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Featured Articles: Technology, Computing, and Simulation

To Infinity and Beyond: The Past, Present, and Future of Tele-Anesthesia

Bridges, Kathryn Harter MD; McSwain, Julie Ryan MD; Wilson, Phillip Ryan MD

Author Information
doi: 10.1213/ANE.0000000000004346

Abstract

See Editorial, p 272

Telemedicine, a term originally created in the 1970s, literally means “healing at a distance.”1,2 The World Health Organization now defines telemedicine as the provision of health care services via the use of communication technology for the diagnosis and treatment of diseases and for continuing education of health care providers in settings where distance is a factor.3 Over the past decade, the use of telemedicine for patient evaluation and treatment has grown. Initially used primarily for radiological and emergency medicine services, the use of telemedicine technology has expanded to include nearly every field of medicine, from subspecialty services to primary care. Anesthesiology has embraced the use of telemedicine both as a means to perform preoperative evaluations and to provide remote intraoperative patient monitoring in a care team model. Models for postoperative care in both home and intensive care unit (ICU) settings have also evolved to include virtual care capabilities. Telemedicine presents a unique opportunity to expand the reach of anesthesiologists to patients throughout the perioperative period and marks a source of potential growth and expansion within the specialty.

PREOPERATIVE USES

The first reported use of telemedicine in the field of anesthesiology consisted of a 2004 case series in which 10 patients underwent preoperative evaluation using a viewing screen equipped with a mounted camera operated by a nurse at a remote facility.4 Patient satisfaction with the experience was high, as was the satisfaction of the anesthesiologists who ultimately cared for the patients in the operating room. Similar patient and staff satisfaction was noted in later studies, including a large series of 140 multidisciplinary pediatric consultations in which 71% of patients noted that they were “completely satisfied” with their experience.5,6 More recently, a 2015 study of 27 patients living in remote areas of Australia underwent virtual anesthesia preoperative evaluation and reported 98% satisfaction with the technical quality of the examination and a 95% perceived efficacy.7

Mullen-Fortino et al8 demonstrated, in addition to high patient satisfaction, the added benefit of shortened in-person visit times for those patients who underwent a telemedicine consultation before visiting clinic for further testing. For those patients, the average in-person preoperative clinic appointment took 24 minutes less than those patients who had not had a telemedicine consultation in advance, thus conveying a time benefit to the patients and improved overall clinic efficiency.8 Of note, willingness to participate in telemedicine consultation is not universal, as demonstrated by Fishman et al,9 who conducted a survey in which roughly half of respondents indicated that they did not wish to undergo a telemedicine evaluation even when travel costs were great. This may suggest either a discomfort with technology or a desire for in-person human interaction and notes consideration in an era with rapidly expanding technological growth.

From a financial standpoint, telemedicine may offer cost savings for patients. Zetterman et al,10 on introduction of remote preoperative evaluation within the Department of Veterans Affairs (VA) health care system, found that 87.5% of patients felt that the use of telemedicine saved them time and money with 85% reporting that the evaluation was equivalent to an in-person visit. Dick et al5 noted significant cost savings, approximately $1300 on average in travel, lodging, and associated costs, when patients living in remote areas averaging over 800 miles from the tertiary care center were provided the option of telemedicine consultation. Notably, an average yearly savings of $18,000 in patient travel reimbursement were noted in the VA health care system after incorporating preoperative telemedicine evaluations.11 In-person consultation may require patients to take time off of work and arrange alternative childcare, both of which have negative financial impacts. Due to the overall expense, distance may contribute to patients failing to attend an in-person preoperative clinic visit even when it is medically indicated, with a 2006 study revealing that patients living >60 miles away were less likely to keep such an appointment compared to those living <30 miles away.12

Failure to undergo a preoperative anesthesia evaluation may contribute to day of surgery cancellation which has a negative financial impact on both patients and hospitals. Cancellation in the private sector is costly for health care systems: $1400–$7500 per case.13 Up to 25% of day of surgery cancellations are due to inadequate preoperative workup, and it is well established that preoperative clinics reduce risk of such cancellations and delays.14–18 Telemedicine assessment has a similar efficacy with multiple studies reporting limited or no cancellations for incomplete preoperative evaluation.6,8,10,19 Tam et al20 found a 1.3% last minute cancellation rate, consistent with the international average, in patients who underwent telehealth evaluation as opposed to an in-person visit, thus suggesting an equivalent performance between the 2 evaluation options. From a hospital perspective, the estimated cost of implementing telemedicine technology ranges from $1700 to $7000 depending on the equipment chosen and rivals the cost of a single case cancellation, thus potentially producing a net zero or even favorable cost/benefit ratio depending on the institution’s cancellation rate and availability of alternatives such phone screening.21

Patient selection is an important consideration for virtual preoperative evaluation. The use of telemedicine preoperative evaluation has been studied in a variety of patient populations, most notably those living in rural areas, with some living as far as 800 miles from the tertiary care center.4–7 Incarcerated patients in whom arranging travel is complicated underwent successful telemedicine preoperative evaluation before oral and maxillofacial surgery with no complications, highlighting this patient population as one in whom remote evaluation may be beneficial.19 While head and neck and oral surgery patients were the primary focus of many studies in which the telemedicine evaluation was performed,6,21 Mullen-Fortino et al8 expanded teleconsultation to include patients having all types of surgery and reported high patient satisfaction, zero cancellations, and reduced visit times. However, in this study, every telemedicine visit was followed by an in-person visit with physical examination and thus served as an adjunct approach as opposed to a standalone means of preoperative evaluation.

INTRAOPERATIVE USES

One of the earliest reports of the use of telemedicine in the intraoperative setting was in 2004. Cone et al22 describe the use of telemonitoring from an anesthesiologist in the state of Virginia to assist in an anesthetic for a cholecystectomy performed on a patient in Ecuador. Interestingly, the patient had a challenging airway with conventional direct laryngoscopy with a concomitant change in heart rhythm, resulting in a collaborative decision to awaken the patient and perform an awake nasal intubation. The same physician group then published a follow-up report in which they use telemedicine throughout the perioperative period to complete 7 cases during 2 separate surgical missions.23 Equipment included real-time standard patient monitoring, visual transmission of airway confirmation with a fiber optic camera, and audio transmission of heart and lung sounds via an electronic stethoscope. In 2009, Fiadjoe et al24 described the successful use of remote monitoring by a Philadelphia-based anesthesia team for 2 separate liver transplants that occurred in India. Both of these cases also highlight the idea of “telementoring” in which remote teams can collaborate and teach in real time using a variety of audiovisual systems.23 The authors of both case reports, however, note that there are hurdles to overcome including medical licensure (including liability issues and issues with obtaining informed consent), equipment function and maintenance of a secure and encrypted transmission feed, and payment/reimbursement issues. While this report involved transcontinental care between different countries, these same issues exist within the United States across state borders.

Patient conditions can change rapidly in the operating room, necessitating reliable data transmission and communication such that no mistakes are made due to communication disconnection. A recent report from Japan described successful tele-anesthesia transmission at a distance of 300 km.25 Due to personnel shortages, an anesthesia provider on one island in the Sea of Japan was faced with administering anesthesia to ≥2 patients simultaneously. Because this was physically impossible, the solution was the use of tele-anesthesia. An anesthetist on mainland Japan directed the intraoperative care of the second patient while a nurse in the operating room received and executed the anesthetic commands, including managing anesthetic and vasopressor medications. The communication was routed through a virtual private network (VPN), and FaceTime (Apple Inc, Cupertino, CA) was the communication tool used between the nurse at the island hospital and the anesthetist at the mainland hospital. Parallel anesthesia was provided for 279 minutes in 4 pairs of cases during the pilot study with the successful completion of all anesthetic commands and only 7 FaceTime disconnections lasting a total of 10 minutes. Because no commands were given during this disconnection time, the backup plan of telephone communication was not used. Given the pilot study design, it is difficult to comment on overall safety; however, this study demonstrates that it is feasible to reliably conduct an anesthetic via telemonitoring with limited breaks in audiovisual connection.

Another potential use for telemedicine within the intraoperative realm is for educational purposes. Miyashita et al26 describe the use of free video conferencing tools to educate and assist anesthesiologists in remote areas to conduct ultrasound-guided anesthetic procedures in real time. While this nonclinical report evaluated the feasibility of different devices to provide the best real-time visual communication to assist in peripheral nerve blocks, the possibility exists for future studies to evaluate the clinical use of telemonitoring to guide anesthesia providers in remote locations as they learn new procedures.

Furthermore, intraoperative uses of telemonitoring and telementoring within the anesthesia realm could be beneficial in disaster situations that result in mass casualties requiring emergent care where resources, especially anesthesiologists, may be stretched thin. Futuristic applications could include monitoring in space and in the far reaches of earth.

POSTOPERATIVE USES

There have been extensive reports in the literature on the use of telemedicine for postoperative clinic visits or as a way to monitor surgical patients after hospital discharge.27–30 Collins et al31 created a virtual ICU (VICU) that was physically located in a postanesthesia care unit (PACU). The purpose of this VICU was to monitor postoperative patients who needed a higher level of care but for whom no ICU beds were currently available. The authors found that approximately 72% of patients in the VICU were able to be transferred directly to the floor, and all patients were alive on transfer out of the PACU. They concluded that collaborative care with virtual telemonitoring can potentially be a safe solution to provide higher-level care to postoperative patients during periods of ICU overflow. Given the high utilization of ICU beds in many large hospital centers, it stands to reason that other modalities of postoperative ICU care could be used as a surrogate when there are periods of ICU overflow. In addition, it may also allow critical care intensivists to monitor and participate in the care of more patients who may physically be located outside the traditional ICU setting or those hospitalized in remote facilities without dedicated critical care specialists (Figure 1).

Figure 1.
Figure 1.:
Virtual ICU monitoring center at Medical University of South Carolina. An intensivist monitors patients physically located in a hospital elsewhere in the state via real-time, continuous telemetry with immediate access to imaging and laboratory results. Two-way audiovisual communication enables intensivists, critical care nurses, and other critical care team specialists to collaborate to provide remote ICU care. ICU indicates intensive care unit.

Remote monitoring of vital signs and other medical data is a rapidly developing area of medical technology and may have applicability for anesthesiologists in the postoperative care of patients in a variety of settings, including the surgical floor.32 For example, remote monitoring via wireless medical-grade biosensors is currently being used in the postsurgical care of patients in an effort to reduce complication rates via early prediction and notification of patient deterioration.33 While automated notification of changing vital signs via biosensor technology has been shown to decrease activation of rapid response teams and increase involvement of ward teams,33 the overall impact of these devices in the immediate postoperative period for postanesthesia care has yet to be determined.

Anesthesiologists who participate in a Perioperative Surgical Home model of care may find recent technological advances useful for postsurgical care. For example, a recent pilot study described the use of a mobile application for inpatients to record daily postoperative milestones after having colorectal surgery within an Enhanced Recovery Program (ERP).34 Patients recorded adherence to 15 different ERP processes and 6 patient outcomes. Approximately 89% of patients found the application helpful in their recovery, and 76% of patients felt that it increased motivation to recover.34 One could envision the expansion of technology to include mobile applications for self-reporting of protocol adherence as well as wearable devices that record physical activity, both of which have the potential to positively impact ERPs throughout the perioperative continuum.35

Equipment

With the rapid growth of high-quality video technology along with high-speed communications capabilities, opportunities in telemedicine are quickly expanding. A large variety of equipment and communications products are available along a wide range of price points, meaning equipment can be scaled to practice-specific needs in an efficient manner. Larger preoperative clinics may be interested in formal video tower technology. These towers are equipped with high-quality audiovisual capabilities for communication as well as integrated physical examination tools, including digital stethoscopes and examination cameras (Figure 2). Such equipment is highly capable, with a study by Applegate et al6 confirming high concordance with the day of surgery examination documentation. These units provide the highest level of detailed patient interaction and enable a pertinent preoperative physical examination to be performed, with specific focus on cardiopulmonary and airway examinations. An electronic stethoscope used for cardiopulmonary examination coupled with a high-quality headset capable of reproducing lower-frequency sounds ensures audibility of the heart and lung sounds6 (Figure 3). The airway examination may be performed using a handheld video camera with a staff member available to move the camera as needed to complete the adapted American Society of Anesthesiologists (ASA) 11-point airway examination4,6 (Figure 4). Ideally, these tower units should at the very least have a video screen, controllable camera with tilt/pan/zoom options, high-quality microphones and speakers for verbal communication, as well as multiple connector ports for interchangeable digital examination tools.36

Figure 2.
Figure 2.:
Example of a video tower with handheld camera, digital stethoscope, and otoscope attachments.
Figure 3.
Figure 3.:
Example of a telemedicine visit at Medical University of South Carolina. A nurse facilitates the visit by applying an electronic stethoscope to the chest to allow auscultation of heart and lung sounds by the physician. Real-time video allows communication between physician and patient.
Figure 4.
Figure 4.:
Remote airway examination at Medical University of South Carolina. Use of a fiber optic camera allows remote visualization of the airway.

The variety of different vendors and manufacturers available allows for a competitive comparison between models, with specific focus given to durability, optical versus digital zoom and auto focus cameras, Universal Serial Bus (USB) compatibility, level of required setup versus ability to “plug and play,” and general ease of use.37 More in-depth examination tools also exist for point-of-care testing with video towers, including 12-lead electrocardiogram testing, digital spirometers, and even USB-compatible ultrasound probes for cardiac, vascular, or nerve imaging, such as those offered as part of the AGNES Interactive system (AMD Global Telemedicine, Chelmsford, MA).

Mirroring the rapid growth in personal communications software such as “Skype” (Skype Technologies, Palo Alto, CA) or FaceTime as well as business communications software like GoToMeeting (LogMeIn Inc, Boston, MA) and “Zoom” (Zoom Video Communications, San Jose, CA), multiple videoconferencing options are available in the absence of a full telehealth video tower capabilities. Many of the available options are derivations of the previously mentioned business conferencing solutions, with modifications made to ensure Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliance for patient safety. For example, the University of California, Los Angeles Department of Anesthesiology and Perioperative Medicine has incorporated a Tele-Preoperative Evaluation program using software from Zoom in which surgeons may directly refer their patients for virtual telemedicine anesthesia preoperative visits.38 The Zoom videoconferencing software may be used alongside the Epic-based electronic medical record (EMR) system to allow for a smooth incorporation of telemedicine visit referral and documentation. Videoconferencing solutions like these are also flexible in terms of technology investment and portability because they work with high-quality videoconferencing monitors as well as individual smartphone and tablet technology. The ability to conduct a visit with a patient in his or her own home via personal smartphone or tablet greatly increases the reach of telemedicine to even the most remote areas.

Table 1. - Comparison of Facilitated Visit Utilizing Brick-and-Mortar Teleconsultation Site Versus Direct-To-Consumer Visit Using Personal Tablets, Laptops, or Cellular Phones
Facilitated Visit Direct-to-Consumer
Requires origination site facility Yes No
Requires staff to operate video tower equipment Yes No
Able to obtain vital signs Yes No
Able to perform facilitated cardiac/pulmonary examinations Yes No
Able to obtain basic testing (EKG, spirometry) Yes No
Full video-enabled interview Yes Yes
Able to perform airway examination Yes Yes, with patient assistance
Capability for on-site laboratory work Yes No

Dilisio et al39 describe a case report in which a patient scheduled for an in-office anesthetic was predicted to have a difficult airway due to his medical history. The patient used his smartphone to photograph a head shot of himself which was sent to the anesthesiologist for review, thus confirming potential difficulty with intubation and resulting in transfer to a hospital-based operating room. With a study suggesting that <10% of patients were willing to travel for a preoperative visit, the ability to utilize smartphone technology may provide an alternative means of airway assessment.40 The flexibility of videoconferencing technology has led to the distinction between facilitated visits (FVs) utilizing brick-and-mortar teleconsultation sites versus direct-to-consumer (DTC) visits using personal tablets, laptops, or cellular phones.36 Although the ubiquitous nature of smartphones makes these visits attractive, it also predisposes to the inherent difficulties with telemedicine and HIPAA compliance. Table 1 compares advantages and disadvantages of FV versus DTC visits.

HIPAA Compliance

Maintaining HIPAA compliance with any of the above-mentioned technologies can be a difficult endeavor when the appropriate steps are not taken. Essential aspects of HIPAA compliance for these technologies include data encryption, login controls, and auditing ability.37 No single device can be “HIPAA compliant” on its own because compliance also encompasses the means by which the product communicates with other technologies.37 Specifically with reference to smartphone visits, the commonly used personal communication platforms like Skype and Google-based applications inherently present a problem by storing information from communications on their own servers.41 For HIPAA compliance, any third party involved in data storage must have a Business Associate Agreement (BAA) in place with the health care provider, in which they provide their methods of ensuring data security. These agreements protect the health care provider from liability should a data breach occur. Companies that are not geared toward telemedicine typically will not enter these BAA agreements.41

Other Barriers

Aside from HIPAA compliance, many of the main legal concerns regarding telemedicine, including state medical licensing laws, tele-prescribing, billing for services, and informed consent, are by nature less applicable in the setting of preoperative anesthesia care. Preoperative assessments rarely, if ever, require the anesthesiologist to prescribe medication, eliminating one of the barriers most heavily burdened with regulations. Given that anesthesia services are reimbursed in a bundled fashion, a preoperative anesthetic evaluation performed via telemedicine is less susceptible to the rigors of meeting insurance billing standards when compared to typical evaluation and management visits of other medical specialties.

Informed consent is an important factor in many aspects of medicine, and telemedicine itself is no different. Regulations vary on a state-to-state basis, with some requiring written informed consent, while others allow for verbal consent to participate in a telemedicine encounter. The Center for Connected Health Policy, a national telehealth policy resource center, provides a comprehensive list of current state laws and reimbursement policies searchable by state, available online at www.cchpca.org. Reisenwitz42 recommends using a consent form including names and credentialing of all involved health care providers, as well as descriptions of all telehealth services performed and technologies used, to be best protected from a legal standpoint.

DISCUSSION

Telemedicine may have great potential in the field of anesthesiology given the rapid growth of technology and equipment. However, like any new technology within the practice of medicine, it must first be tested and validated for patients, providers, and hospital systems. In addition, the cost/benefit analysis will become an extremely important part of any conversation with regard to implementation of a tele-anesthesia program given the climate of health care and rising costs of care due, in part, to the aging population.

Preoperative Uses

From a preoperative standpoint, remote evaluation has been shown, in certain instances, to save time and money for patients. However, it is unclear whether it would be financially favorable for hospital systems to engage in preoperative telemedicine evaluations depending on the institution’s needs, patient population, and surgical cancellation rate. Patients who do not live close to a preoperative clinic and are scheduled for elective or semiurgent surgery within a short time frame, such as 2–3 days, may find teleconsultation beneficial due to limited time to arrange travel. High patient and provider satisfaction along with advanced video equipment that is able to ensure examination accuracy are other positive attributes. However, very few studies identified what would exclude a patient from potential telemedicine evaluation, such as specific comorbidities or patient age. As the population in the United States continues to age, the need for preoperative evaluation of these patients will expand. Teleconsultation may be beneficial in elderly patients in whom travel is challenging. Similar benefit may exist for those patients who rely on wheelchairs or are bedbound and thus rely on costly mileage-based medical transport. Proximity to a local teleconsultation center versus the brick-and-mortar preoperative clinic would directly impact cost savings for such patients.

Table 2. - Comparison of Traditional Phone Screening Versus Facilitated Telemedicine Visit for Preoperative Evaluation
Phone Screening Facilitated Telemedicine Visit
Able to discuss medical history and anesthesia plan Yes Yes
Able to perform airway examination No Yes
Able to auscultate heart and lungs No Yes
Face-to-face interaction No Yes
Medical staff needed to operate equipment No Yes
Administrative support needed to identify and schedule patients Yes Yes
Able to obtain basic testing (EKG, spirometry) No Yes
Patient participation from home Yes No
Required capital investment Limited Extensive

While the elderly and those with significant comorbidities may benefit from reduced travel need, such patients are also some of the most medically complex. In these patients, physical examination capability, specifically the ability to auscultate the heart and lungs, represents a potential benefit of teleconsultation compared to the traditional phone screen. However, to complete a full preoperative evaluation, including vital signs, airway examination, and cardiopulmonary examination, these patients would still have to travel to a local center that contained both the teleconsultation equipment as well as a health care provider that could assist in using the equipment. From a hospital perspective, it is unclear whether the cost–benefit of setting up such sites would be efficiently utilized compared to a standard means of remote consultation such as phone screening. These sites still require administrative staff to schedule appointments and assist with patient check-in in addition to a staff member, usually a medical assistant or nurse, to operate the examination equipment. Table 2 provides a comparison of preoperative telemedicine evaluation versus traditional phone screening. Furthermore, not all patients desire remote evaluation, and the exact reasons for this have not been elucidated. If discomfort with technology is to blame, this represents a potential barrier to adoption of tele-evaluation. Alternatively, some patients value an in-person interaction, and this option must persist to fulfill the expectations patients may have for a more personal patient–physician relationship.

Intraoperative Uses

For telemedicine to be successful within the intraoperative realm, equipment would need to, at minimum, reliably transmit ASA monitors including electrocardiography, pulse oximetry, and end-tidal carbon dioxide with little to no interruption in transmission feed. In addition, video recording of the operating room would be extremely desirable so that remote providers can evaluate the surgical field as well as all anesthesia monitors and operating room conditions.43 If the above conditions could be reliably met, then the intraoperative use of telemedicine could potentially increase the availability of highly trained specialists to remote areas. However, there are unique concerns and challenges with the remote practice of anesthesia. Patient conditions change rapidly in the operating room. Thus, communication breakdown and the disruption in data transmission could potentially lead to catastrophic outcomes as well as draw into question who is ultimately liable for these outcomes. In addition, unfamiliarity with the skill set of staff providing direct patient care may give anesthesiologists pause because even simple procedures can result in complications if performed by inexperienced hands. Rigorous evaluation of direct care providers to ensure adequacy of procedural skills and overall competency before instituting an intraoperative telemedicine consultation program may mitigate some of these risks.

Postoperative Uses

Remote monitoring devices that transmit postoperative vital signs could have future application for anesthesiologists, especially those that participate in the perioperative surgical home model, in improving postoperative anesthetic care. In addition, these devices could assist anesthesiologists in detecting early postoperative complications as well as aid surgical teams in the management of such complications. However, it is unclear which postsurgical patient groups may benefit from this type of monitoring over conventional PACU care. Further research needs to be performed to see if remote monitoring technology is reliable, cost-effective, and can truly decrease postoperative PACU complications, especially in failure-to-rescue scenarios, before widespread use could be recommended. For those patients necessitating ICU level of care, the development of a VICU increases capacity for critical care monitoring in times of ICU overflow which presents a potential solution to a commonly encountered dilemma. However, there also needs to be further research into which surgical populations may best benefit from postoperative telemonitoring as well as evaluating the cost–benefit of using this type of postoperative care as compared to traditional approaches.

Equipment and HIPAA Compliance

Selection of equipment and assuring compliance with federal privacy laws is a daunting hurdle. Institutions should thoroughly define needs and potential for future growth to ensure the appropriate system is chosen. Budgeting for initial equipment purchase and maintenance costs should be individualized based on projected volume and scope of use within each health system. In addition, adequate system security and staff training is imperative. Staff should not only be rigorously trained in HIPAA compliance, but they should also receive comprehensive training in equipment use such as navigating the camera and using physical examination equipment. Staff that function as facilitators should also be trained in how to troubleshoot digital equipment and replace simple parts as needed, as well as be involved in writing and assessing protocols in the event of a midvisit equipment malfunction.37 Maintaining formal working relationships with equipment vendors is essential to help identify new technology needs, update existing technology, assist with maintenance, and troubleshoot when equipment malfunction occurs.38

CONCLUSIONS

With the rapid expansion of technology in daily life, it is only natural for applications to expand into the practice of medicine. The use of telemedicine within anesthesia is a relatively new concept compared with some other specialties; however, its use within the preoperative, intraoperative, and postoperative phases of care is now gaining momentum in practice as well as in the literature. Telecommunication growth within the perioperative realm is rapidly expanding between patients and providers as well as between providers for assistance and education across institutions and borders. However, security of connection, HIPAA and medical licensure compliance, as well as cost–benefit analysis are a few of the issues that need to be further explored and researched. As telemedicine programs develop within perioperative care, it is imperative for institutions to share knowledge, successes, and pitfalls to improve health care delivery in the age of technology.

DISCLOSURES

Name: Kathryn Harter Bridges, MD.

Contribution: This author helped review the literature, draft the manuscript, and perform final review of the manuscript.

Name: Julie Ryan McSwain, MD.

Contribution: This author helped search the literature, draft the manuscript, and edit the manuscript.

Name: Phillip Ryan Wilson, MD.

Contribution: This author helped search the literature, draft the manuscript, and format the references.

This manuscript was handled by: Maxime Cannesson, MD, PhD.

FOOTNOTES

GLOSSARY

ASA = = American Society of Anesthesiologists

BAA = = Business Associate Agreement

DTC = = direct-to-consumer

EMR = = electronic medical record

ERP = = enhanced recovery program

FV = = facilitated visits

HIPAA = = Health Insurance Portability and Accountability Act of 1996

ICU = = intensive care unit

PACU = = postanesthesia care unit

USB = = Universal Serial Bus

VA = = Department of Veterans Affairs

VICU = = virtual intensive care unit

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