Patient and Provider Preferences for Monitoring Surgical Wounds Using an mHealth App: A Formative Qualitative Analysis

Abstract

Background:

Surgical site infections complicate approximately 10% of all inpatient operations and account for nearly 20% of surgical re-admissions. Post-operative hospitalizations have become shorter over time, yet limited resources exist for patients to use at their home to communicate surgical wound problems with their medical providers. This study evaluated the attitudes of patients and providers towards using a remote wound monitoring application.

Methods:

This formative descriptive qualitative study reports the result of analysis of the interview content of five patients and five providers from a colorectal surgery clinic at the Medical University of South Carolina in Charleston, South Carolina. Semi-structured, face-to-face interviews were conducted in the clinic setting, were recorded, and professionally transcribed. Two of the authors independently reviewed and coded the transcribed interviews to identify themes across all 10 interviews. After independent coding, authors reviewed findings to reconcile and streamline the primary themes representing attitudes of patients and providers toward remote wound monitoring.

Results:

Five primary codes were found across our interviews: current barriers, infection types, workflow, interest in surgical site infection (SSI) monitoring, application considerations, and requested application features. We subcoded “symptom clarification” and “positive anticipation” under “interest in SSI monitoring,” as well as “anticipated issues” and “application features” under “application considerations.” From these codes, we synthesized findings into three overarching themes: smartphone app for remote wound monitoring has potential to improve patient–provider communication, specific wound evaluation processes are acceptable to patients and providers, and new collaboration with telehealth service is a welcome addition for interdisciplinary team management.

Conclusions:

A prospective approach to the development of a remote wound monitoring application enables a user-centric development process. Our analysis shows a readiness from both patients and providers to implement remote wound monitoring for identifying potential SSIs and coordinating surgical wound care within the community.

Surgical site infections (SSIs) are costly complications that occur in 10% of all inpatient operations, accounting for nearly 20% of surgical hospital re-admissions [1]. Shorter post-operative admissions increase the risk of SSIs first manifesting at home where patients lack immediate evaluation by their providers [2]. Despite widespread adoption of pre-habilitation and early recovery after surgery (ERAS) protocols, the timing of routine follow-up care has not been altered [3]. A post-operative in-person clinic visit seven to 14 days after hospital discharge is still standard practice, occurring after the window for most post-operative complications. As a result of this timeline, the burden of wound monitoring and care can fall directly onto the patients, and they may be ill-equipped for this challenge [4].

Recent telehealth initiatives suggest that remote post-surgical patient care might replace traditional in-person follow-up visits [5 –8] Surgical wound evaluation and triage for SSI is possible with patient-generated images facilitated by mobile healthcare apps [9 –11]. Although the majority of operations do not result in SSIs or immediate complications, even low-risk post-operative patients are seen in person. This practice congests the clinic workflow, appropriates limited provider time, and limits access to new patients [6,12,13]. There has been a dramatic increase in the number of mobile healthcare apps, but prior to the coronavirus disease 2019 (COVID-19) pandemic, there was not widespread adoption. As health systems prioritize use of telehealth to address patient safety and convenience, planning for the implementation of mobile health applications to facilitate remote post-discharge care of surgical patients becomes more important.

This preliminary study, undertaken prior to the COVID-19 pandemic, evaluated interest in the implementation of a post-discharge remote wound monitoring mobile application. The research question was: would patients and surgical care providers such as clinic staff, advanced practice providers (APPs), and physicians find a remote wound monitoring program useful and feasible in the post-discharge setting?

Patients and Methods

This study was determined to meet criteria for exempt research by the Medical University of South Carolina Institutional Review Board. Participants were provided an information sheet about the nature of the study at the time of recruitment and received a $25 Walmart gift card as compensation for their time at the culmination of each interview. This formative descriptive qualitative study consisted of the analysis of the interview content of five patients and five providers from a colorectal surgery clinic at the Medical University of South Carolina in Charleston, South Carolina. Participants were interviewed in a semi-structured format, face-to-face in the clinic setting. Interview audio recordings were then transcribed by a professional transcription service. Two of the authors (S.S., L.N.) independently reviewed and coded the transcribed interviews to identify themes across all 10 interviews. After independent coding, these authors reviewed findings to reconcile and streamline the primary themes representing attitudes of patients and providers toward remote wound monitoring.

Clinical setting and process of usual care

The site of the study was the Colorectal Surgery Clinic at the Medical University of South Carolina (MUSC). This clinic is staffed by two colorectal surgeons, one physician assistant, and several nurses, and is an intended site for future pilot studies. Usual post-operative follow-up visits after colorectal surgery were scheduled one to two weeks after discharge from the hospital, or earlier if the patient had concerns. Subsequent clinic visits varied depending on the underlying pathology: one to three weeks, one month, three months, six months, and/or one-year follow-up appointments were common practice.

Participant selection

Two groups of stakeholders, categorized as either patient or provider, were recruited for interviews. The five patients included in this preliminary study were chosen based on varied characteristics, including age, gender, and type of surgery/underlying disease to better diversify data and gain broader perspectives. Inclusion criteria for the patients recruited were adult, English-speaking patients who had a scheduled appointment for routine post-operative care after elective colorectal surgery within the past month. We purposively selected five clinicians from the clinic for interviews. The same investigator conducted all interviews to reduce variability (L.N).

Data collection

Interview questions were designed to elucidate views on current management of SSIs, the feasibility of implementation of a wound monitoring app, and any positive or negative anticipatory thoughts regarding integration of telehealth monitoring into clinical practice. Semi-structured interviews lasted 15 to 20 minutes, conducted within a private clinic examination room within the MUSC Colorectal Clinic, were audio recorded, and professionally transcribed.

Qualitative data analysis

All transcripts from patients and providers were stripped of any identifiers, uploaded, and independently coded using NVivo 12.6.0 Software (QSR International Pty, Victoria, Australia) by two separate investigators. A qualitative thematic analysis [14] was undertaken to describe patient and provider perspectives on remote wound monitoring. A coding scheme was developed using the interview guide to examine concepts related to communication, follow-up, wound monitoring, education for identifying symptoms of infection, concerns about wounds, and willingness to use a smartphone app to evaluate wounds over time. The investigators then discussed, reconciled, and consolidated their codes to discover shared themes across all interviews. Under the classification of wound monitoring, codes and related subcodes were developed. A concept map was created to demonstrate the relations of the codes/subcodes. Last, the themes were specified in actionable terms that can guide future development of an app for remote wound monitoring.

Results

Interviews revealed unique perspectives from all stakeholders regarding SSI monitoring and implementation of a wound monitoring app. After reviewing responses from each participant, five specific codes and three overarching themes were identified from the verbatim quotes within the set of interviews. Wound management was conceptualized within the following codes and subcodes: infection types, current barriers, interest in SSI (with subcodes: clarification of symptoms, and positive anticipation), workflow and app considerations (subcodes: anticipated issues and app features). Five primary codes were found across our interviews: current barriers, infection types, workflow, interest in SSI monitoring, application considerations, and requested application features. We subcoded “symptom clarification” and “positive anticipation” under “interest in SSI monitoring,” as well as “anticipated issues” and “application features” under “application considerations.” From these codes we synthesized findings into three overarching themes: smartphone app for remote wound monitoring has potential to improve patient–provider communication, specific wound evaluation processes are acceptable to patients/providers, and new collaboration with telehealth service is a welcome addition for interdisciplinary team management.

Participants

Interviews took place during October through November 2019. Two colorectal surgeons, one physician assistant, and two clinic nurses participated for the provider point of view. We approached 15 patients who met inclusion criteria as patient stakeholders; five agreed to proceed with interviews. Table 1 presents patient stakeholder characteristics.

Table 1.

Patient Stakeholder Characteristics (n = 5)

	18–45	2 (40%)
Age	46–70	1 (20%)
	70+	2 (40%)
Gender	M	2 (40%)
	IBD	5 (100%)
Surgery indication	Malignancy	0%
	Diverticulosis	0%
	1–2 wks	0%
Time interval between surgery and interview	2 wks to 1 mo	4 (80%)
	1–3 mo	2 (20%)

IBD = irritable bowel disease.

Codes

Five major codes were created using quotes from both patient and provider stakeholders regarding the process of wound management (Fig. 1). Both investigators reconciled their preliminary analysis and consolidated their codes. The corresponding inclusion criteria were as follows:

FIG. 1.

Key code categories from patient and provider interviews. This concept map displays consolidated codes after reconciliation by two investigators. We visualized wound management as the key social process, further characterized by the main codes, child or subcodes, and example quotations. SSI = surgical site infection.

Infection types: described wound characteristics and/or categories of infections that providers and patients observed during post-operative courses.

Current barriers: included issues patients and providers perceived related to the current practice for post-operative surgical site care.

Interest in SSI monitoring with subcodes of symptom clarification and positive anticipation related to participants anticipated uses for remote wound monitoring and affirmations of usefulness.

Workflow: referenced how the clinic currently operates and the timelines by which patients are seen for their post-operative care, including in the event of complications.

App considerations with subcodes of anticipated issues and communication/app features: mentioned items that patients and providers had concern about or wished to be included during development of the application.

After considering the five main codes and to further synthesize key messages related to these findings, we distilled the analysis to form themes that reflected attitudes across all stakeholders. The three themes provide direction for our formative research: smartphone app for remote wound monitoring has potential to improve patient–provider communication; specific wound evaluation processes are acceptable to patients/providers; and new collaboration with telehealth service is a welcome addition for interdisciplinary team management. Quotes from patients and providers show how we arrived at these themes, are shown in Table 2.

Table 2.

Selected Quotes from Patient and Provider Stakeholders Supporting Three Themes

Smartphone app for remote wound monitoring has potential to improve patient/provider communication	…being able to communicate with somebody without having to drive down here and then not being able to get the help—like somebody actually here that could say, “Hey, this is what you need to do” or “It looks fine”
	I use a lot of apps. So I think I might have been more inclined to have a little bit more peace of mind for somebody to see it and say, “No, this is normal.”
	I don't know if we're telling them enough up front what really to expect.^*
	I think that would be helpful. The ability to exchange messages? Yes…100%
	…Peace of mind too. Not once an hour…Even couple of times daily, even like an early and a late would be very helpful
	…the time or distance for someone to come in can be a barrier^*
Specific wound evaluation processes are acceptable to patients/providers	…if they're having issues and need an evaluation, then we try to get them scheduled sooner with either the provider if they're here or their advanced practitioner.^*
	I actually used …My Chart to send a message and a picture of my wound
	…if they call thinking that they might have an issue, we ask about the incision site if it's hot or, you know, red. If there's any drainage and what the color of the drainage is. And then also if they're running a fever, nausea, vomiting. Or, you know, blood in their diarrhea. Things of that nature^*
	…patients call with concerns or questions about their incision site, whether it be red, drainage, fevers, and then from there we would schedule them for an appointment here if they can make it here or schedule for an evaluation locally with their PCP.^*
	I was concerned about the drainage…there was a dark spot, and I was like, “What is this? Is this necrotic? What's going on with this?”
New collaboration with telehealth service is a welcome addition for interdisciplinary team management	…it would be a real asset for us^*
	I think it would be phenomenal.^*
	Well I think it would be beneficial because, I mean, we only have the three nurses and they take all of the phone calls^*
	…it would filter out some of the ones that either aren't necessary or would get the people that do need to come in here scheduled and stuff sooner^*
	I think that would be great as long as they have direct access to our APPs and authority to tell the patients, versus creating a second loop of work for us, where they would just send us and then that patient's following up with that telehealth person and then me.^*
	A lot of other providers outside of MUSC don't want to touch our patients after they've had surgery^*

Indicates provider response.

PCP = primary care physician; APP = advanced practice provicers; MUSC = Medical University of South Carolina.

Discussion

Surgical site infection is a common post-operative complication that often results in costly re-admissions [1,15]. In prior studies evaluating the usefulness of a mobile app for remote wound monitoring in patients who have already developed an SSI, participants may have been influenced by recall bias, favoring remote monitoring, and these feelings may not reflect the feelings of patients who recover without complications [16,17]. Furthermore, past implementations demonstrated sustainability challenges because they were managed by the implementation team alone (excluding clinic stakeholders in an attempt to preserve their workflow) or a sole nurse in the clinic (altering and slowing clinic workflow) [16,18]. Informed by this prior work, we initiated this pre-implementation evaluation to establish the degree of readiness for a telehealth-based remote patient monitoring service using a patient-centered mobile app. This study revealed common themes related to management of postoperative surgical wound sites and elucidated critical viewpoints from both patients and providers regarding the feasibility and usefulness of a surgical wound monitoring mHealth/telehealth application before its implementation.

The stimulation of collaborative, interdisciplinary post-operative monitoring between surgical patients, surgical providers, and telehealth staff is a new paradigm for surgical wound care. Our study suggests that there is a readiness for remote wound monitoring as an optional patient-driven telehealth service. This new paradigm, in theory, both preserves current clinic workflows and maintains a manageable workload of involved clinicians, while giving patients peace of mind through active monitoring of their patient-generated health data. Patient and provider participants indicated willingness to adopt such a paradigm; this allows consideration of stakeholder perspectives more closely aligned with the anticipated workflow. We observed a previously described divergence in the wound monitoring needs of provider and patient users [16]; providers indicated that they want actionable data to alert them to wound problems, whereas patients prefer more communication, including reassurance of normal wound healing.

The benefits of broadened telehealth initiatives have swiftly become evident in the wake of the COVID-19 pandemic. This momentum, born in the interest of patient safety, was facilitated by many including policy changes and regulatory waivers from Centers for Medicare & Medicaid Services in response to COVID-19 and provisions of the U.S. Coronavirus Aid, Relief, and Economic Security (CARES) Act, as well as states' inclusion of telehealth as a Medicaid covered benefit. Across the United States, telehealth utilization increased to 14% of all ambulatory visits during the first wave of COVID-19 infections in the spring of 2020, but in the MUSC health system, with an existing telehealth infrastructure, telehealth visits accounted for 68% of ambulatory encounters in mid-April 2020 (internal data) [19]. Although these dramatic trends were not sustained, the imperative for access brought new opportunity for engagement and adoption of new communication streams. Remote patient monitoring initiatives will likely develop more rapidly in centers with dedicated human resources for implementation and dissemination.

Our study was limited in scope, including only five patients who underwent colorectal operations for inflammatory bowel disease in a single surgical clinic. A broader sample of patients of varying health literacy, life experience and other colorectal surgical indications may afford a better understanding of the potential barriers to implementation. The data accumulated here are formative, acquired prior to actual implementation of telehealth-based remote wound monitoring, and as such, sustainability of the implementation could not be formally evaluated. However, the consistent responses from the interviewees resulting in three strong themes establishes proof of concept for initiating implementation within the environment in which the evaluation was conducted. Site specificity is an integral aspect to the implementation of a patient-centered approach to post-discharge wound assessment and prevention of surgical site infections. Ultimately, this study forms the basis for including site-specific implementation planning in future multidisciplinary, multicenter trials studying the impact of remote post-operative wound triage.

Conclusions

A prospective approach to the development of a remote wound monitoring enables a user-centric development process. Our analysis shows a readiness from both patients and providers to implement remote wound monitoring for identifying potential SSIs and coordinating surgical wound care within the community.

Footnotes

Funding Information

This study was supported by the South Carolina Clinical & Translational Research Institute with an academic home at the Medical University of South Carolina through CTSA NIH/NCATS grant number UL1 TR001450. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the NIH or NCATS.

Author Disclosure Statement

The authors have no significant financial disclosures or conflict of interests relevant to the manuscript.

References

Merkow

, Ju

, Chung

, et al. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA, 2015; 313:483–495.

Woelber

, Schrick

, Gessner

, Evans

. Proportion of surgical site infections occurring after hospital discharge: A systematic review. Surg Infect, 2016; 17:510–519.

Saunders

, Fernandes-Taylor

, Rathouz

, et al. Outpatient follow-up versus 30-day readmission among general and vascular surgery patients: A case for redesigning transitional care. Surgery, 2014; 156:949–956.

Sanger

, Hartzler

, Han

, et al. Patient perspectives on post-discharge surgical site infections: Towards a patient-centered mobile health solution. PloS One, 2014; 9:e114016.

Chen

, Davis

, Balentine

, et al. Utility of routine postoperative visit after appendectomy and cholecystectomy with evaluation of mobile technology access in an urban safety net population. J Surg Res, 2014; 190:478–483.

Armstrong

, Coyte

, Brown

, et al. Effect of Home monitoring via mobile app on the number of in-person visits following ambulatory surgery: A randomized clinical trial. JAMA Surg, 2017; 152:622–627.

Healy

, McCrone

, Tully

, et al. Virtual outpatient clinic as an alternative to an actual clinic visit after surgical discharge: A randomised controlled trial. BMJ Qual Saf, 2019; 28:24–31.

Harkey

, Kaiser

, Zhao

, et al. Postdischarge virtual visits for low-risk surgeries: A randomized noninferiority clinical trial. JAMA Surg, 2021; 156:221–228.

Evans

, Lober

. A pilot use of patient-generated wound data to improve postdischarge surgical site infection monitoring. JAMA Surg, 2017; 152:595–596.

10.

Gunter

, Fernandes-Taylor

, Rahman

, et al. Feasibility of an image-based mobile health protocol for postoperative wound monitoring. J Am Coll Surg, 2018; 226:277–286.

11.

Broman

, Gaskill

, Faqih

, et al. Evaluation of wound photography for remote postoperative assessment of surgical site infections. JAMA Surg, 2019; 154:117–124.

12.

Gunter

, Chouinard

, Fernandes-Taylor

, et al. Current use of telemedicine for post-discharge surgical care: A systematic review. J Am Coll Surg, 2016; 222:915–927.

13.

Hwa

, Wren

. Telehealth follow-up in lieu of postoperative clinic visit for ambulatory surgery: Results of a pilot program. JAMA Surg, 2013; 148:823–827.

14.

Vaismoradi

, Turunen

, Bondas

. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study: Qualitative descriptive study. Nurs Health Sci, 2013; 15:398–405.

15.

Zimlichman

, Henderson

, Tamir

, et al. Health care-associated infections: A meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med, 2013; 173:2039–2046.

16.

Sanger

, Hartzler

, Lordon

, et al. A patient-centered system in a provider-centered world: Challenges of incorporating post-discharge wound data into practice. J Am Med Inform Assoc, 2016; 23:514–525.

17.

Sanger

, Hartzler

, Lober

, et al. Design Considerations for post-acute care mHealth: Patient perspectives. AMIA Annu Symp Proc, 2014; 2014:1920–1929.

18.

Dodwad

SJM

, Hart

, Lordon

, et al. Implementation of an mhealth postoperative wound management program. J Am Coll Surg, 2017; 225:e88.

19.

Koonin

. Trends in the Use of Telehealth During the Emergence of the COVID-19 Pandemic—United States, January–March 2020. MMWR Morb Mortal Wkly Rep, 2020; 69:1595–1599.