure injury in each direction
for the purposes of presenting the depth of the wound on the
video. The function of the video or the system was designed
to run and exit the program using the touch screen user inter-
face, for which the video settings of the iPhone 3GS and
iPhone 4 were optimized at 30 frames per second at a resolu-
tion of 640 × 480 and 640 × 940 pixels, respectively.
(3) Medical examination
The degree of recovery from a pressure injury is depen-
dent on baseline characteristics, and different types of dress-
ing are recommended based on infectious symptoms.17 We
used a patient-reported questionnaire and caregiver informa-
tion to collect patient data regarding the presence of infec-
tious symptoms. These baseline characteristics were
collected during the initial registration and then saved as part
of each user’s profile. Data were entered via an onscreen
keyboard or voice recording, the latter being an option for
elderly patients who are often inexperienced in entering text
via an iPhone touch screen interface. Additionally, patients
could obtain further information from the researcher using
an open question format.
Remote physician evaluation and recommendation
Patient data were transmitted from the smartphone to a web-
site via an open application programming interface (API).
From the website, physicians monitored baseline characteris-
tics, prescription and treatment data, and types of dressing.
(1) Wound evaluation
One plastic surgeon, one WOC nurse, and one researcher
grossly examined the wound sites of each patient and
assessed the pressure injuries. We evaluated the wounds
using a specially modified version of the Pressure Sore Sta-
tus Tool (PSST), which comprised 13 questions; in an
attempt to obtain the wound scores (Table 1). Subsequently,
caregivers transmitted images, videos, and other relevant
information concerning the pressure injury to the website
via a smartphone (Figure 2b). The same information was
also collected through teleconsultation, which was used for
comparison. The evaluators were blinded to all information
other than wound-related data in order to minimize bias in
determining the concordance rate.
(2) Automatically generated recommendation
Based on PSST scores and algorithm design, specific
dressing types (primary dressing for packing dead space,
secondary dressing for covering) were recommended and
transmitted to patients. To ensure patient safety, the recom-
mendations were reviewed and approved by physicians. If
applicable, physicians forwarded the recommendations to
patients after making modifications through a click reaction.

Figure 2. Data collection and physician evaluation. (A) Caregivers of patients were instructed to transmit the photographs. The
size of the pressure injuries was automatically measured by a 1 cm × 1 cm indicator on the screen. Automatic size measure-
ment was performed by touching the screen and dragging or dropping the indicator, thereby modifying its movement and even-
tually adjusting the recorded size of the pressure injury. (B) The wound team checked all PSST items based on the information
the caregiver sent. Medical staff who wished to confirm the explanation could obtain information by clicking on the separate link
window labeled “help.” PSST, Pressure Sore Status Tool.

Wound Rep Reg (2018) 26 S19–S26 © 2018 by the Wound Healing Society S21
Teleconsultation of chronic wound management Pak et al.

Table 1. Pressure Sore Status Tool (PSST)

Items Criteria

1. Size 1 = Length × width < 4 cm2

2 = Length × width = 4–16 cm2
3 = Length × width = 16.1–36 cm2
4 = Length × width = 36.1–80 cm2
5 = Length × width > 80 cm2
2. Depth 1 = Nonblanchable erythema on intact skin
2 = Partial-thickness skin loss involving epidermis and/or dermis
3 = Full-thickness skin loss involving damage or necrosis of subcutaneous tissue; may extend down to, but
not through, the underlying fascia; and/or mixed partial and full-thickness and/or tissue layers obscured by
granulation tissue
4 = Obscured by necrosis
5 = Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or
supporting
6 = Suspected deep tissue injuries
3. Edges 1 = Indistinct, diffuse, none clearly visible
2 = Distinct, outline clearly visible, attached, even with wound base
3 = Well-defined, not attached to wound base
4 = Well-defined, not attached to base, rolled under, thickened
5 = Well-defined, fibrotic, scarred or hyperkeratotic
4. Undermining 1 = Undermining <2 cm in any areas
2 = Undermining = 2–4 cm involving <50% of wound margins
3 = Undermining = 2–4 cm involving >50% of wound margins
4 = Undermining >4 cm in any areas
5 = Tunneling and/or sinus tract formation
5. Type of necrotic tissue 1 = Invisible
2 = White/Gy nonviable tissue and/or nonadherent yellow slough
3 = Loosely adherent yellow slough
4 = Adherent, soft, black, eschar
5 = Firmly adherent, hard, black eschar
6. Amount of necrotic 1 = None visible
tissue 2 = <25% of wound bed covered
3 = 25%–50% of wound covered
4 = 50%–75% of wound covered
5 = 75%–100% of wound covered
7. Type of exudate 1 = Nonbloody
2 = Serosanguineous: thin, watery, pale red/pink
3 = Serous: thin, watery, clear
4 = Purulent: thin or thick, opaque, tan/yellow
5 = Foul purulent: thick, opaque, yellow/green with odor
8. Amount of exudate 1 = None
2 = Scant
3 = Small
4 = Moderate
5 = Large
9. Skin color surrounding 1 = Pink or normal for ethnic group
wound 2 = Bright red and/or blanches to touch
3 = White or gray pallor or hypopigmented
4 = Dark red or purple and/or nonblanchable
5 = Black or hyperpigmented

(Continues)

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Pak et al. Teleconsultation of chronic wound management

Table 1. (Continued)

Items Criteria

10. Peripheral tissue 1 = Minimal swelling around wound

edema
11. Peripheral tissue
induration
12. Granulation tissue
13. Epithelialization
2 = Nonpitting edema extends to <4 cm around wound
3 = Nonpitting edema extends to >4 cm around wound
4 = Pitting edema extends to <4 cm around wound
5 = Crepitus and/or pitting edema extends to >4 cm
1 = Minimal firmness around wound
2 = Induration <2 cm around wound
3 = Induration 2–4 cm extending to <50% of the adjacent areas to the wound
4 = Induration 2–4 cm extending to >50% of the adjacent areas to the wound
5 = Induration >4 cm in any areas
1 = Skin intact or partial-thickness wound
2 = Bright, beefy red; 75%–100% of wound filled
4 = Pink and/or dull, dusky red and/or fills <20% of wound
5 = No granulation tissue present
1 = 100% of wound covered, surface intact
2 = 75%–100% of wound covered and/or epithelial tissue
extends>0.5 cm into wound bed
3 = 50%–75% of wound covered and/or epithelial tissue
extends to <0.5 cm into wound bed
4 = 25%–50% of wound covered
5 = <25% of wound covered

When patients had a body temperature of >37.8  C, they Outcome measures

were automatically advised to immediately consult a physi-
cian. Patients who had no fever or a temperature of
<37.8  C were given 6 points for Question 2, “depth,” and
then asked to respond to Question 3, “edges.” Patients with
a total score of 1 point (“indistinct,” “diffuse” or “not
clearly visible”) were advised to use a heavy dressing.
Patients with a total score of >2 points were advised to
visit the hospital. Patients with a score of <5 points for
Question 2, “depth,” were asked to respond to Question
10, “peripheral tissue edema.” Patients with a total score of
>5 points were advised to visit the hospital. Patients with a
total score of 3–4 points were generally advised to use an
antimicrobial dressing. According to data, such as the
amount of exudate (Question 8), the amount of necrotic tis-
sue (Question 6), and the degree of epithelialization
(Question 13), patients were advised to secondarily use a
light or heavy hydrocolloid dressing, or a light or heavy
foam dressing.
Patients with a body temperature of <37.8  C, a score of
<5 points for Question 2, “depth,” < 3 points for Question
10, “peripheral tissue edema,” and no notable findings other
than fever upon medical examination were generally advised
to use an antimicrobial dressing.
Patients with a body temperature of <37.8  C, a score of
<5 points for Question 2, “depth,” < 3 points for Question
10, “peripheral tissue edema,” and no notable findings upon
medical examination were advised to respond to Question
7 (type of exudate), Question 8 (amount of exudate), Ques-
tion 2 (depth of wounds), Question 6 (amount of necrotic
tissue), Question 13 (degree of epithelialization), and Ques-
tion 9 (wound skin color).
The primary efficacy variable was the rate of concordance
between PSST scores obtained by the mobile device and by
a trained on-site wound team. The secondary efficacy vari-
ables included the dressing type agreement rate between the
automatically generated recommendation and the primary
manual recommendation by the wound team, and the pres-
sure injury wound recovery rate.
Statistical analysis
Statistical analysis was performed using SPSS software ver-
sion 18.0 (SPSS Inc., Chicago, IL). To analyze the internal
consistency of the PSST, we evaluated the reliability of
PSST scores at a Cronbach’s α coefficient of 0.839. We also
used Cohen’s κ coefficient and percentage to analyze the
rate of concordance. Statistical significance was set at
p < 0.05, p < 0.01, and p < 0.001.
RESULTS
In the current study, the patients were enrolled from August
1, 2010 to September 2, 2012. We collected data from a
total of 60 patients with pressure injuries, who each visited a
hospital four times throughout the 248 sessions of data col-
lection. Our clinical series of patients were comprised of
seven cases of death and two cases that were lost during
follow-up due to loss of data. Therefore, we finally analyzed
239 data sets.
We assessed concordance rates for wounds based on the
scores of 13 questions on the PSST scale. We measured the

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Teleconsultation of chronic wound management Pak et al.

Table 2. Concordance of pressure injury assessment

Variables (N = 239) Reliability Kappa (p) Accuracy (%)

Size 0.726 (p < 0.001) 87.9

Depth 0.919 (p < 0.001) 94.6
Edges 0.866 (p < 0.001) 90.0
Undermining 0.887 (p < 0.001) 92.5
Type of necrotic tissue 0.924 (p < 0.001) 95.8
Amount of necrotic tissue 0.872 (p < 0.001) 90.0
Type of exudate 0.936 (p < 0.001) 96.2
Amount of exudate 0.813 (p < 0.001) 85.8
Skin color surrounding wound 0.946 (p < 0.001) 96.2
Peripheral tissue edema 0.916 (p < 0.001) 96.7
Peripheral tissue induration 0.830 (p < 0.001) 93.7
Tissue granulation 0.881 (p < 0.001) 92.1
Epithelialization 0.949 (p < 0.001) 97.1
Total score 0.706 (p < 0.001) 58.2

degree of consistency based on Cohen’s κ coefficient, as DISCUSSION

proposed by Landis JR and Koch GG: κ coefficient < 0 indi-
cated poor consistency; 0 < κ coefficient < 0.20, slight con-
sistency; 0.20 < κ coefficient < 0.40, fair; 0.41 < κ
coefficient < 0.60, moderate; 0.61 < κ coefficient < 0.80,
substantial; and 0.81 < κ coefficient < 1.00, excellent.18 The
κ coefficients indicated substantial agreement for wound size
and total score, and excellent for all other items (Table 2).
We found that the overall concordance rates were statisti-
cally significant for all items (p < 0.001).
We checked the concordance rate for type in primary
dressing and secondary dressing. For the primary dressing,
the κ coefficient for the concordance rate of automatic algo-
rithm and manual recommendation was 0.771, while that of
teleconsultation system and manual recommendation was
0.971 (Table 3). For the secondary dressing, the figures were
0.798 and 0.989, respectively. All values were statistically
significant figure (p < 0.001).
Of the 60 patients, 52 recovered or remained with a
wound, and the PSST score decreased to a maximum of
17 points. On the other hand, the wounds of eight patients
worsened during the study.
This study was developed to establish a standard pressure
injury management protocol in a teleconsultation setting to
minimize deviation from recommended wound care prac-
tices in a nonhospital, teleconsultation setting, with the aim
to improve the overall quality of wound care. We presented
strong evidence documenting the utilization of a smart-
phone, patient-driven system, and demonstrated that the
measurements obtained were comparable to the ones
obtained by a trained on-site wound team. Furthermore, we
confirmed agreement between automatically generated rec-
ommendations and primary manual recommendations. In
addition, we noted high satisfaction levels among caregivers
and medical staff, along with an improvement in caregivers’
medical knowledge. In fact, we can confirm that after getting
accustomed to the system, caregivers were capable of doing
a fairly accurate PSST assessment.
This system aims not only to promote the monitoring and
management of pressure injuries but also to facilitate the
wound healing process. To this end, we developed a variety
of additional functions in the application: The system is

Table 3. Concordance of recommendation for wound dressing

Variables (N = 239) Reliability Kappa (p) Accuracy (%)

Primary dressing Automatic algorithm vs. Manual 0.771 (p < 0.001) 84.0
recommendation
Teleconsultation system vs. Manual 0.971 (p < 0.001) 98.1
recommendation
Secondary dressing Automatic algorithm vs. Manual 0.798 (p < 0.001) 92.6
recommendation
Teleconsultation system vs. Manual 0.989 (p < 0.001) 99.6
recommendation

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Pak et al.
designed to remind patients to adjust their position at 2 hour
intervals to prevent the aggravation of pressure injuries. It
also provides information on prescription data, wound dress-
ing methods, and medical examination results in text form.
In addition, it allows patients to access information in a
diary format by date, in which the latest recommendation
for dressing materials appears at the beginning. Our system
also incorporates nutritional data to help develop patient-
specific knowledge based on the Clinical Decision Support
System. Patients feel comfortable when they are aware that
their clinical course is being monitored meticulously and
continuously in a teleconsultation setting, which in turn may
increase their adoption of the system.15
This system has several strengths. First, mobile devices
are widely used, so patients and caregivers do not have to
buy extra equipment. Patients can save a great deal of
money and time. It is possible to eliminate problems that
may occur when moving. Most importantly, the degree of
user convenience is relatively high among caregivers who
are familiar with currently available smartphones. Second, in
this study, the virtual examination was designed to be as
accurate as possible through the use of both images and
video of the wounds. It is difficult to sufficiently examine
pressure injuries using still images alone. Third, the differ-
ence between actual size and measurement was minimized
according to users, by a tool that could objectively measure
wound size.
The authors recommend that telemedicine researchers
address security concerns to increase the availability of tele-
medicine services and improve the quality of care pro-
vided.19,20 Security issues should be eliminated at every
stage: database server, application, and mobile device. It is
important to store data on a secure hospital server and the
data should receive protection that is at least equal to or
higher than that of the other medical records. From the
beginning of the application’s development, researchers
must collaborate with researchers in security and associated
fields. In this process, we prevented even developers from
accessing medical information. Nevertheless, there are limits
to the security of mobile devices, because they use machine-
based security systems; if the mobile device is hacked, pro-
tection may not be possible. For this reason, researchers
should choose the device that offers the best security avail-
able. In addition, we recommended designing the system to
delete the data from the mobile device following transmis-
sion (store-and-forward system). We are in full agreement
with concerns about security, the most important obstacle to
the development of telemedicine, and must strive for ade-
quate protection in the future.
There is an argument related to the cost of telemedicine.
Costs vary greatly depending on the medical environment of
a given country. Cost may have an impact on the effective-
ness of teleconsultation. For telemedicine to be widely used,
appropriate medical fees must be set up through social
agreement.
There are several limitations to this study. First, diagnos-
ing and treating wounds solely on the basis of a virtual
examination is not easy, even though we did the best we
could with 2D images. If the camera module is developed, it
will serve to complement this part. The 3D image analysis
technology with scenes, for example, in which the therapist
presses the surrounding tissues when shooting the video,
could be used to reduce the score difference and increase the
Wound Rep Reg (2018) 26 S19–S26 © 2018 by the Wound Healing Society
Teleconsultation of chronic wound management
matching rate of virtual and on-site PSST. Further studies
are required to design a system that can make decisions
based on a combination of various data, rather than virtual
images alone. Second, we unfortunately could not measure
the exact cost of the system in this study, because the medi-
cal fee for telemedicine had not been established in our
country to provide evidence of cost-effectiveness. In Korea,
it usually costs about $200 to travel to the hospital four
times, so there is likely to be a certain degree of cost sav-
ings. Third, we could not apply this system to all chronic
wounds. It works well when applied to stable chronic
wounds, but it is difficult to use when the wound necessi-
tates urgent care, or emergent interventions are required due
to aggravation or sudden worsening. Fourth, there may be a
bias depending on education level, familiarity with smart-
phones, and the clinical conditions of caregivers. There is a
specificity of telemedicine that involves the interaction
between the patient and the physician using the devices. We
attempted to simplify the procedures that caregivers must
follow for the transmission of images, video, and other data
to physicians, and made size measurement automatic. We
think this bias can be reduced through caregiver training and
increased efforts to make our system more user-friendly.
Further large-scale prospective studies are warranted to
support our results, in conjunction with greater efforts to
improve the convenience of our system and to provide an
evidence-based rationale. In addition, more efforts are
needed to confirm the scope of our system beyond its rate of
concordance. Our innovative system can contribute to mini-
mizing the likelihood of inefficient, unprofessional wound
management in nonhospital settings, achieving prompt
recovery from pressure injuries, and reducing medical costs
for patients. As such, it may provide a foundation for the
future development of teleconsultation in clinical practice.
ACKNOWLEDGMENTS
This work was supported by KT and the Seoul National
University Bundang Hospital u-Health cooperative research
project.
REFERENCES
1. Wald HS, Dube CE, Anthony DC. Untangling the web--the
impact of internet use on health care and the physician-patient
relationship. Patient Educ Couns 2007; 68: 218–24.
2. Michael BD, Geleta D. Development of ClickClinica: a novel
smartphone application to generate real-time global disease sur-
veillance and clinical practice data. BMC Med Inform Decis
Mak 2013; 13: 70.
3. Acampora G, Cook DJ, Rashidi P, Vasilakos AV. A survey on
ambient intelligence in health care. Proc IEEE Inst Electr Elec-
tron Eng 2013; 101: 2470–94.
4. O’Connor PJ, Desai JR, Butler JC, Kharbanda EO,
Sperl-Hillen JM. Current status and future prospects for elec-
tronic point-of-care clinical decision support in diabetes care.
Curr Diab Rep 2013; 13: 172–6.
5. Trovato M, Scholer A, Vallejo E, Buncke G, Granick M. eConsul-
tation in plastic and reconstructive surgery. Eplasty 2011; 11: e48.
6. Jones SM, Banwell PE, Shakespeare PG. Telemedicine in
wound healing. Int Wound J 2004; 1: 225–30.
7. Hazenberg C, Van Baal J, Manning E, Bril A, Bus SA. The
validity and reliability of diagnosing foot ulcers and
S25
Teleconsultation of chronic wound management
pre-ulcerative lesions in diabetes using advanced digital pho-
tography. Diabetes Technol Ther 2010; 12: 1011–7.
8. Coiera E. Communication systems in healthcare. Clin Biochem
Rev 2006; 27: 89–98.
9. Barnard CM, Goldyne ME. Evaluation of an asynchronous
tele-consultation system for diagnosis of skin cancer and other
skin diseases. Telemed J E Health 2000; 6: 379–84.
10. Eminovic N, De Keizer N, Bindels P, Hasman A. Maturity of
teledermatology evaluation research: a systematic literature
review. Br J Dermatol 2007; 156: 412–9.
11. Du Moulin M, Bullens-Goessens Y, Henquet C, Brunenberg
D, de Bruyn-Geraerds D, Winkens R, et al. The reliability of
diagnosis using store-and-forward teledermatology. J Telemed
Telecare 2003; 9: 249–52.
12. Salmhofer W, Hofmann-Wellenhof R, Gabler G, Rieger-
Engelbogen K, Gunegger D, Binder B, et al. Wound teleconsulta-
tion in patients with chronic leg ulcers. Dermatology 2005; 210:
211–7.
13. Mair F, Whitten P. Systematic review of studies of
patient satisfaction with telemedicine. BMJ 2000; 320:
1517–20.
S26
Pak et al.
14. Tachakra S. Level of diagnostic confidence, accuracy, and rea-
sons for mistakes in teleradiology for minor injuries. Telemed J
E Health 2002; 8: 111–21.
15. Sukumar S, Roghmann F, Trinh VQ, Sammon JD, Gervais M-K,
Tan H-J, et al. National trends in hospital-acquired preventable
adverse events after major cancer surgery in the USA. BMJ Open
2013; 3: e002843.
16. Helal A, Cook DJ, Schmalz M. Smart home-based health plat-
form for behavioral monitoring and alteration of diabetes
patients. J Diabetes Sci Technol 2009; 3: 141–8.
17. Bowler PG, Duerden BI, Armstrong DG. Wound microbiology
and associated approaches to wound management. Clin Micro-
biol Rev 2001; 14: 244–69.
18. Landis JR, Koch GG. The measurement of observer agreement
for categorical data. Biometrics 1977; 33: 159–74.
19. Garg V, Brewer J. Telemedicine security: a systematic review.
J Diabetes Sci Technol 2011; 5: 768–77.
20. Barlow J, Singh D, Bayer S, Curry R. A systematic review of
the benefits of home telecare for frail elderly people and those
with long-term conditions. J Telemed Telecare 2007; 13:
172–9.
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