DATA-DRIVEN

WOUND CARE:
A BUSINESS AND
CLINICAL OPPORTUNITY

Keith Harding, Tyler Rogers, Doug Brennand and Douglas Queen

E X E C U T I V E S U M M A RY
Wound care
management
is a complex
and difficult
enterprise
One key reason for this is that wound care lacks clear ownership
and as a consequence, the information needed to manage it is not
available to provide a single source of truth. Without this knowledge,
organizations struggle to bring wound care under control, leading
to resource waste, spiraling costs and poor clinical outcomes.
Accurate holistic assessment of the patient and the wound, includ-
ing its measurement and documentation, will provide an under-
standing of primary treatment objectives resulting in improved pa-
tient outcomes and reduced costs. Practitioners involved in wound
care need to ensure they have the essential skills required to plan,
implement and evaluate care on an individual basis.

Suboptimal care can lead to delayed healing, increased pain, in-

creased infection and inappropriate use of wound treatments, all
of which impact on patients’ quality of life and outcomes. It is vital
therefore that holistic wound assessment is seen as an essential
aspect of care for every individual living with a wound.

Digital wound care management unifies this complex and multi-

factorial information, creating an opportunity for healthcare or-
ganizations to realize the benefits of better information and data
management. Understanding your wound population, associated
costs and clinical burden helps an organization improve its opera-
tions, leading to clinical and operational benefits. In addition, bring-
ing wound care into the era of ‘big data’ allows more sophisticated
analytics to be applied to the important and complex problem.
Background

Wound care is not for the faint of heart. Not only does its physical manifestation require an iron stomach
to deal with their appearance, smell, and the pain of the patient, they are also exceedingly complex to man-
age. Ask any layperson how to heal a wound, and they might say clean it, place a bandage over it, leave for
a few days, and as if by magic, the body heals the wound. Unfortunately, this is certainly not the case for
chronic wounds such as pressure injuries, and diabetic foot and leg ulcers. Chronic wounds, by definition,
are those that have not healed after three months.

Much can happen to the wound such as the introduc- Given this long time to heal, wounds are problemat-
tion of a bacterial or fungal infection, lack of resolution ic for healthcare organizations to manage, requiring
of underlying causes of the wound, or further injury. multiple interactions from multiple stakeholders to un-
In addition, many factors not conducive to wound derstand the situation, and push towards the goal of a
healing exist, such as comorbid conditions such as single patient’s wound healing. Multiply this problem
diabetes and cardiovascular disease, as well as oth- by multiple factors of the wound, multiple wounds on
er factors such as smoking and interference from a patient, and then multiple patients in your healthcare
other medications the patient may be taking. Indeed, organization, and suddenly, you have an exponentially
wounds have been described as a major snowballing difficult problem to manage.
threat to the healthcare system (Sen, 2009), for exam-
All the while, who is keeping track of these wound
ple lower-limb amputation rates are as high as 25% for
and patient numbers? Certainly, some information is
people with diabetic foot ulcers (Singh, 2005).
captured in the patient’s electronic health record or
The evolution of wound care (Figure 1) as a clinical a clinicians notebook, but mostly, that information is
specialty began around 50 years ago with George not available at a touch of a button for analysis and
Winters’ findings, (Winter GD, 1962) shortly followed management.
by industry taking up the mantle of both product de-
velopment and subsequent marketing to deliver their
products to clinicians globally (Queen D et al, 2004;
Queen D, 2011).

The challenges were significant because as a medi-

cal community, wound care knowledge was poorly
advanced, with gauze being the primary therapeutic
available (Jones VJ, 2006).

4 © SWIFT MEDICAL INC. 2019

Figure 1 - Evolution of Wound Healing as a Clinical Specialty

Evolution of Wound Healing

as a Clinical Speciality
ly)
(Ref: Harding KG & Queen D, 2009)
An nual
-15%
g (10
owin
nts is Gr
r o f Patie
be
Num

Total
Integrated
Service Approach
Delivery
Treatment
Assessment
& Diagnosis

Improved Improved Standardization True Clinical

Diagnosis Treatment of Delivery Specialty

MARKET DRIVERS

• Care providers and patients desire better outcomes and to reduce treatment burden
• Healthcare desires to reduce hospital based treatments requires more procedures
to be community based
• Payers desire to reduce the cost burden of treating long term wounds or at a minimum
capping costs with an increasing incidence
• Government initiatives in the UK (and other geographies) now incentivising “a return to com-
munity” or “out of hospital”
• Governments are restricting the usage of certain treatment options both from a cost
(e.g. biologicals) and healthcare perspective (e.g. antibiotics and the use of silver)
Wound Care Challenge
Wound care is a patient-centric approach with significant complexity due to many factors. Patients are often in mul-
tiple care settings, seeing multiple caregivers (Figure 2).

Consistency of approach and documentation is often an issue and can have a significant impact on clinical outcome.
Wound care is complex and oftentimes suboptimal. A multitude of patient factors can be involved, especially related
to comorbidities (Table 1). This information with its collection and computation takes significant experience and skill,
and is unlikely to be analyzed for rational clinical decision-making.

Figure 2 - Patient-Centered Wound Care

Patient-Centered Skin & Wound Care

Hospitals & Health

Pharmacy
Systems

Primary Care Pharmacy

Skilled Nursing 
Wound Care Clinics
Facilities

Caregivers Specialists Co-Morbidities

Nurse Therapy Dermatologist Diabetes COPD

Surgeon Educator Cardiologist Diabetic Neurop- Paraplegia/
athy Quadriplegia
Doctor QI/Risk Manager Vascular Surgeon
Infection Aging
Podiatrist Admin Podiatrist/Chiropodist
Immune System Poor Nutrition
Rehabilitation Patient/Family Endocrinologist
Deficiency
Dementia/
Nutritionist Other providers Oncologist
Arterial/Venous- Alzheimer’s
Social Worker General Surgeon Insufficiencies
Emotional
Physical Therapy Wound Care Specialist Cardiovascular Disorders
Occupational Disease
Depression
 Table 1 - Examples of Multifactorial Assessment Parameters

Physical Tests and Observations • Surrounding skin and wound edge characteris-
(Others) tics (e.g. punched out ulcers may be arteria; oe-
dema, pigmentation and induration may indicate
• Oxygen - e.g. transcutaneous O2 (perfusion)
venous ulcer)
• Ankle brachial pressure index (ABPI), arterial
• Wound site (e.g. sacral wounds may be pres-
Doppler, angiography (perfusion, PAD)
sure ulcers, lower leg wounds may be arterial or
• Imaging studies - e.g. X-rays, high freq
venous ulcers)
ultrasound, Duplex scanning (venous disease),
• Colour, odour, viscosity and quantity of exudate
CT/MRI scans
• Presence/level/character of pain
• Photoplethysmography (venous disease)
• Nutritional screening/assessment - e.g. body
(Bio)Chemical Tests
mass index (BMI), mini-nutritional assessment
• Glucose (diabetes melitus)
short form (MNA-SF) (malnutrition, obesity)
• Haemoglobin (oxygenation)
• Psychological screening - e.g Hospital
• Plasma albumin (malnutrition)
Anxiety and Depression Scale (HADS)
• Lipids (hypercholesterolaemia)
(depression, anxiety)
• Urea and electrolytes (renal function)
• Temperature (pyrexia, infection)
• HbA1c (long-term control of diabetes)
• Blood pressure (hypertension)
• Rheumatoid factor, antibodies (rheumatoid
• Neurological examination (neuropathy)
arthritis, connective tissue disease)
• Arterial pulses
• C-reactive protein (CRP) (inflammation,
Biological Tests infections)

• White cell count (infection)

Biological Tests (Wound)
• Erythrocyte sedimentation rate (ESR),
• Microbiological culture - qualitative
(inflammation, infection)
and quantitative (infection)
Physical Tests and Observations • Wound histology and cytology (vasculitis/
(Wound) malignancy)

• Wound dimensions (two or three dimensional)

• Wound or periwound oedema, or erythema/heat
• Wound bed - e.g. type of tissue, presence of
exposed bone/tendon, color, odor
• Wound margin - e.g. undermining, rolled edge

SWIFTMEDICAL.COM 7
Wound care lacks E X A M P L E S O F T H E VA LU E
O F S TA N D A R D I Z E D R E C O R D S
robust evidence to
support data-driven
decision making. 1
The collection
of real world data has Medical billing codes rely on accurate
and reliable information to determine
proven to be difficult how much your organization charges for
your procedures - these are grounded in
and expensive… the data inputted into patient healthcare
records.

But why should anyone care about this data? The 2

patient comes through your organization, they are
treated, a bill is paid, and everyone’s happy - right?
Unfortunately, it’s not that simple. Reimbursement of procedures, such as
hyperbaric oxygen therapy (HBOT), relies
Not knowing these statistics and not having a
on complete data and documentation
standardized account of what occurred, regard-
for payment to be authorized. Compli-
less of how well your organization did their job, is
ance in data input is critical to qualify for
a missed opportunity for your healthcare organi-
this payment, and missing information
zation to ensure you are getting paid for the work
therefore presents a lost opportunity to
that was done, and further to maximize revenue
maximize revenue.
and profitability. But also to provide high quality,
best practice to the patients for whom you pro-
vide care.

Certainly, consistent, complete, clean, and analyz-

able data has many benefits for your organization
today. In addition, information technology is evolv-
3
ing at a staggering pace. Advances in artificial in-
telligence, machine learning, and the harnessing
Knowing your utilization of consum-
of ‘big data’ analytics are fast becoming powerful
ables, and the outcomes delivered to
tools that can provide scientific and economic in-
patients, could help your organization
sights that would have otherwise have been hid-
evaluate what have been cost- effective
den from healthcare organizations.
treatment, which helps you better tailor
your formulary.

8 © SWIFT MEDICAL INC. 2019

 What Data is Needed to Complete Wound

What Is Wound Assessment and Design a Care Plan?

Wound assessment should include a comprehensive

Assessment? assessment of the patient and also their wound to

identify any factors that may influence healing. Re-
sults of all assessments must be clearly and accu-
rately documented and include the recommended
steps for reassessment.

A full and total assessment of the patient is essential

to identify the causative or contributory factors that 1) Assessment of the Patient
could potentially influence or delay wound healing. Taking a patient history and understanding their full
It is about assessing the wound, wound bed and co- medical history is important to be able to assess and
morbidities, planning appropriate interventions, eval- design a care plan. Table 1 highlights the extent of the
uating their outcome and continual reassessment comprehensiveness of this patient assessment.
to demonstrate progress. Accurate, consistent and
timely wound assessment underpins effective clinical
decision making, enabling appropriate goals to be set 2) Assessment of the Wound
for the management of the wound in order to manage Assessment of the wound is multifactorial also and at
morbidity and costs (Posnett et al, 2009). a minimum should include the following:

There are many wound assessment tools available • Cause of the wound
currently. However, evidence suggests that many pa- • Wound size
tients are still not receiving comprehensive and knowl-
• Wound site
edgeable wound assessment (Schultz et al, 2004).
• Wound bed
This can lead to delayed wound healing, increased risk
of infection, inappropriate use of wound treatments • Signs and symptoms of infection
and a reduction in the quality of life for patients. • Level of exudate
• Assessment of the surrounding skin
Consistency in wound care documentation is key.
Consistency will build trust that what is in the patient • Documentation
record is an accurate depiction of the wound. Having a
dedicated wound team or, better yet, a certified wound Why should you Measure the Wound?
specialist (e.g. CWS or WOCN) conducting the weekly Wound measurement is an essential part of wound
wound assessments should accomplish much great- assessment. It should be recorded on initial presen-
er consistency than relying on non-specialist bedside tation, and at regular defined intervals as part of the
nurses, who may not have received any wound as- reassessment process. There are various methods
sessment training. Wound care policies should dic- available to measure wounds and it is important to
tate who will consistently perform the wound assess- use the same method each time, with the patient in
ments and at what frequency. the same position. Continuous monitoring of changes
in wound size is an important way of evaluating re-
sponse to treatment. One of the key data components
relative to a patient’s wound care journey.

SWIFTMEDICAL.COM 9
Why should you Document the Wound Size and Parameters?
What is the purpose of wound documentation? The primary purpose is communication. Communica-
tion among current providers regarding present or past care enables the entire health care team to share
information about the care and treatment of the patient. Documentation is not only important for the reasons articu-
lated previously but can have serious implications related to regulatory, reimbursement of legal issues. Communica-
tion, of course, can be verbal or written, but it is written communication (the patient chart) that will most likely make
its way into court.

Reimbursement
Reimbursement directly impacts how clinicians deliver care. Increasingly, third-party payer sources
(Medicare, Medicaid) are examining where their money is going and whether they’re getting the
most from providers on behalf of their beneficiaries. Thus, third-party payers are requiring more
documentation regarding patient outcomes to justify payment. Clinicians who can document com-
prehensive and accurate assessments of wounds and the outcomes of their interventions are in a
stronger position to obtain and maintain coverage and thus reimbursement.

Regulatory
It is important to keep in mind that CMS mandates that skilled home nursing service must be provid-
ed with the expectation of the patient’s restorative potential. In other words, home nursing services
are provided on the condition that the patient “improve materially in a reasonable and generally pre-
dictable period of time.” Home nursing is not considered reasonable and necessary if the patient is
not able to heal the wound (Fife et al, 2012).

Legal
No matter the setting in which you practice, as a healthcare provider you are constantly under the
threat of a malpractice lawsuit. In nursing homes, the top targets for litigation are pressure ulcers,
malnutrition, and dehydration. Up to 20% of all U.S. legal medical claims and more than 10% of
settlements are wound related (Pfaff, 2005) and there are more than 17,000 pressure ulcer-related
lawsuits filed annually in the United States (AHRQ, 2018). So, for both you and your organization, it
is important to take the necessary measures to avoid being sued.

10 © SWIFT MEDICAL INC. 2019

Wound Care Opportunity
There are many examples in the medical literature that have used wound care data in an evidence-based manner
to advance clinical and economic outcomes for healthcare organizations. Data-driven wound care is not a new con-
cept, but newer technological approaches present opportunities to do things in a much larger scale.

CASE 1

One multidisciplinary wound care center at the Karolinska University Hospital in Solna, Sweden,
was able to reduce the rate of lower limb amputations in patients with diabetes by 60% by intro-
ducing the implementation of best practice guidelines, education, and better team coordination
around patients with wounds (Alvarsson AA, 2012). They also speculate that more can be done to
improve on this through better coordination and referral into specialized multidisciplinary teams
to manage their wounds - certainly, better information management would be critical in improv-
ing this.

CASE 2

In the context of hospitals and long-term care, a well-coordinated clinician team reduced wound
care consumable cost by 55.8% (Ott C, 2018). In one study, a home healthcare team made pro-
cess and product innovations in order to improve wound care (Hurd T, 2013). Compared to be-
fore, they made a 78% total cost saving in nursing and material cost. In addition, wound healing
time was cut from 46 to 13 weeks and also the team reduced the need for daily wound dressing
changes. They also found greater adherence to wound care best practice. Another study details
the adoption of digital wound care management leading to a significant drop in healing time, cost
of consumables and number of visits (Khalil H et al, 2016).

SWIFTMEDICAL.COM 11
 CASE 3

Centralizing wound care management under a single point of accountability, such as a skin and
wound coordinator, in combination with quality improvement, enabled through the adoption of
the Skin and Wound solution by Swift Medical has been demonstrated to reduce the prevalence
of pressure injuries (Au y et al, 2019). In the case of Teays Valley long-term care facility in West
Virginia, they were able to reduce the prevalence of pressure injuries by 77% over six months using
data to inform problematic cases and use root cause analysis to mitigate problems in their organi-
zation. Swift Skin and Wound gave metrics on critical statistics including wound population, num-
ber of wounds, wound healing progression, and treatments used, which was available in real-time
allowing the organization to act quickly and prioritize wound cases.

Patient-centric care by connecting information silos Swift Medical is bringing both big data and
with real-world evidence may be the key to solving this machine learning to wound care. Being de-
data deficit in wound care management. Alternative ployed in over 1,700 healthcare facilities, and
information outside of the context of clinical trials ex- monitoring over 200,000 patients per month
ists in the form of the real-world evidence which can is a wealth of data that is currently being lev-
form the basis for informing how wound care can be eraged to seek insights about patients with
improved. wounds that have evaded analysis so far.

So far, we have only discussed the practical applica- One example is predicting how long it would
tion of data. However, much more is possible with take for a wound to heal. We have demon-
the use of big-data, artificial intelligence and machine strated that the application of big data on
learning (AI/ML). What is “big data” and how can it be wound healing rates has yielded a predictive
applied? The term “big data” refers to datasets that are algorithm that is over two-times more accu-
generally too large to be processed by traditional soft- rate than conventional PUSH-based calcula-
ware. Now, specialized algorithms can analyze this tions (Gupta R et al, 2019).
data and give invaluable insights previously unattain-
Plans to bring machine learning and artificial
able by conventional methods (Woods JA et al, 2018).
intelligence to wound care are currently un-
AI/ML takes this further, by being able to extrapolate derway, and it will be exciting to see what will
data further to predict what may occur in the future. be achieved through the application of this
Machine learning enables healthcare systems to ca- advanced technology.
ter to individual clinicians, nurses or patients by learn-
ing and adapting to their specific situation, thereby
streamlining and improving healthcare across all lev-
els and specialties. Predicting which treatments will
be most effective and safe for a particular patient is
one of the most significant applications of machine
learning in healthcare.

12 © SWIFT MEDICAL INC. 2019

Data-Driven Approach

Artificial intelligence (Data-Driven) has the potential to (“woundology”). Data-driven approaches have great
be a catalyst for the evolution of more informed wound potential to improve the delivery of wound care by aug-
care practice. The promise of data-driven wound care menting clinical workflows and guiding treatments
is predicted today on broad and extensive datasets that will improve patient prognosis. This approach will
from which to learn. Data-driven models today may not replace clinicians but greatly augment and amplify
make decisions with the benefits of tens of millions the effectiveness of those who provide wound care.
of patient records, and billions of data-points. Artificial This is a truly symbiotic relationship.
Intelligence (Data-Driven) has the potential to be the
catalyst for the evolution of more informed wound
‘Woundology’ — a generational influence
care practice. A physician is likely to only see patients
numbering in the few tens of thousands across their A recent study showed how around 40% of Americans
career (Rajkomar A et al, 2019), and can exhibit many credit technology for the biggest improvement in life
cognitive and affective biases (Croskerry P, 2013), as over the past 50 years. The current generation of
they are simply human. Machines, on the other hand, health care providers continues to adapt to the ever‐
can handle large data volumes and exhibit much changing new frame of reference. But the most signifi-
less bias, if any. cantly impacted generation will be the millennials. The
emergence of technology has wired them differently
Data-driven approaches will “upskill” resources and from birth.
drive collaboration with specialized clinical skills pro-
viding better insight. For example, automatically iden- What makes them different is that it is not a case of
tifying tissue types and wound stage will remove the adapting new technology into existing practice, but
human necessity and provide a more consistent and rather it is the existence of technology, not only in ev-
clinically relevant output. Enhanced wound and pa- eryday life but also in their everyday working environ-
tient risk measures and prognostic capabilities will ment. Technology will become more easily embraced
multiply the effectiveness of the care team. Machines as millennials become the new generation of caregiv-
will provide augmentation of approach rather than er, but also the next generation of decision-makers
replacement of human interaction. and patients. What makes millennials different is their
willingness to challenge “the norm” and to think dif-
With massive imagery and data sets, the patient and ferently. Disruption is their norm, and as such change
the clinician will benefit from the aggregated knowl- can and will happen.
edge of millions of prior encounters and outcomes.
Similar approaches have been successfully applied Millennials are more engaged and involved than pre-
in other clinical settings, such as radiology and dia- vious generations—just think social media (Queen
betic retinopathy, to streamline clinical diagnosis and D and Harding KG, 2018). Millennials are also highly
improve patient outcomes (Abramoff MD et al, 2016). peer‐influenced and driven by a belief of social respon-
sibility, a winning combination for healthcare. A recent
Through the use of technology systems such as mo- study has shown that by 2020 millennials will be mak-
bile skin and wound measurement apps, the wound ing the majority of healthcare decisions in the United
community can collect large volumes of calibrated States and by 2025 they will make up at least 75% of
and structured data. Subsequently, through data the workforce.
analysis (AI) techniques begin to truly understand
the areas of focus and change required to drive the
evolution of the specialization of the clinical area

SWIFTMEDICAL.COM 13
Data-Driven Wound Care Can Drive The Evolution of the Specialty
Artificial intelligence married to human intelligence will allow a more precise, patient-centric care, result-
ing in better outcomes. The ability to standardize practice through the many settings of care delivery,
and to “up-skill” its delivery can help relieve the systemic burden of wounds.

In wound care, data-driven approaches will impact on all areas, from prognosis, diagnosis, and treat-
ment, to workflow efficiency and broadening access to quality care. Engaging with technology will real-
ize the promise of better outcomes for patients through the enhanced delivery of care by their care team.

Figure 3 - Financial Implications Across the Care Continuum

Example of Financial Implications

Evidence-based treatment and pressure ulcer prevention is more important than ever.

ACUTE CARE:
The Centers for Medicare and Medicaid Services (CMS) no longer reimburses for
Hospital Acquired Pressure Ulcers.

LONG-TERM CARE:
Federal regulations allow surveyors to impose fines and withhold federal reimburse-
ment for failure to implement and document evidence-based practice for pressure
ulcers.

HOME HEALTH:
The implementation of OASIS-C, which measures quality of patient care, could have
a financial impact on agencies, as reimbursement could be at risk.

Sources: National Centre for Biotechnology Information I www.ncbi.nlm.nih.gov, National Pressure Ulcer Advisory Panel (NPUAP
I www.npuap.org, Healthcare Cost and Utlisation Project (HCUP) I www.hcup-us.ahrq.gov, Agency for Healthcare Research and
Quality’s (AHRQ) I www.ahrq.gov
 Data as a Driver and Measure of ROI
in Wound Management

Securing Gaining funding involves competing dard wound management practic-

against other healthcare fields which es result in failed management and
funding for are better recognized and considered squandered resources providing poor
wound more important and has supportive data to show good use of healthcare
management outcomes data. Demonstrating value funds. Many economic analyses of
for money is reliant on having data the effect of interventions in wound
is challeng-
showing that the treatment modality management rely on previously pub-
ing, especially or care plan is clinically effective. lished data and on modeling. This
in the many use of previously published informa-
In wound management, this is not so
healthcare easy. Collecting such data in wound
tion is driven by the paucity of data
in wound management. However,
systems management is difficult for a number using data from other sources and
where wound of reasons: relying on modeling are fraught with
management • Data collection is often sporad- methodological difficulties that may
compromise the validity and general-
is not ic or, where collected, poor or
inconsistent methodology makes izability of the results.
recognized analysis difficult
Routinely collected data, that is, data
as a clinical • Data demonstrating clinical
that are collected in the course of
specialty efficacy and effectiveness may be
clinical contact and not specifically
limited or not available
for the purpose of a research study,
• Financial data may be based on
have the advantage of being ‘in the
measures that do not provide a
real world’. This is in contrast to
true indication of cost
data acquired from highly controlled
It is clear that when implemented clinical trials where the patients se-
properly, wound management that lected may not be representative of the
uses appropriate interventions based general population. Real world data
on accurate diagnosis delivers bene- also has the potential to allow for the
fits to patients, healthcare systems, longer time horizons that are more
and society. However, low rates of suited to investigating prevention.
accurate diagnosis and non-stan-

SWIFTMEDICAL.COM 15
Conclusions

Understanding your wound population gives you the • Wound care has remained relatively static for the
data and power you need to know how to better re- past 50 years
source your organization. Knowing who your patients • The next generation of caregiver and care consum-
are, what wounds are present, what it takes to manage er could drastically change the face of wound care
these wounds, the treatments and interventions used, delivery and the evolution of the specialty
and the costs of these, means you can more efficient- • The social media and social engagement model
ly staff your organization, rationalize costs, and spot have a huge impact on understanding and belief.
emerging trends that will define how you will manage While our current generation of caregiver is way
your organization in the future. At the same time, this more sceptical of such sources, the millennial gen-
information improves wound management and care eration embrace and utilize this environment and
quality, and in turn, outcomes for your patients. more importantly trust it
• As the quality of the information increases and
The future of big data and machine-learning and arti- the reliable, validated sources recognized, this
ficial intelligence is beginning to yield exciting results, will become the most significant resource, even
and adoption of this technology will most certainly over face-to-face healthcare consultation with
give healthcare organizations a competitive advan- a professional
tage in demonstrating wound care mastery (Figure 4).

Figure 4 - Digital Wound Care Benefits

Digital Wound Care For Better Quality

of Care and Outcomes

Enhance your services Greater visibility Better compliance

Make your wound care man- We provide real-time data into We help provide accountability
agement more comprehensive, your patient population, down to the most rigourous compli-
efficient, and cost-effective to the wound assessment level ance standards
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