Telemedicine has expanded from limited use in rural and underserved settings to applications across medicine and surgery. The American Medical Association reported a 53% growth in telemedicine provision between 2016 and 2017 with most being at urgent and ambulatory care centers. Significant growth has yet to be realized across surgical specialties.1
Telemedicine is defined as the use of communications technology to provide and support health care at a distance. Telemedicine was first conceptualized in the 1950s, but widespread use was hindered by the lack of access and technology. The utilization of telemedicine has rapidly grown as computer and smartphone technology have become pervasive. Telemedicine has many potential benefits, such as expansion of health care access, reduced medical costs, and improved patient outcomes. However, multiple challenges remain, including variation in state laws and licensing regulations, and limitations on the physical examination.
Several varieties of telemedicine are defined by the technology being used and the service being provided. An “asynchronous” encounter refers to transmission of patient information that is not used in real time and is also called “store and forward.” “Synchronous” telemedicine uses real-time interactive technologies such as 2-way video conferencing for the encounter. “Remote patient monitoring” requires a patient’s health information to be sent to a provider and stored in the medical record for future use. “Mobile health care services” use technologies such as smartphone applications and text messages to manage and track health conditions or to promote healthy behaviors.2
Many societies and organizations have outlined minimum performance standards as well as technical and practice guidelines for telemedicine. These include the Society of American Gastrointestinal and Endoscopic Surgeons, American College of Radiology, American Telemedicine Association, and the American College of Physicians. Numerous models and programs exist to provide a unique service that will address specific needs of a unique patient population. For instance, the Arizona Telemedicine Program was established by state funding in 1997 and operates a private broad-band telecommunications network that allows videoconferencing and store-and-forward technologies. It has been used for teleradiology and to conduct teleconsults within the Department of Corrections, avoiding tens of thousands of miles of travel by prisoners every year.3
Evidence is being gathered to objectively assess the effect of telemedicine in surgical practice.4–6 A prospective pilot study conducted at an academic general surgery practice demonstrated that online postoperative follow-up visits following laparoscopic cholecystectomy, laparoscopic hernia repair, and umbilical hernia repair were feasible and took significantly less time (15 vs 103 minutes) than in-person clinic visits. Online visits were asynchronous, and included a secure symptom survey, surgeon review of store-and-forward wound images, and correspondence via patient portal.4 A randomized trial from the Netherlands at academic and nonacademic hospitals compared health care utilization and patient-reported quality of care between a group of patients with IBD assigned to care via a telemedicine system (myIBDcoach) to patients receiving standard care. At 12 months, both groups reported high quality-of-care scores, and the mean number of flares, corticosteroid courses, emergency visits, and operations did not differ between groups. The telemedicine group had significantly fewer outpatient visits.5
Telemedicine lends itself readily to colorectal surgical practice. Applications include a postoperative telemedicine visit to assess patient progress after hospital discharge. The visit provides an opportunity to identify issues ranging from pain control to wound and ostomy care and to avoid progression that may result in heavy utilization of colorectal office resources, emergency department visits, and readmissions. Colorectal surgeons can simplify the provision of telemedicine in their practices because many of the visits can be provided in the perioperative “global” period. This limits the need to submit reimbursement for any visit related to the initial procedure. Other applications include outreach to patients who have had colorectal surgery but live a significant distance away. Patients with chronic postoperative issues, including complex wounds and ostomy complications, can be followed more closely without the burden of multiple office visits.
The regulatory environment surrounding telemedicine is complex. There are 50 states and territories that have various laws governing provision and reimbursement of telehealth services. Private payers may have their own guidelines for reimbursement that vary. Some states require that the patient be physically within state boundaries to receive “tele-care,” whereas others allow provisions for care across state lines. This provision becomes particularly important in rural areas or for hospitals/physicians that provide care for extended geographic “catchment” areas (Table 1).7
Reimbursement for telemedicine has been a barrier to widespread adoption, but meaningful progress has been made in the past year. Live video is the modality most often reimbursed. Centers for Medicare & Medicaid Services has now designated codes/modifiers for the provision of telemedicine service. Some examples of codes that might be used in colorectal practice are shown in Table 2.
The use of telemedicine services in surgical practice is rapidly evolving. Specific use in colorectal practice has yet to be widely implemented. Recent advances in technology and reimbursement have made it timely for us to consider formal implementation of this valuable care modality in our colorectal practices (Table 2).8
2. Daniel H, Sulmasy LS; Health and Public Policy Committee of the American College of Physicians. Policy recommendations to guide the use of telemedicine in primary care settings: an American College of Physicians position paper. Ann Intern Med. 2015;163:787–789.
3. Krupinski EA, Patterson T, Norman CD, et al. Successful models for telehealth. Otolaryngol Clin North Am. 2011;44:1275–1288, vii.
4. Kummerow Broman K, Oyefule OO, Phillips SE, et al. Postoperative care using a secure online patient portal: changing the (inter)face of general surgery. J Am Coll Surg. 2015;221:1057–1066.
5. de Jong MJ, van der Meulen-de Jong AE, Romberg-Camps MJ, et al. Telemedicine for management of inflammatory bowel disease (myIBDcoach): a pragmatic, multicentre, randomised controlled trial. Lancet. 2017;390:959–968.
6. Fisher AV, Campbell-Flohr SA, Leahy-Gross KM, et al. Improving translational care after complex abdominal operation: results of a telemedicine-based transitional care intervention. J Am Coll Surg 2018;227:S150–S151.
7. State Telehealth Laws & Reimbursement Policies. Spring 2019. Center for Connected Health Policy. https://www.cchpca.org/sites/default/files/2019-05/cchp_report_MASTER_spring_2019_FINAL.pdf
. Accessed August 1, 2019.