Where Are We Now?
Greek mythology tells us that Chiron taught Asclepius, the god of medicine, the art of hands-on healing . Now, 2500 years later, advances in electronic capabilities allow physicians to use telemedicine to treat patients miles away without ever physically touching the patient. Telemedicine is defined as the use of telecommunication technology to assess and treat patients . The advantages of telemedicine are the ability of a physician to provide diagnostic, monitoring, and treatment recommendations from a remote location, saving patients time and travel expenses. This allows the physician to provide healthcare with the added convenience and safety benefit of social distancing during a pandemic. Success with telemedicine has been reported in numerous specialties, including cancer care, urology, and vascular surgery [1–3].
The specialty of orthopaedic surgery is unique in that the physical examination plays a critically important role in the diagnosis of disease and the monitoring and treatment of patients. In orthopaedics, patients with trauma are a diverse population that includes all age groups and socioeconomic statuses. These patients often have difficulty getting to follow-up office visits because of mobility issues caused by their injuries, but most have access to cellular phones or computers that allow for telehealth appointments .
In April 2020, in response to the coronavirus disease 2019 (COVID-19) pandemic, the United States federal government recommended alternatives to face-to-face office visits and agreed to payments for telehealth visits throughout the COVID-19 public health emergency [4, 5]. Orthopaedic trauma surgeons, along with physicians in all medical specialties, were required to limit office visits to patients with urgent or emergent conditions.
Siow et al.  provide us with information regarding the use of telehealth visits for patients with orthopaedic conditions during the COVID-19 pandemic. These investigators concluded that approximately half of their trauma clinic visits could be conducted virtually within the first 2 weeks of introducing telehealth to their clinic system. Their no-show proportions before and after the introduction of telehealth were unchanged. These clinicians were able to markedly reduce in-person patient-provider interactions in this patient population. The authors further noted that they were able to use healthcare extenders to remove sutures, arrange for imaging, and ensure that the patients had access to mobile devices and internet connectivity for their telehealth visits. The study gives a strategy to provide quality care for patients while protecting the workforce during a pandemic.
Where Do We Need To Go?
There appears to be little doubt that telehealth is convenient, versatile, and usable for the patient, even for those who have experienced orthopaedic trauma. However, many questions remain regarding the safety of telehealth medicine in this patient population. Most importantly, I am most concerned that the evidence we have on this topic has focused only on efficacy and convenience; safety endpoints have largely not been considered. Are we likely to miss important diagnoses, or fail to recommend time-sensitive treatments, because of the provider’s limited ability to examine the patient on a computer screen? Can wounds be assessed adequately without an in-person assessment? Can the ROM and stability of a joint be properly assessed by visual examination alone? Can the degree of swelling, tenderness of a structure, or a healing fracture be evaluated accurately without touching the patient? All of these issues could result in delays in treatment and intervention, exposing our patients to the risk of serious complications.
In addition, our profession needs to work with both private and government payers to develop standards for quality, safety, and reimbursement for telehealth medicine. The Centers for Medicare & Medicaid Services only authorized payment for these telehealth visits during the COVID-19 public health emergency . Without evidence-based medicine, it is doubtful that financial support for telehealth visits will continue.
How Do We Get There?
Perhaps the most-important issue pertaining to the increased use of telemedicine is for surgeons and patients to become comfortable with delivering and receiving care in the absence of in-person visits. Increased experience with virtual care is the only way that can occur [7, 10]. Moving forward, to assess the efficacy and safety of and patient satisfaction with telehealth medicine, multicenter studies need to be performed that cover longer periods of time (the current study  only covered 4 weeks of telemedicine) and without overlay of pandemic health issues.
It will be important to assess with long-term studies whether telehealth follow-up visits for patients with orthopaedic trauma provides equal, better, or worse outcomes after injury and/or surgery compared with in-person office visits. There is little doubt that telehealth is more convenient and perhaps less expensive for patients, but this would need to be balanced with the disability and costs of untoward results and complications. When considering a new diagnostic tool such as a blood test or scan, we usually compare it with a gold standard for diagnosis.
Presumably, in this situation that would be an in-person examination. Therefore, what is really needed to validate telehealth usage is a comparison of telehealth diagnoses in a study setting that would also allow the same patient an in-person exam.
Additionally, specific details regarding the minimal equipment needed for a patient to participate in a telehealth visit need to be established. For instance, are there standards for image quality in order to accurately evaluate a patient’s injury or surgical incision? Furthermore, what are the standards for which an in-person office visit is required in order to properly assess a patient’s situation?
With the advances in current and future technology, telehealth is an appealing and interesting proposition that can allow for improved access and cost savings for patients. However, we must be able to prove that it is safe. If we are able to demonstrate this, telehealth use could be greatly expanded. Telemedicine could also be used to evaluate patients and allow for triage to office-based visits instead of emergency room visits, at a tremendous cost savings for healthcare .
1. Aponte-Tinao L, Farfalli G, Albergo J, Plazzotta F, Sommer J, Luna D, de Quirós F. Face to face appointment vs. telehealth in first time appointment orthpaedic oncology patients: a cost analysis. Stud Health Technol Inform. 2019;264:512-515.
2. Barsom EZ, Jansen M, Tanis PJ, van de Ven AW, van Oud-Alblas MB, Buskens CJ, Bemelman WA, Schijven MP. Video consultation during follow-up care: effect on quality of care and patient-and provider attitude in patients with colorectal cancer. Surg Endosc. 2020. DOI: 10.1007/s0064-020-07499-3
3. Borchert A, Baumgarten L, Dalela D, Jamil M, Budzyn J, Kovacevic N, Yaguchi G, Palma-Zamora I, Perkins S, Bazzi M, Wong P. Managing urology consultations during COVID-19 pandemic: application of a structured care pathway. Urology. 2020. DOI: 10.1016/j.urology.2020.04.059
4. Centers for Disease Control and Prevention. Interim guidance for healthcare facilities: preparing for community transmission of COVID-19 in the United States. Available at: https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/guidance-hcf.html
. Accessed April 9, 2020.
5. Centers for Medicare and Medicaid Services. Medicare telehealth health care provider fact sheet: Medicare coverage and payment of virtual services. Available at https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet
. Accessed April 9, 2020.
6. Rahab BS, Knusel KD, Khan HA, Marcus RE. Are there nationwide socioeconomic and demographic disparities in the use of outpatient orthopaedic services? Clin Orthop Relat Res. 2020;1478:979-989.
7. Rao SS, Loeb AE, Amin RM, Golladay GJ, Levin AS, Thakker SC. Establishing telemedicine in an academic total joint arthroplasty practice: needs and opportunities highlighted by the COVID-10 pandemic. Arthroplast Today. 2020. DOI: 10.1016/j.artd.2020.04.014
8. Saunders C, Allen PJ, eds. Chiron (Greek mythology). Available at: GodChecker.com
. Accessed June 21, 2020.
9. Siow MY, Walker J, Britt E, Kozy J, Zanzucchi A, Girard P, Schwarts A, Tent W. What was the change in telehealth usage and proportion of no-show visits for an orthopaedic trauma clinic during the COVID-19 pandemic? Clin Orthop Relat Res. [Published online ahead of print July 3, 2020]. DOI: 10.1097/CORR.0000000000001396
10. Tanaka MJ, Oh LS, Martin SD, Berkson E. Telemedicine in the era of COVID-19: the virtual orthopaedic examination. J Bone Joint Surg Am. 2020;102:e57.
11. Wootton R. Recent advance: telemedicine. BMJ. 2001;323: 557-560.