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Review Articles

Telemedicine and Orthopaedic Surgery

The COVID-19 Pandemic and Our New Normal

Lanham, Nathan S. MD1; Bockelman, Kyle J. DO2,a; McCriskin, Brendan J. MD1

Author Information
doi: 10.2106/JBJS.RVW.20.00083
  • Free
  • Disclosures

Abstract

Over the past several decades, there has been a rapid emergence of technological advances that have facilitated health-care delivery at a distance1. Multiple forms of telemedicine have enabled providers to evaluate patients, monitor follow-up, and interpret diagnostic imaging and other tests. This has led to improved access to care, cost-effectiveness, and efficiency. The coronavirus disease 2019 (COVID-19) pandemic and the response that it has engendered have disrupted health-care systems around the world. Initiatives such as telemedicine have been encouraged and employed in order to limit this disruption and combat the spread of COVID-192.

Orthopaedic surgery is a dynamic multifaceted specialty that is high-volume and technology-dependent. Therefore, efforts to improve efficiency and leverage technology through telemedicine could benefit patients and providers in the field of orthopaedic surgery under any circumstances. This review article is intended to define and provide a framework for telemedicine classification, summarize positive and negative findings in the literature pertaining to telemedicine and orthopaedic surgery, and provide a few pragmatic steps that can be taken to begin implementing telemedicine in a practice.

Defining Telemedicine

Telemedicine has been defined as patient care that is provided at a distance using information technology, including cell phones, computers, or other electronic devices1. The U.S. Centers for Medicare & Medicaid Services (CMS) defines telemedicine, or telehealth and related terms, as the exchange of medical information from 1 site to another through electronic communication to improve a patient’s health. This electronic communication must include an audio and a video component in order to be considered a telehealth encounter by CMS. More broadly, the World Health Organization (WHO) defines telemedicine as the delivery of health-care services at a distance, using electronic means for the diagnosis, the treatment, and the prevention of disease and injury, as well as for research and evaluation and the education of health-care providers in order to improve the health of their patients1.

Classification

Telemedicine may be classified according to the nature of the interaction and the type of information that is being transmitted3. Synchronous and asynchronous telemedicine are the 2 major classifications that characterize telemedicine as it relates to the timing of the provider-patient interaction. Synchronous telemedicine, often called real-time telemedicine, employs videoconferencing and other technologies to facilitate provider-patient interaction. Asynchronous telemedicine, often called store-and-forward telemedicine, involves generating images or data and transmitting them electronically for later review4.

The CMS recognizes 3 types of telemedicine services that can be provided to patients: telehealth visits, virtual check-ins, and electronic (E)-visits. Telehealth visits are considered virtual encounters between the provider and the patient for services that usually occur in-person at a clinic or a hospital. The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home for the encounter to be recognized and reimbursed as a telehealth visit5.

The CMS also reimburses virtual check-ins, or brief communications with technology-based services, which allow for patients to communicate with their providers and avoid unnecessary trips to their provider’s office or hospital. These virtual check-ins are intended for patients who have an established relationship with a provider and when the communication is not related to a medical visit that has occurred within the previous 7 days and does not lead to a medical visit within the next 24 hours5.

Lastly, established patients may have non-face-to-face patient-initiated communications, or E-visits, with their providers by using online patient portals. This E-visit service only can be reported when the billing practice has an established relationship with the patient. The patient must generate the initial inquiry, and communication can occur over a 7-day period. This 7-day period may involve multiple messages between the patient and the provider and is billed according to the amount of time that is required to satisfy the patient’s inquiry5.

Telemedicine Encounters

Prior to the initiation of a telemedicine encounter, the staff or the provider should inform and educate the patient about the nature of the telemedicine service compared with in-person care. This information can be presented in writing or verbally and should include a discussion of record-keeping, scheduling, privacy and security, potential risks, mandatory reporting, follow-up, and contingencies if the encounter is disrupted6. Each of these items may be included in an all-encompassing waiver consent form that may be electronically signed. Most importantly, patient-specific concerns about the telemedicine encounter should be addressed accordingly.

The patient encounter should reflect the level of assessment that is required to manage a patient, taking into consideration the information that can be elicited remotely. Audio-based evaluation may be used solely for consultation if the evaluation, the diagnosis, and the treatment can be reliably made with a complete medical history and is consistent with established standards of care and state and federal laws and regulations, especially as they relate to the prescribing of medications.

Preparing and standardizing the conditions of the virtual physical examination can help to optimize the quality and efficiency of the telemedicine encounter. As part of this preparation, patients can be sent a pre-encounter checklist containing certain positives and negatives that are relevant to the chief concern, in addition to diagrams for the localization of pain and sensory abnormalities. Patients also should confirm that the camera and the microphone on their electronic device are functioning appropriately prior to the encounter. Specific tools that can aid virtual physical examination include web-based goniometers, which have been noted to be compatible with most telemedicine applications7. In addition, some physical examination tests that require manual resistance can be simulated by having the patient grasp an object of a known size and weight. Additional evaluation of strength and neurologic status can be achieved with patient-demonstrated activities, such as having patients sit back in a chair and then rise without using their arms for assistance. In the absence of provocative testing, discrete palpation, and stability testing, some authors have advocated for increased utilization of advanced imaging studies such as magnetic resonance imaging (MRI)7.

Following each patient encounter, documentation should be provided and maintained in a secure Health Insurance Portability and Accountability Act (HIPAA)-compliant form and location. This includes assessment and discussion with the patient about pertinent diagnostic tests, imaging or laboratory results, and treatment options6.

Advantages

The purported advantages of telemedicine include cost-effectiveness, improved access to care, patient satisfaction, and efficiency. Buvik et al. performed an economic evaluation based on a randomized controlled trial of 389 patients who had been referred for an orthopaedic outpatient consultation8. One group was randomized to receive a video-assisted remote consultation, while the control group received standard care with an outpatient consultation at the hospital. The remote consultation involved trained nurses who set up the videoconferencing at the remote site. The nurses assisted during the consultation and performed physical tasks, such as changing casts or removing stitches. Digital radiographs also were made at the remote sites if needed and were shown to patients during consultations with the orthopaedic provider to help inform patients about their pathology. The authors found that the video-assisted orthopaedic consultations were cost-effective provided that the number of consultations performed per year was >1838. Another study evaluating cost data obtained from a randomized controlled trial showed that telemedicine was less costly than conventional care if the number of evaluated patients was >80 per year; however, if the distance to specialist care was reduced from 160 km to 80 km, the number of patients needed in order to realize the same cost benefit increased to approximately 200 per year9.

Harno et al. prospectively evaluated the costs of videoconferencing and outpatient clinic appointments for 225 patients who had been referred to orthopaedic surgeons and found that the use of telemedicine reduced direct costs by 45% and was cost-effective10. In another study, first-time telemedicine appointments with orthopaedic oncology specialists for patients with suspected bone tumors were found to decrease health-care costs between 12% and 72% when compared with conventional face-to-face appointments. The cost analysis performed by the authors considered the cost of transportation as the primary variable that was responsible for telemedicine’s cost-savings11.

Despite the evidence in support of telemedicine’s cost-effectiveness, other authors have identified weaknesses and have recommended additional studies to consider alternative economic evaluations12. Some of these include how studies define costs, which can involve 1 or a combination of factors that are not uniform across all studies and therefore make cost comparisons difficult11.

Multiple studies have found that telemedicine increases access to care for patients in remote locations. Aarnio et al. prospectively evaluated orthopaedic telemedicine consultations that were performed in which the locations of the patient and the provider were approximately 240 km apart13. Two-thirds of the patients who were evaluated with videoconferencing were afforded definitive treatment, and the videoconferencing obviated the need for these patients to travel for an in-person appointment13. A randomized trial comparing telemedicine with standard outpatient appointments found that patients in the telemedicine group were offered a follow-up appointment more often. In addition, telemedicine led to fewer tests being ordered and increased patient satisfaction when compared with standard outpatient consultation14. Buvik et al. performed a randomized controlled trial comparing video-assisted remote orthopaedic consultations and standard outpatient consultations in an orthopaedic clinic for patients living in remote locations15. The telemedicine consultations were rated as “good” or “very good” in 98% of cases and were found to be non-inferior to the standard in-person evaluations15.

The United States Army found that its telemedicine program, which consisted of email consultations from health-care providers in austere settings of deployment to subspecialty orthopaedic consultants, limited the number of unnecessary medical evacuations16. Rogers et al. equipped 4 rural hospital emergency departments with real-time videoconference technology to facilitate consultation with 3 trauma surgeons at level-I trauma centers17. Telemedicine consultations in the study were with more severely injured patients than the general trauma population that was admitted to the level-I trauma center. These findings were attributed to the increase in capability of the rural hospitals, which leveraged the level-I trauma surgeons’ expertise to perform patient care. More than 80% of the rural referring providers believed that telemedicine improved trauma care and was lifesaving on multiple occasions17.

Not only has telemedicine been shown to decrease cost and improve access to care, it has also been shown to improve provider efficiency and decrease patient wait times for clinical evaluation. Clegg et al. found that real-time telemedicine reduced the wait time for wound-care consultations in rural locations from 48 hours to <24 hours when compared with in-person consultations18. Another study found that teleradiology for remote orthopaedic consultation diminished the need for in-hospital consultation and reduced the average time for decision-making by more than half19.

Gamus et al. evaluated the remote care of lower-extremity ulcers over a 12-month period and compared telemedicine with face-to-face consultations20. The telemedicine evaluation was performed with synchronous videoconferencing, and a nurse-assisted setting was implemented during all treatment sessions for both groups. No difference in healing was found between the groups, and the telemedicine group had a substantially reduced number of visits (4.36) when compared with those who had face-to-face care (6.32)20. Similarly, another study evaluated the efficiency and orthopaedic surgery specialty care wait times of patients in remote locations using telemedicine. The authors found that nearly 70% of patient consultations were resolved after 2 telemedicine evaluations, and wait times for referrals to orthopaedic subspecialty care decreased from 201 to 40 days21.

Challenges and Barriers

Despite multiple studies demonstrating telemedicine’s efficacy, widespread implementation faces multiple barriers, including regulatory support, reimbursement, liability, and the technology itself.

Establishing a patient-provider relationship using telemedicine subjects the provider and the practice to all of the usual regulatory considerations. The provider needs to be licensed at the site of origin, and the video and medical record transmission should be HIPAA-compliant1. Although many state licensure statutes have provisions for interstate consultations and have enacted special “telemedicine licenses,” these are not uniformly present in all states. In addition, The Joint Commission requires that physicians practicing with telemedicine technologies be credentialed in the hospital where they are transmitting17. Additionally, the Ryan Haight Act prohibits the prescribing of controlled substances without a valid prescription and requires at least 1 in-person evaluation. Although there are exemptions granted for telemedicine, providers must meet specific criteria, and these vary from state to state. The current public health emergency is 1 of the exemptions to the Ryan Haight Act and was granted by the U.S. Drug Enforcement Administration (DEA) in March 2020 to help curtail the spread of COVID-1922.

The next challenge is reimbursement. Medicare only pays for video consultation if the patient lives in a designated rural Health Professional Shortage Area, and reimbursement by private payers varies5. Thus, under the current payment models, reimbursement is limited. However, during the COVID-19 pandemic, several insurance companies as well as the CMS, with the support of multiple regulatory bodies, made necessary changes to their policies that enabled providers to engage patients with telemedicine and bill for their services5.

Malpractice insurance and liability for providers who are engaged in telemedicine also have raised concerns17,18,23. Some institutions have attempted to resolve these concerns by covering providers in the same fashion as an in-person visit, and they require the use of a separate consent form for telemedicine encounters17. In addition, each telemedicine encounter is videotaped and kept as part of the permanent medical record for each patient encounter23. Other liability concerns have been raised in which a referring provider could be held liable for not obtaining a telemedicine consult if the service was available17.

Clegg et al. noted technological difficulties with the implementation of their telemedicine system, such as orders and progress notes that were not inserted into the chart after the consultation had been completed18. Similar challenges were noted by Rogers et al.17. On multiple occasions, the hospital and the trauma surgeon were not able to connect using the videoconferencing system. Additional technical failures included loss of remote camera control and nonfunctional audio17.

Baruffaldi et al. compared asynchronous and synchronous real-time teleconsulting for orthopaedic second opinions24. The authors found that asynchronous teleconsulting was preferred in the majority of cases, although there were issues with the lack of information or the low quality of the information that had been received from the referring sites. The authors found that clinicians’ confidence in their diagnosis was lower in asynchronous consultations, and clinical complexity and organizational requirements were noted to be the main factors affecting the choice of the consulting procedure24. Although videoconferencing has been found to be feasible for the examination of orthopaedic outpatients when randomized to telemedicine, there have been problems examining these patients. There are instances where the diagnosis and subsequent treatment are contingent on specific physical examination findings or inspection can be impeded with poor-quality audio-video or imaging technology. Therefore, some authors endorse the remote evaluation of orthopaedic patients only when reliable and high-quality audio-video or imaging technology is not critical for developing a treatment plan25.

Finally, the costs of implementation and maintenance have been cited as barriers to the widespread adoption of telemedicine. The cost of installing the required surveillance equipment to complete remote wound consults through videoconferencing has been noted to be substantial18. This finding has been echoed in other studies, with starting costs ranging from $10,000 to $17,0008,17. These costs do not include maintenance or service subscription fees, which can add additional costs. Telemedicine encounters that are recorded and archived as part of the permanent medical record necessitate large data storage capability, which also can increase costs.

Nevertheless, there are lower-cost alternatives in the form of videoconferencing software and mobile applications (apps) that can be easily downloaded onto computers, tablets, and smartphones. Zoom for Healthcare, GoToMeeting, and Skype for Business are a few examples of the products that purport HIPAA-compliant videoconferencing capability26. The WhatsApp Messenger is another example of a relatively inexpensive nonmedical mobile app that has been shown to effectively facilitate orthopaedic care in multiple clinical settings27,28. The cost-effectiveness and ubiquitous presence of these technologies should be balanced against their requirements of patient resources and fluency with technology. Presuming that all patients possess the necessary technology and understanding of this technology to effectively leverage it for telemedicine may disenfranchise certain groups of patients. Therefore, consideration of lower-cost alternative forms of telemedicine cannot ignore the patient factors that may compromise their efficacy.

Implementation

Despite multiple challenges and barriers, telemedicine possesses several advantages and can serve as a valuable tool to reduce costs, increase access, and improve patient satisfaction and efficiency. Providers who are interested in developing a telemedicine service-line in their practice should set clear goals that reflect the needs of their patient population and practice. This begins with determining which telemedicine platform capabilities would enable effective telemedicine consultations. Some of these platform capabilities include, but are not limited to, the ability to screen share and review imaging with patients while also simultaneously maintaining videoconferencing. Other examples include audio-only platforms and asynchronous texting or emailing. While patient satisfaction has been demonstrated in both synchronous and asynchronous telemedicine platforms, studies citing patient satisfaction with asynchronous telemedicine have primarily involved older patient populations29. Therefore, the capability to deliver multimodal telemedicine services allows for a more efficacious patient-centered approach.

Additionally, there must be an analysis of the projected cost impact and a review of state regulations to ensure that a patient-provider relationship can occur using telemedicine. The Center for Connected Health Policy (CCHP) is 1 of many resources that can help providers understand many of the policies and regulations pertaining to telemedicine (Table I). Reviewing telemedicine vendors and options in addition to ensuring HIPAA compliance with secured encrypted transmissions for personal health information should then follow (Table II). Many of the larger electronic medical record (EMR) companies provide telemedicine options that interface with their EMR. Thus, providers currently using an EMR system should consider engaging their EMR’s representatives. Lastly, verifying state licensure rules and policy compliance along with reviewing malpractice considerations with your malpractice insurance carrier can mitigate medicolegal liability.

TABLE I - Telemedicine Resources
Resource Description
Center for Connected Health Policy (CCHP)* Nonprofit organization originally established by the California Health Care Foundation
Serves as the National Telehealth Policy Resource Center
Resources dedicated to national and state-specific telehealth policy
National Consortium of Telehealth Resource Centers (TRC) Federally funded with charter from the Office for the Advancement of Telehealth
Provides assistance, education, and information to individuals and organizations interested in providing health care at a distance
Regional telehealth resource center hub
National Telehealth Technology Assessment Resource Center (TTAC) Grant funded with support from the Office for the Advancement of Telehealth, Health Resources and Services Administration, U.S. Department of Health and Human Services (HHS)
Based out of the Alaska Native Tribal Health Consortium (ANTHC)
Offers a variety of services in the areas of technology assessment and selection for providers
American Telemedicine Association (ATA)§ Nonprofit association that is headquartered in Washington, DC
Seeks to accelerate the adoption of telehealth
Promotes policy and provides education and resources to include telemedicine clinical practice guidelines
*cchpca.org.
telehealthresourcecenter.org.
telehealthtechnology.org.
§americantelemed.org.

TABLE II - Telemedicine Vendor Considerations*
Determine upfront and maintenance/subscription cost(s)
Assess platform capabilities (screen sharing, uploading outside images)
System compliance with HIPAA and medical boards
Type of services provided (synchronous “real-time” videoconferencing versus asynchronous “store-and-forward”)
24/7 service and technical support
Integration with current practice and electronic health record
Support for insurance claims/billing
*https://www.aaos.org/quality/practice-management/telemedicine/. HIPAA = Health Insurance Portability and Accountability Act.

Future Directions

The use of telemedicine is likely to increase in the United States. A 2017 survey of 184 health-care executives conducted by the American Telemedicine Association found that 88% of the executives believed that they would invest in telemedicine in the near future, and 98% believed that it offered a competitive advantage. However, 71% believed that lack of coverage and payments were barriers to implementation1. A more recent survey of >800 physicians in the U.S. found that 48% are now using telemedicine in their practices as a consequence of COVID-19, which is up from 18% in a similar survey that had been conducted in 201830. Another survey of >600 private practices and 140 billing companies found a 35% decline in patient volume during March 2020. The survey also found that 41% of respondents had begun offering telemedicine options to patients, up from 22% in a previous 2018 survey31.

Despite telemedicine’s tremendous upside, traditional research methods may be challenging with telemedicine, given the rapidly increasing utilization of health technology among patients and health-care systems, especially during the COVID-19 pandemic. Thus, the traditional methods of randomized controlled trials to evaluate the efficacy of an intervention or a change in care delivery may not be feasible. Some authors have instead suggested more pragmatic methods that balance the traditional research paradigms and the ever-changing landscape of telemedicine and its many facets32. In addition, future research regarding telemedicine must more clearly and uniformly define cost analysis and cost savings in order to enable comparison among studies. Barriers to regulatory support and reimbursement that have required specialty society involvement in the form of evidence-based practice guidelines and political advocacy have largely been eliminated during the COVID-19 pandemic. Nevertheless, sustained coordinated efforts among providers, researchers, insurance carriers, and policymakers will be necessary if telemedicine is to continue to grow in practice and scope.

Overview

Telemedicine is a multidimensional rapidly evolving modality that is capable of improving access to quality cost-efficient health care for patients needing orthopaedic specialty services. The COVID-19 pandemic has compelled providers to negotiate a myriad of challenges that have brought telemedicine to the forefront of health care. With the support of the CMS and other insurance carriers, telemedicine initiatives were quickly supported and enacted in order to continue providing health care to patients during the pandemic. Patient satisfaction is a key component of telemedicine and will drive its evolution. Beyond the COVID-19 pandemic, telemedicine will undoubtedly serve an increasing role as our new normal in orthopaedic surgery.

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