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SPECIAL SECTION on COVID-19 and PM&R

Implementation and Patient Satisfaction of Telemedicine in Spine Physical Medicine and Rehabilitation Patients During the COVID-19 Shutdown

Bhuva, Sheena MD; Lankford, Craig MD; Patel, Nayan MD; Haddas, Ram PhD

Author Information
American Journal of Physical Medicine & Rehabilitation: December 2020 - Volume 99 - Issue 12 - p 1079-1085
doi: 10.1097/PHM.0000000000001600

Abstract

What Is Known

  • Physicians have been resistant to incorporating telemedicine despite cost savings and expansion of technology. Barriers to physician use of telemedicine include ambiguity on reimbursement and the inability to perform a thorough physical examination.

What Is New

  • The results of this study show that telemedicine can provide very effective and satisfactory care in a physical medicine and rehabilitation spine practice. This was especially notable with follow-up visits where imaging and treatment plan can easily be discussed over telemedicine. Stay-at-home orders and improved reimbursement during the COVID-19 pandemic have spurred adoption of telemedicine with high patient satisfaction.

Telemedicine may seem like a novel service in medicine, but the modality was first introduced in the late 1950s when a closed-circuit television link was established between a psychiatric practice and a hospital for consultations.1 In the early 2000s with the improvement of technology, telemedicine became popular in stroke care and intensive care units,2 thus, bringing life-saving care and education to geographically remote patients and healthcare facilities that lacked accessibility to physician specialties. In addition to providing access to care to patients, a major benefit of telemedicine is the decreased cost and burden for the patient and caregivers.3 Because a telemedicine visit can be conducted at the patient’s home or work, patients can significantly reduce time and money associate with travel.4 In addition, patient cost savings also occur with decreasing the need for an altered normal schedule while taking time off of work or using childcare to physically go to an office visit.5

There are financial benefits to healthcare systems as well. The Veterans Affair healthcare system provides travel reimbursement to qualifying patients, and this amount is a large expense for the US government with a projected cost of nearly US $1 billion in 2015.6 Telemedicine can decrease the amount spent on travel reimbursement for the Veterans Affair. Another example of cost savings is in skilled nursing facilities. Most skilled nursing facilities do not have an after-hour physician, which is often physical medicine and rehabilitation (PM&R) physicians, and some do not have reliable physician access because of location.7 Telemedicine in skilled nursing facilities has been shown to decrease unnecessary hospitalizations and readmissions.7 A 365-bed skilled nursing facility in Brooklyn implemented telemedicine and estimated an associated cost savings of US $1.55 million to Medicare and other payers in just 1 mo.7 There have been studies of telehealth services in the outpatient PM&R musculoskeletal field and possible healthcare cost reduction.8 However, these mostly focused on telerehabilitation for conditions such as chronic neck pain9 and other musculoskeletal disorders,10 and not so much comparing telemedicine with a face-to-face physician visit. The PM&R department in the Veterans Affair system has been an early adapter to telemedicine especially with patients who have mobility impairments from a spinal cord injury, traumatic brain injury, or amputation. Despite an increase in telemedicine use over the years in the Veterans Affair, the number of telemedicine patient visits with a PM&R physician is drastically less than the number of telehealth visits with a physical therapist.11

Although cost savings and expansion of technology would be incentives for using telemedicine, physicians have been resistant to change and have not been quick to incorporate telemedicine.12 According to The Physicians Foundation 2018 survey of America’s physicians practice patterns and perspectives, only 18.5% practiced some sort of telemedicine. This included primary care and specialists. In general, significant barriers to physician use of telemedicine include state and federal ambiguity on reimbursement and the inability to auscultate the heart or lungs.13,14 Specific barriers for a spine PM&R practice include feasibility of a thorough physical examination such as testing reflexes, subtle changes in weakness or sensation, and when indicated rectal tone. These findings can help diagnose more emergent conditions requiring surgical intervention.15 Moreover, procedures such as electrodiagnostic studies and spine injections cannot be performed virtually.

Based on the previously mentioned barriers that have been documented in a systematic review, physicians and patients in the past have not been moved by an urgent desire to transition toward telemedicine.16 That mindset changed in the middle of March 2020 during the SARS-CoV-2 pandemic (also known as COVID-19). Clinics around the country were essentially shut down, and in most states, all elective procedures were halted in an attempt to decrease hospital burden and conserve personal protection equipment. Almost overnight, practices changed the way they provided patient care by turning to telemedicine.17 The Centers for Medicare and Medicaid Services broadened access to telemedicine and fortunately began reimbursing at the same rate as in-person visits.18 This allowed physicians to provide safe care virtually while decreasing the spread of COVID-19.

There remains a lack of research on the patient experience and execution of telemedicine when used as a substitute for traditional face-to-face office visits in the PM&R spine subspecialty. Therefore, the purpose of this study was to investigate the implementation and patient satisfaction of telemedicine visits in a PM&R spine practice during the recommended shutdown because of the COVID-19. Implementation in this study is defined by the ability to provide similar care to an in-office visit by obtaining a history and physical examination, reviewing images and discussing treatment plan, maintaining high patient satisfaction, and also decreasing cost to the patient in terms of travel and time. These were outcomes that were studied in a review of the effectiveness of outpatient telehealth consultations.19

METHOD

After receiving institutional review board approval, we prospectively recruited patients who presented to our PM&R spine telemedicine service. This study conforms to all Strengthening The Reporting of OBservational Studies in Epidemiology guidelines and reports the required information accordingly (see Supplemental Checklist, Supplemental Digital Content 1, https://links.lww.com/PHM/B137). Patients provided written informed consent to be included in the study.

Subjects

An anonymous survey was sent to all 680 patients seen via telemedicine during the COVID-19 lockdown between March and June 2020. These patients were seen by three PM&R physicians via telemedicine at a single outpatient multidisciplinary spine private practice through a Health Insurance Portability and Accountability Act–compliant platform (Doxy.me). Of the 172 responses, there were 80 male (46.7%) and 92 female (53.3%) patients with an average age of 64.47 yrs (SD = 12.42; Fig. 1).

FIGURE 1
FIGURE 1:
Age frequency among spine pain management patients (N = 172).

Testing Procedures

After patients’ telemedicine appointments, each patient was sent an anonymous survey regarding their appointment through the practice’s secure patient portal. The full set of questions can be found in Table 1. Age and sex were asked for demographic purposes and to assess whether there was a difference in satisfaction in older patients. Type of visit was evaluated for any difference between new and various types of follow-up visits. Audio versus audio with video was asked to ensure that most visits used the synchronous audiovisual component for the survey to fully capture any technological issues. Patient satisfaction level and preference of telemedicine over in-person visit were asked as major outcomes of our study. Questions about reviewing imaging, ordering modalities, and documenting issues with patient participation in history, physical examination, or treatment plan were asked for establishing implementation of providing similar care as an in-person visit. In addition, round-trip distance for a potential in-office visit was asked to demonstrate patient cost-saving measures of time and money related to travel.

TABLE 1 - Telemedicine questionnaire
Question Response Option
What type of telemedicine visit did you have with the doctor? • New patient
• Postoperative
• Postinjection
• Follow-up without procedure such as medication refills or established patient with a new complaint
• Other
Did your visit include audio alone or audio with video? • Audio alone
• Audio with video
Overall, how satisfied were you with your telemedicine appointment? • Very dissatisfied
• Dissatisfied
• Neither dissatisfied nor satisfied
• Satisfied
• Very satisfied
Did your doctor review your imaging (x-rays, CT, and/or MRI) with you? • Yes
• No
• Not applicable, I did not have imaging to review
Did your doctor order any medications, tests or procedures during your visit? (please check any that apply) • No
• Yes, prescription medications
• Yes, imaging (x-rays, CT, and/or MRI)
• Yes, physical therapy (telehealth PT or in-person PT)
• Yes, injection, radiofrequency ablation/rhizotomy, or other pain procedure
• Yes, nerve conduction study/electromyography (NCS/EMG)
• Yes, referred to a surgeon
Were any of the following problematic during your encounter? (please check any that apply) • Ability to communicate symptoms and relevant history
• Ability to participate in the physical examination
• Ability to understand X-ray, CT, or MRI results
• Ability to understand treatment plan
• Ability to ask questions
• None of the above
How many miles would you have to travel to see the doctor in person at his/her office? (round trip) • 0–10 mile
• 11–25 mile
• 26–50 mile
• 51–100 mile
• 101–200 mile
• 200+ mile
If given the option, would you choose a telemedicine visit over an in-person visit? • Yes
• No
What is your age? • <20 yrs
• 20–29 yrs
• 30–39 yrs
• 40–49 yrs
• 50–59 yrs
• 60–69 yrs
• 70–79 yrs
• 80–89 yrs
• 90–99 yrs
• 100+ yrs
What is your sex? • Male
• Female
• Prefer not to say

Statistical Analysis

We described the sample using frequency (percent) for categorical variables and mean (standard deviation) for continuous variables. Statistical analyses were conducted using SPSS, Version 23.0 (IBM, Inc, Chicago, IL).

RESULTS

Overall, 57.6% of the patients were seen for a follow-up appointment for medication refills and/or new complaint in an established patient, whereas 20.9% were seen for a postinjection appointment (Table 2). A total of 90.4% of the appointments were video calls when only 9.6% were audio only.

TABLE 2 - Telemedicine appointment type (N = 172)
What Type of Telemedicine Visit Did You Have With the Doctor?
Appointment Type n %
New patient 12 7.0
Postoperative 3 1.7
Postinjection 36 20.9
Follow-up without procedure 99 57.6
Other 22 12.8

Overall, 83.7% of the patients were very satisfied with their telemedicine appointment and 13.9% were satisfied with the telemedicine appointment (Fig. 2). When analyzing patients 60 yrs and older, 83.2% were very satisfied with their telemedicine appointment and 14.2% were satisfied with the telemedicine appointment. In 23.3% of the cases, the PM&R physician reviewed the available patient’s imaging (x-ray, CT, or MRI) with them. In 70.9% of the cases, the patient did not have images to review, and in 5.8% of the cases, the physician did not review imaging with the patient.

FIGURE 2
FIGURE 2:
Satisfaction from telemedicine (N = 172).

Overall, in 44.44% of the cases, the PM&R physician prescribed medication to the patient. In 21.60% of the cases either an injection, radiofrequency ablation/rhizotomy was ordered, and in 9.87% of the cases, telehealth physical therapy or in-person physical therapy was ordered. A total of 17.90% of the cases did not require further medical orders (Table 3).

TABLE 3 - Follow-up procedure (n = 168)
Did Your Doctor Order Any Medications, Tests, or Procedures During Your Visit?
Procedure Type n %
No 29 17.90
Yes, prescription medications 72 44.44
Yes, imaging (x-rays, CT, and/or MRI) 6 3.70
Yes, physical therapy 16 9.87
Yes, injection, radiofrequency ablation/rhizotomy, or other pain procedure 35 21.60
Yes, nerve conduction study/electromyography (NCS/EMG) 3 1.85
Yes, referred to a surgeon 1 0.61

Figure 3 represents technical problems during the telemedicine appointments. Most patients (87%) did not have any issues during their telemedicine encounter. Only 8% and 3% had issues with the video and audio, respectively (Fig. 3).

FIGURE 3
FIGURE 3:
Technical problems during telemedicine (N = 168).

Overall, 41.86% of the patients had to travel less than 10 miles if they would see the PM&R physician in person. A total of 22.67% and 15.69% of the patients had to travel less than 25 and 50 miles, respectively, to visit with the PM&R physician face to face. A total of 7.55% of the patients would have had to travel greater than 100 miles (Table 4).

TABLE 4 - Distance needs to travel for a traditional appointment (N = 172)
How Many Miles Would You Have to Travel to See the Doctor in Person at His/Her Office? (Round Trip)
No. Miles to Travel to the Office n %
0–10 72 41.86
11–25 39 22.67
26–50 27 15.69
51–100 21 12.20
101–200 2 1.16
200+ 11 6.39

Lastly, 64.5% of the patients would rather have telemedicine over in-person appointments (Fig. 4). A total of 56.1% of the patients who are 60 yrs and older prefer telemedicine over in-person appointments. A total of 67.4% of follow-up patients prefer telemedicine over in-person visits.

FIGURE 4
FIGURE 4:
Telemedicine over in-person appointments (N = 172).

DISCUSSION

The purposes of this study were to investigate patient satisfaction and to describe the implementation of telemedicine visits in a PM&R spine private practice. Most patients expressed very high satisfaction rates with telemedicine despite potential barriers for implementation such as age, technical issues, belief of less personal interaction and decreased ability to provide thorough clinical care, and physical examination hindrances. There were likely many factors involved that lead to the high patient satisfaction rate that we will attempt to address.

Age did not seem to play a factor in telemedicine implementation because almost 60% of patient respondents were older than 60 yrs. This correlates with the known prevalence that low back pain due to osteoarthritis, disc degeneration, and spinal stenosis increase with age.20 Eighty-three percent of patients older than 60 yrs were very satisfied with their telemedicine visit, which is a similar ratio compared with the overall satisfaction. Implementation may also have been easier because the older population has increased smartphone usage significantly from 2012 to 2019 with current ownership at 68% of baby boomers (age = 55–73 yrs) and 40% of the silent generation (age = 74–91 yrs).21 Although most older respondents in our study were satisfied with their telemedicine visit and many seniors have a positive outlook toward technology and its benefits, they do face unique barriers such as physical challenges and confidence with devices such as smartphones and tablets.22 Because older patients consist of a large population of a PM&R spine practice, telemedicine platforms need to be easy to use, which will help with patient satisfaction. Anecdotally with our study, some patients needed help from their children or grandchildren setting up their telemedicine visit, but feasibility was easier because of the telemedicine platform (Doxy.me) used. There was no need to download software or create an account, which made the process easier and smoother for the patient unlike previous telemedicine platforms, which were poor in design and technically challenged the staff,23 thus adding another previous barrier for incorporating telemedicine. In addition, there was a subset of patients in these older age groups who remarked that because of social distancing due to the COVID-19 pandemic, they had become more accustomed to using virtual chat functions such as FaceTime, WhatsApp, and Zoom to keep in touch with family and friends, which also likely helped with decreasing the potential age barrier for implementation and patient satisfaction.

Technical problems with either the video or audio portion due to WiFi or connectivity issues were seen in a small percentage of the survey responses. Although income and city type were not asked in this survey, it is reasonable to believe that these factors may have played a role in implementation and patient satisfaction. Our practice is located in a large suburb where Internet access is more readily available; however, we do have some patients who live in rural and low-income areas, which are disproportionately affected because of poor broadband Internet access.24 This did lead to a percentage of dropped calls and excess time attempting to re-establishing connection. The COVID-19 pandemic has highlighted the importance of broadband Internet access in health care.25 The American Medical Informatics Association released a letter urging the Federal Communication Commission to categorize broadband access among the social determinants of health and recommended specific actions for the taskforce.26 This would allow patients to participate in telemedicine visits despite living in a rural or low-income area. Increased access would naturally lead to better patient and physician satisfaction as well as implementation because fewer technical issues would interrupt the telemedicine visit. Although one may initially believe that a telemedicine visit provides less personal interaction and a barrier in establishing the physician-patient relationship, this did not seem to be the case in our study. Using a synchronous audiovisual platform via telemedicine allowed the PM&R physicians to maintain empathy through verbal and nonverbal communication for appropriate patients who have psychological distress due to their pain. Low back pain can cause anxiety and depression, and these conditions can in turn exacerbate low back pain symptoms.27 Empathic communication with patients can reduce patient anxiety and even pain levels,28 which have been linked to patient satisfaction.29 Most telemedicine visits in the study combined audio and visual components, which allowed the physician to use empathic communication if desired during the patient encounter.

Despite needing to adhere to strict social distancing guidelines because of the COVID-19 pandemic, telemedicine implementation allowed clinical care to not only continue in follow-up patients but also be used in new patients. Using telemedicine for established patients can provide effective follow-up visits when compared with traditional face-to-face office visits.30 This conclusion was supported by our data where 64.5% of survey respondents would choose a telemedicine visit over an in-person visit. Specifically, those who fell under the umbrella of follow-up visits would choose telemedicine over in-person was 67.4%. The survey documented patient encounters where physicians were still able to prescribe medications, order imaging, refer to physical therapy, and order procedures such as injections or electrodiagnostic studies without an in-person visit, thus saving patients time and money on travel. In addition, the telemedicine platform used by the PM&R physicians allowed sharing of the physician’s computer screen to review imaging with the patient. This was similar to the process of reviewing imaging in an in-person clinic visit. Patients could see their imaging from their own home or office while a treatment plan was discussed in a social distancing manner. Studies have shown that patients who see their imaging, especially with regard to musculoskeletal pathology, are empowered and have a better understanding of their condition.31 Ability to review images is another factor that may have contributed to patient satisfaction. The previously mentioned examples show that implementing telemedicine can be efficacious in a spine PM&R practice in terms of providing similar care to a personal in-office visit by reviewing images and discussing treatment plan, maintaining high patient satisfaction, and also decreasing cost to the patient in terms of travel and time.

The use of telemedicine for patients may be limited by being able to do a thorough physical examination, but with PM&R spine, there are portions of the musculoskeletal examination that can be performed virtually to help establish diagnosis. Caregivers and family members can also assist in some aspects of the physical examination with the patient’s consent.32 Specifically for spinal pathology, range of motion can still be examined as well as neural tension signs such as Spurling’s33 and straight leg raise or slump test.34 Patients can walk on their heels and toes, perform calf raises, and tandem walk to assess for any dorsiflexion/plantarflexion weakness or myelopathy.35 Tricep dips or wall push-ups can help elicit elbow extension weakness in cervical radiculopathy.36 Being able to do these physical examination maneuvers by implementing telemedicine can help establish a diagnosis in a timely manner, which leads to patient satisfaction.37

Study Limitations

It is important to note that there are limitations to our study. This study had a 25% response rate, which we understand leads to a small sample size and a sampling bias. The patients who responded may be more comfortable with technology and therefore may respond in a more positive way. The pandemic and associated stressors may also have a component in reducing response rate. Furthermore, it is important to note the limitations of online surveys including issues of time, space, and number of responses allowed for a given price. Lastly, no comparison group was available for our analysis. A future study should focus on the efficiency and stratification of telemedicine in comparison to the traditional face-to-face visit. A more robust future study can involve multiple centers in different practice and city settings.

CONCLUSIONS

The results of this study show that implementing telemedicine can provide very satisfactory care in a PM&R spine practice. Patient satisfaction was high and was one of the primary outcomes that was collected in the study. Positive execution of telemedicine was also established by the survey responses. The responses showed telemedicine can provide similar care to an in-office visit. This was shown through the ability of obtaining a history and physical examination, reviewing images, discussing treatment plan, ordering appropriate interventions, and maintaining high patient satisfaction. In addition, time and money were saved for the patient and healthcare system while minimizing risk and decreasing the spread of COVID-19. Stay-at-home orders and improved reimbursement during the COVID-19 pandemic have spurred adoption of telemedicine with high patient satisfaction in our practice. Physical medicine and rehabilitation physicians should take advantage of technology and use telemedicine as a feasible option for their practice. Insurance companies should note the advantages of telemedicine and continue to provide reimbursement during this current pandemic and ensuing years. We hope that federal regulations remain open to change as physicians and patients adapt and navigate through this new way of clinical practice.

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Keywords:

Telemedicine; Physical Medicine and Rehabilitation; Spine; COVID-19; COVID-19 Shutdown; Satisfaction

Supplemental Digital Content

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