International Journal of Reliable and Quality E-Healthcare

Volume 6 • Issue 4 • October-December 2017

The Potential of Mobile Health in Nursing:

The Use of Mobile Communication
Technology in Plasma-Supported
Outpatient Wound Care in Germany
Anne Kirschner, Vocational Education Centre Müritz, Waren, Germany
Stefanie Kirschner, Vocational Education Centre Müritz, Waren, Germany
Christian Seebauer, Department of Oral and Maxillofacial Surgery/Plastic Surgery, University Greifswald,
Greifswald, Germany
Bedriska Bethke, Department of Health, Nursing and Administration, University of Applied Sciences Neubrandenburg,
Neubrandenburg, Germany

ABSTRACT

Mobile information and communication technologies are increasingly used in nursing. In a new
plasma-supported treatment for patients with chronic wounds in outpatient nursing settings, the
LiveCity camera can be used as an innovative mobile communication technology. It enables rapid
and high quality exchange of information between remotely located doctors and nursing staff. This
procedure promises to deliver positive outcomes regarding the quality of the treatment and patient
safety while avoiding additional hospitalisation and saving time and costs. This is achieved by rapidly
confirming diagnoses and agreeing on a joint treatment appropriate for the current wound status. Thus,
complications in wound healing can be promptly identified and countermeasures initiated through
quick and easy access to medical and nursing expertise.

Keywords
Chronic Wound, Cold Atmospheric Plasma, Communication Technologies, Delegation, LiveCity Camera, Mobile
Health in Nursing, Wound Care

INTRODUCTION

The use of digital and electronic technologies in medicine is referred to as e-health. E-health services
include telemedicine and mobile health (m-health), both of which are becoming increasingly popular
among health experts. Telemedicine enables medical information to be exchanged between two sites
using electronic information and communication technology. It is used for prevention, diagnostics,
treatment and ongoing care with the aim of improving the health status of patients as well as the
quality of treatment including its efficiency (Andelfinger, 2016; Omboni, Caserini & Coronetti, 2016;
Marx & Deisz, 2015; Central Association of Health Insurance Funds, 2013). As a rule, telemedicine
is restricted to stationary devices, unlike m-health (Metelmann & Metelmann, 2016). The term

DOI: 10.4018/IJRQEH.2017100106

Copyright © 2017, IGI Global. Copying or distributing in print or electronic forms without written permission of IGI Global is prohibited.


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m-health is therefore used if communication between doctors and patients takes place using mobile
telecommunication devices or multimedia technologies (Omboni, Caserini, & Coronetti, 2016).
In 2009 WHO collected data on the implementation of e-health initiatives in its member states.
The data indicate that m-health was or is becoming established in a range of programs around the
world. In particular, projects such as health call centres and toll-free emergency services have been
set up. In European countries m-health initiatives are also being established with about 60% of all
European countries introducing toll-free emergency numbers, about 30% launching mobile treatment
services and about 5% introducing decision support systems (WHO, 2009).
Particularly in the German healthcare system, mobile information devices and telemedicine are
becoming more and more important to overcome the challenges created by the demographic change
and its consequences (including the increasing age of the population and the associated multimorbidity
and increased need for nursing care) (Breitschwerdt, Reinke, Kleine Sextro, & Thomas, 2016).
Telemedicine and mobile information and communication technology (m-health) is also increasingly
used in the area of nursing care in Germany.

BACKGROUND

To determine the extent to which telemedicine and mobile information and communication
technologies (m-health) have become established in nursing care (particularly in wound care), the
(predominantly German) literature was first analysed. This included a review of relevant projects on
the internet. The German Telemedicine Portal, which was established as an initiative of the German
Federal Ministry of Health to enable a nation-wide search for information about previous and ongoing
telemedicine projects, was included as an essential source of telemedicine and m-health based projects.
It provided information aimed at users about more than 200 different telemedicine projects (Deutsches
Telemedizinportal, 2016; German Federal Ministry of Health, 2016a).
There are telemedicine projects that use assistive technologies to expand the care and support
options for the home setting while also measuring and visualising the quality of care achieved.1 In
other projects, GPS technology is used that enables people with dementia to be located at all times,
helping the patients themselves, their relatives and nursing staff to manage daily life.2 Several other
telemedicine projects in the area of nursing care were carried out in Germany between 2008 and 2013:

• ZIM NEMO TECLA (a network of technical nursing assistant systems);

• Mneme (development of a telemedicine care model for patients with dementia in the domestic setting);
• RoBIn (Rosenheim nursing network by internet) (Deutsches Telemedizinportal, 2016).

It is becoming clear that telemedicine in Germany is used increasingly to encourage

interdisciplinary and interprofessional cooperation between medicine and nursing. Particularly in
regional areas (in regional areas of Germany) with low population densities, where providing medical
care is only possible to a limited degree, telemedicine projects as an adjunct to medical care are
becoming more important. In 2005 this led to the development of the AGnES concept (local systemic
e-health interventions that aim to provide doctors with relief). Specially qualified staff (nursing staff,
medical assistants) take over selected medical tasks and are supported in the process by various
telemedicine systems (e.g. monitoring of the patient using telecare systems and direct telemedicine
communication between the general practitioner and the nursing staff) (Van den Berg, 2009).
In 2012 the Thuringian Telemedicine Project started in Germany. The aim of the project is to
expand remote collaboration between various professional groups in gerontopsychiatry as well as to
transfer cross-facility queries, treatment-related information and diagnostic and therapeutic processes
quickly and easily between doctors, specialists and nursing staff (Institut für Biomedizinische Technik
und Informatik, 2012). Another similar project that was also started in 2012 is the DocConnect project

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that aims to improve the care of patients in aged care and nursing homes by increasing the speed of
information transfer between doctors and the homes (Deutsches Telemedizinportal, 2016).
In Western Australia a study surveyed managers and doctors about their priorities for telemedicine.
Management placed wound care at the top of their list of priorities and for doctors it was in second
position (Bahaadini K, Yogesan K, Wootton R.; 2009). We were not able to find a similar survey for
Germany but it is obvious that telemedicine and m-health are becoming increasingly important in
Germany, particularly as part of wound care provided by nursing staff.
Telemedicine and m-health are also becoming more important in dermatology, particularly as
part of wound care provided by nursing staff. Relevant projects can be seen in Table 1.
What is remarkable is that outpatient wound care in Germany does not include a system that
enables direct contact between a doctor and nursing staff. This rapid communication would be
important particularly in the German system for outpatient wound care because the responsibilities
between doctors and nursing staff are so precisely delineated. Outpatient wound care in Germany is
structured as follows:

1. Doctors are responsible for making the diagnosis for wound care. It is a task that must not be
delegated to other professional groups (e.g. nursing staff) because of the particular specialist
knowledge required. In the wound care process, doctors are also responsible for taking the medical
history, determining the indication, examining the patient, including any invasive diagnostic
procedures, and informing and advising the patient. They decide which treatment to apply and
carry out any invasive treatments and surgical procedures. Consultants or general practitioners
are responsible for making the diagnosis;
2. Insured patients can claim home-based nursing care according to section 37 of the German
Social Code V if the nursing care is intended to safeguard medical treatment. That also includes
wound care delegated by the doctor to nursing staff. Section 28 of the German Social Code
V paragraph 1 legislates the delegation of medical tasks to nursing staff (BMJV 2016). In
the ‘Agreement on the delegation of medical services to non-medical personnel in outpatient
contracted medical care according to section 28 paragraph 1 page 3 of the German Social
Code V’ dated October 2013, ‘wound care following consultation with a doctor’ is defined as
a task that can be delegated. The doctor, therefore, decides if and to whom ongoing outpatient

Table 1. Telemedicine projects related to wound care (as of September 2016)

Telemedicine projects related to wound care that can be found in the German Telemedicine Portal 2016, a portal that provides
information about completed and ongoing telemedicine projects

Project Name Description Aim of the Project Project Schedule

In expert discussions (GPs, specialists and The aim of the project was to
clinicians) using a networked telemedicine accelerate wound treatment, to No information
Wundnetz Witten system, digital photos of wounds are discussed minimise the number of dressing provided by project
and suggested treatments prepared on the changes and to reduce patient management
basis of the photos transportation

Nursing staff transmit high-quality videos

with an (optional) oral report to wound The aim was to minimise expensive
Telekonsultation specialists who suggest treatment. The general personal house calls by doctors that 01.10.2008 to
Chronische Wunde practitioner prescribes and if necessary were often required simply to assess 30.06.2012
supplements the treatment and this is carried wounds.
out by the outpatient nursing service.

Medical practitioners should have

A wound photography application with
DigiWund – Digitale
important image parameters has been
Wunddokumentation
developed for digital wound documentation.
the simplest possible access to digital
01.03.2013 to
wound documentation. It should
30.04.2014
provide instructions for wound care as
well as software for wound analysis.

Source: Deutsches Telemedizinportal, 2016; Imhoff-Hasse, 2008; Walter, 2012

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wound care is delegated. He or she is responsible for selecting the tasks and must, therefore,
ensure that the nursing staff are capable of carrying out the delegated tasks based on their
professional qualifications or general skills and abilities (KBV and GKV Spitzenverband,
2014). Nursing staff in outpatient services and nursing assistants specifically trained in wound
care (e.g. wound experts from ICW®3) are employed;
3. Along with the responsibility to select the tasks, the doctors are also responsible for any training
and must ensure that the employees are trained to carry out the delegated wound care tasks
independently. Regular monitoring of the delegated wound care tasks by the doctor is required
(monitoring duty) (KBV & GKV Spitzenverband, 2014);
4. The responsibility for implementing tasks in outpatient wound care then lies with the nursing
staff or the wound experts. They must be proficient in the procedures used in wound care and
be familiar with hygiene requirements. They must also document the course of the wound
and the treatment in detail. This documentation forms part of the communication needs of the
professional groups involved in the wound care and enables doctors to exercise their responsibility
for monitoring and diagnosis.

Outpatient wound care is thus considered a task delegated by doctors to nursing staff. However,
particularly in outpatient wound care, situations can arise in which nursing staff would like to or must
consult with a physician urgently to have a diagnosis confirmed or to discuss a particular treatment
procedure. What is remarkable is that there are no systems in remote wound care that enable immediate
contact between a doctor and nursing staff. Particularly in outpatient wound care, situations can arise
in which nursing staff need to urgently consult a doctor to have a diagnosis confirmed or to discuss
a particular treatment.
The doctor is usually not on site, however. Mobile information and communication technologies,
specifically the LiveCity camera system, enables fast and high-quality exchange of information between
the doctor and the nursing staff. The LiveCity camera system is described below using the example
of plasma-supported wound care in the outpatient nursing setting in Germany.

MOBILE TELECOMMUNICATION IN PLASMA-

SUPPORTED OUTPATIENT WOUND CARE

According to the German Professional Association for Medical Technology, there are about 2
million people in Germany who suffer from chronic wounds (Bundesverband Medizintechnologie
e. V., 2015). This number will continue to grow. The reason for this development is the measurable
increase in diseases that have an associated risk of chronic wounds such as obesity, diabetes or
arteriosclerosis. Chronic wounds are the result of one or more underlying diseases, and their treatment
is time-consuming, costly and requires considerable material and staff resources (Augustin, Mayer
& Wild, 2016). Ideally, patients with chronic wounds should be treated in their homes, because
care based on the model of acute care is not indicated for chronic wounds. The acute care model is
not compatible with either the chronic nature of the disease nor with the daily needs of the patients
(Deutsches Netzwerk für Qualitätsentwicklung in der Pflege, 2015; Schmidt, 2016). However,
statistics indicate that in Germany only minimal numbers of patients with a chronic wound are
treated at home (0.4% of patients with diabetic foot syndrome and 1.7% of patients with a leg ulcer)
(Medizinischer Dienst des Spitzenverbandes Bund der Krankenkassen, 2012, cited from Deutsches
Netzwerk für Qualitätsentwicklung in der Pflege, 2015). They are predominantly treated in hospital
(Heyer, 2016). The reason behind this is considered to be the lack of multi-professional outpatient
teams as well as a failure to negotiate care interfaces. One approach to providing optimal care and
treatment for patients with chronic wounds at home and to avoid hospitalisation and readmission is
plasma-supported outpatient wound care, which could be supported by using mobile communication
and information technologies.

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Cold atmospheric plasma (CAP) is a new contactless and pain-free treatment option available
for treating pathogen-associated, superficial dermatoses, particularly chronic infected wounds.
Poor circulation and tropism, as well as reduced local immune response and regeneration potential,
encourage the infection of chronic wounds with pathogenic microorganisms (RKI, 2014). Effective
treatment of wounds infected with bacteria has become a challenge because of rising resistance and
a lack of novel antimicrobial substances. Several studies have verified the outstanding antimicrobial
potential of the cold physical plasma, regardless of the species of microorganism and the resistance
pattern (Karrer & Arndt, 2015). As well as its antimicrobial properties, some studies were able to
demonstrate a positive effect on the wound healing thanks to a local increase in the blood circulation
and tissue regeneration (Tiede & Emmert, 2016). That reduced the healing time for chronic wounds
and improved the quality of life of patients.

Delegation of Plasma-Supported Wound Care

Close cooperation between doctors and nursing staff can considerably improve plasma-supported
wound care for those affected because medical and nursing expertise are required to carry out local
wound care that is adapted to the particular stage of the wound, and that is based on comprehensive
diagnostics. Plasma-supported wound care is a medical task that could be delegated to specialist nursing
staff. That would involve initial wound care by a doctor (responsible for the diagnosis) who decides
if and to whom he or she will delegate ongoing wound care of the patient. The doctor is, therefore,
responsible for the duty of selecting, initiating and monitoring the wound care (Kassenärztliche
Bundesvereinigung& GKV-Spitzenverband, 2014). Plasma-supported wound care in patients’ homes
could be taken over by specialist nursing staff based on a delegation agreement4. Nurses would,
therefore, assume responsibility for carrying out the treatment and would themselves be responsible
for providing high quality and effective wound care. Outpatient plasma-supported wound care is
a highly specialised and individual treatment carried out directly on the patient which would be
administered far from any inpatient infrastructure. In this case, specialist nursing staff would have to
rely on themselves as a rule. If information to compare or confirm a diagnosis or about the treatment
is urgently required, this usually has to be obtained laboriously by telephone. That costs time and
money, both of which are in short supply in outpatient care in particular. Nursing services are under
enormous cost pressures from nursing and health insurance funds. They are supposed to design patient
treatment that is as efficient and cost effective as possible (Breitschwerdt, Reinke, Kleine Sextro, &
Thomas 2016). One option to ensure rapid, efficient and cost-effective as well as high-quality exchange
of information between doctors and specialist nursing staff is mobile information and communication
technologies, specifically the m-health system of LiveCity camera.

The LiveCity Camera System

The LiveCity camera was developed as part of an EU-funded project “LiveCity – Live Video-to-Video
Supporting Interactive City Infrastructure”. The aim of the project is to enable or improve real-time
communication between individuals or groups who are far away from each other using HD video
communication (Metelmann & Metelmann, 2015). Video-to-video communication has a wide range
of possible uses, for example, in emergency services to create a link between a doctor and paramedics;
in the city administration to improve convenience and access for (particularly older) residents and
as a virtual classroom to enable distance education (European Commission, 2012). The LiveCity
camera system is made up of:

• A video camera that is worn over the right ear using a headband;
• Headphones with an integrated microphone;
• A small PC (to make the internet connection) that can be carried in a backpack or belt bag.

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The camera system and the connection to remotely located persons are operated using a simple
push button on the strap of the backpack or belt bag (Metelmann & Metelmann, 2016).

Incorporation of the LiveCity Camera into Plasma-

Supported Outpatient Wound Care
There are many specific situations in nursing and medical care in which m-health could be used,
including plasma-supported outpatient wound care. As mentioned above, situations may arise in
outpatient wound care in which it is vital that medical and nursing staff be able to communicate with
one another. Particularly when comparing or confirming diagnoses and treatments, detailed information
is essential. That includes an assessment of the wound, which can only be done by making a close
examination. Until now, it was necessary for the doctor to visit the patient at home or for the patient
to visit the doctor’s surgery. With the LiveCity camera system, the wound can be assessed remotely
by the doctor. That saves time and money, both of which can rapidly rise particularly in rural regions,
e.g. as a result of long travelling distances for doctors or ambulance transport of patients requiring
care to the medical practice. The LiveCity camera transmits HD videos and the associated voice
messages with no time delay from one site to another (Metelmann & Metelmann, 2015). Because the
camera is fixed over the right ear of the specialist nursing staff, the doctor can view the wound from
the perspective of the nurse. That makes it easier for the doctor to orient themselves in the video and
enables coordinated agreement between the doctor and specialist nursing staff. Having the camera
fixed over the right ear also means that the nurse has both hands free. That means that any measures
discussed between the doctor and the specialist nursing staff can be immediately implemented. This
saves time and can increase the quality of the treatment measures. A close assessment of the wound
could also be enabled in that the examining doctor can adjust the transmitted video to their needs. The
software is designed so that the light, contrast or volume can be adjusted, for example. The snapshot
function enables the video to be analysed in greater detail thanks to the high pixel count (Metelmann
& Metelmann, 2015). Particularly when assessing the wound margins or the wound film, this function
could be useful for the treating doctor (off-site).

DISCUSSION AND CONCLUSION

To date, the LiveCity camera has been trialled in emergency services in Germany (Metelmann
& Metelmann, 2015). The trial of the LiveCity camera in the simulation centre of the Greifswald
University Medical Centre indicated that in emergencies an m-health-supported link can be created
between paramedics (in the patient’s home) and the emergency doctor (in the hospital) using the
LiveCity camera. Internet-supported communication is possible (Metelmann & Metelmann, 2016).
This potential could in our opinion also be used in outpatient wound care provided by nursing staff.
The implementation still needs to be trialed. Although outpatient nursing and emergency services are
very different areas of application and the training of the specialist staff involved differs, both areas
are similar in that highly specialised and complex measures have to be carried out in an unknown
environment (e.g. a patient’s home) and sometimes support is required. Another common feature
of both areas is that certain tasks have to be specified by responsible medical staff, and discussions
and exchange of information are essential in this regard (Breitschwerdt, Reinke, Kleine Sextro, &
Thomas, 2016). As in emergency services, the operation of the camera – as part of plasma-supported
outpatient wound care – should be placed in the hands of specialist nursing staff who are trained in
its use. That has several advantages including:

• (Predominantly older) patients are not further stressed by the operation of the camera
• The nursing staff can continuously monitor and review the equipment, which assures the quality
of the procedure;
• One device can be used for several patients which is cost effective (Metelmann & Metelmann, 2016).

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For patients, using m-health in plasma-supported outpatient wound care is also associated with
other advantages such as:

• An improvement in the diagnosis and treatment by prompt exchange of information between

professionals which is associated with faster and improved healing and which can increase the
quality of life;
• A reduction in hospitalisations because medical and nursing expertise can be more readily
accessed. Moreover, complications can be avoided or identified sooner;
• Avoiding (often) long and strenuous journeys to general practitioners and specialists and the long
waiting times that are usually necessary. Particularly those patients with (open) chronic wounds
feel uncomfortable in closed spaces with strangers, because the wound is frequently accompanied
by odours. That is distressful for patients (Panfil, Uschok & Osterbrink, 2009).

What must also be considered is that timely, high-quality treatment of chronic wounds is also
of interest to the healthcare system from an economic perspective. In German wound centres,
the following healthcare costs for statutory health insurance were identified using the example of
venous leg ulcers: on average (n = 218) the mean total costs per patient and year were about €9570.
Statutory health insurance incurred costs of about €7630 (Purwins et al., 2010 in BVMed, 2015) and
the majority of the costs resulted from the treatment, which can last between 6 months and six years.
Rapid and tailored wound management could reduce the treatment time, however, and thus lower
the costs (BVMed, 2015, Heyer, 2016).
Legally and lawfully in Germany action is necessary that simplifies and improves the cross-sector
use of telemedicine and particularly of m-health (inpatient, outpatient) and thus of integrated care in
the healthcare system. The first steps are the introduction of several acts in Germany (the Statutory
Health Insurance Modernisation Act, the Act to Enhance Competition in Statutory Health Insurance
and the Panel Physicians Amendment Act) and in particular the framework agreement on the scope
of the provision of outpatient services by telemedicine as defined in section 87, paragraph 2a(8) of
the German Social Code (SGB V). Medical, nursing and rehabilitation services can now be provided
and invoiced centrally by specialised facilities (Klar, 2011). In addition, the “Act on Safe Digital
Communication and Applications in the Healthcare System”5 in Germany is intended to further
reinforce telemedicine services (Bundesministerium für Gesundheit, 2016). These developments
could also have a positive effect on the introduction of m-health supported outpatient wound care and
open up funding. It must be mentioned at this point that, according to the framework agreement on
the scope of services provided by outpatient telemedicine, telemedicine and also mobile information
and communication technologies may only be implemented if the appropriate, regular and personal
doctor/patient contact continues to be available (GKV-Spitzenverband, 2013). M-health supported
outpatient wound care can in no way replace personal medical contact but can minimise it. Finally, it
must also be mentioned that an m-health-supported link between specialist nursing staff and a doctor
via the LiveCity camera should not be considered as monitoring of the nursing staff but rather is a
means to provide rapid support when treating patients. However, it should be taken into account that
wound care in Germany is a task that can be delegated by medical practitioners to specialist nursing
staff. The responsibility for diagnosis and arrangement of treatment still remains with the doctor.
Thanks to m-health, a diagnosis can be made confidently and quickly and treatment adjusted from
a remote location.

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ENDNOTES
1
VAMOS (efficiency of care using assistive modular technologies in needs-based scenarios) – project
schedule: 01.08.2008 to 31.07.2012 (German Telemedicine Portal, 2016)
2
AMi (AMI-AlzheimerMonitoring) – project schedule: 01.01.2009 to 01.01.2011 (Alzheimer Monitoring,
2016)
3
ICW: The Initiative Chronische Wunden was established in 1995 by doctors, nurses, employees of funding
organisations and activists. The aim is to improve the care of patients with chronic wounds (Initiative
Chronische Wunden e.V., 2016)
4
Agreement about delegation of medical services to non-medical personnel in contractual outpatient care
as defined by section 28, paragraph 1, page 3 of the German Social Code (SGB V) (“Vereinbarung über
die Delegation ärztlicher Leistungen an nichtärztliches Personal in der ambulanten vertragsärztlichen
Versorgung gemäß § 28 Abs. 1 S. 3 SGB V“ des § 28 Abs. 1 S. 3 SGB V”)
5
“Gesetz für sichere digitale Kommunikation und Anwendungen im Gesundheitswesen”

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International Journal of Reliable and Quality E-Healthcare
Volume 6 • Issue 4 • October-December 2017

Anne Kirschner has a Master of Science in Nursing and Administration, University of Applied Sciences
Neubrandenburg; doctorate at the medical faculty, University Greifswald, Dr. rer. med.

Stefanie Kirschner has a Master of Science in Nursing and Administration, University of Applied Sciences
Neubrandenburg; doctorate at the medical faculty, University Greifswald, Dr. rer. med.; Bachelor of Arts in vocational
education studies in nursing and healthcare; University of Applied Sciences Neubrandenburg; Teacher, Vocational
Sector of Health and Nursing, Vocational Education Centre Müritz, Germany; Membership: National Center for
Plasma Medicine.

Christian Seebauer born 6th Decembre 1979 in Zeulenroda, Germany Degree • 2012 medical degree Education
• 1999-2006 medical school, Jena, Germany • 2011-2015 dental medical school, Greifswald, Germany Career •
2007-2010 resident for trauma surgery, CMSC Berlin, Germany • 2011 resident for maxillofacial surgery, Jena,
Germany • 2011 – to date resident for maxillofacial surgery, Greifswald, Germany Membership • National Center
for Plasma Medicine.

Bedriska Bethke is Professor ambulant care/nursing science, Department of Health, Nursing and Administration,
University of Applied Sciences Neubrandenburg; Membership: National Center for Plasma Medicine.

58