Telehealth in Orthopaedic Surgery

Melvin C. Makhni, MD, MBA

Harry M. Lightsey IV, MD

Caleb M. Yeung, MD

None of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Makhni, Dr. Lightsey, and Dr. Yeung.

INTRODUCTION

The role of telehealth in value-based health care is evolving. Though the benefits and limitations of this form of care delivery are debated, the COVID-19 pandemic forced individuals and institutions to adopt telehealth, and state and federal governments to support its use. During this time, previous barriers to telehealth implementation were deconstructed to maintain a functioning health care system. Many of the projected benefits and limitations of telehealth were realized, and several unexpected developments also arose. Furthermore, many orthopaedic practices transformed their health care delivery pathways to offer virtual care to almost all patients; as the pandemic wore on, care gradually shifted back to the office setting. Continued shifts in the health care, legal, and technologic landscape will continue to affect the manner in which telehealth can be implemented in orthopaedic surgery. Optimal practices will continue to evolve to best care for patients in a safe, convenient, and cost-effective manner.

BACKGROUND

Despite the recent global focus on telehealth, no single definition exists to encapsulate its scope. This is largely because of the rapidly changing nature of technology. Various overlapping and sometimes interchangeable terms are used to refer to remote care delivery, including telemedicine, telehealth, e-health, and e-care. Other terms such as remote patient monitoring, mobile health, and digital health complicate matters further.

The National Academy of Medicine has defined telemedicine as the use of electronic information and communications technologies to provide and support health care when distance separates the participants.¹ Although many groups such as the Health and Human Services Department use the terms telemedicine and telehealth interchangeably, the American Telemedicine Association defines telehealth more broadly to encompass technology-enabled health and care management and delivery systems that extend capacity and access.²

In this context, telemedicine refers to interactions between a patient and a clinician, or between two health care providers. This care can be delivered synchronously through real-time phone or video consultations, or asynchronously through means such as email or messaging. Telehealth refers to the entire spectrum of applications that contribute to remote care, including telemedicine as well as other facets such as artificial intelligence, virtual reality, and remote patient monitoring. Remote patient monitoring (RPM) uses various technologies to enable both real-time and longitudinal data collection to enhance health care monitoring.

HISTORY

Telehealth originated in the early 20th century. As early as 1906, Dr. Willem Einthoven practiced telecardiology by sending heart tracings from a local hospital to his laboratory more than 1 km away where a string galvanometer was located.³ Throughout the 1920s to 1940s, telephone-mediated consultations became popular in the United States, Norway, Italy, and France.⁴ The first radiographic images were transmitted in the 1950s. In the late 1960s, Massachusetts General Hospital paired with Logan International Airport to trial a telemedicine station designed to provide occupational health care to employees and to assist in the delivery of emergency medical attention.⁵

Advances in technology continued to drive telehealth development, broadening its capabilities. In the 1980s, digital transmission had progressed sufficiently to support videoconferencing, used primarily for peer-to-peer consultations. The 1990s and 2000s represented a watershed period for telehealth; during this timeframe, it became widely recognized as a viable health care platform deserving of federal investment.

In 2016, the Health Resources and Services Administration invested $16 million to expand telehealth in rural areas; more recently, the Health Resources and Services Administration reinforced this initiative, appropriating nearly $12 million to increase telehealth-based access to care in rural communities.⁶ In March 2020, in response to the COVID-19 public health emergency, Congress passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act. The CARES Act provided unprecedented levels of support for telehealth by expanding Medicare telehealth flexibilities as well as allocating billions of dollars to support increased telehealth capacities across the country.⁷

TELEHEALTH IN ORTHOPAEDICS: BEFORE COVID-19

Within orthopaedic surgery, telehealth was underutilized prior to the coronavirus pandemic despite multiple studies demonstrating its efficacy, cost-effectiveness, and patient satisfaction⁸,⁹,¹⁰,¹¹,¹²,¹³,¹⁴,¹⁵,¹⁶,¹⁷,¹⁸,¹⁹,²⁰ (Table 1). This trend reflected the various challenges to widespread implementation, ranging from legislative barriers, practitioner hesitation, and technologic limitations.

Legislative Barriers

Prior to the coronavirus pandemic, federal and private payer endorsement of telehealth was curtailed by various restrictions on approved services and providers as well as permissible technology and prescribing capabilities (Table 2).

Comprehensive legislative limitations on almost all aspects of care placed undue burden on health care facilities, providers, and patients and significantly contributed to overall underuse of telehealth.

TABLE 1 Studies Supporting Telehealth in Orthopaedics Prior to COVID-19

Studies Demonstrating Efficacy and Accuracy
Bertani et al 2012	Prospective analysis of 48 teleconsultations for 39 patients for diagnostic and therapeutic problems. Teleconsultation modified surgical indications and technique in 77% of consultations. Clinical outcomes were “good” or “very good” in 81% of treated patients.
Good et al 2012	Prospective review of 36 patients with acromioclavicular joint hook plates comparing functional assessment using Skype versus outpatient visit. No significant differences were observed in Oxford and Constant shoulder score between modalities.
Zennaro et al 2014	Prospective study consisting of 42 children demonstrating a significant decrease in the number of consultations, faster activation of ancillary services (cast and plaster room), and a decrease in overall decisionmaking time when radiographs were available via an iPad.
Buvik et al 2016	Randomized trial consisting of 199 patients who underwent videoassisted remote consultation and 190 patients who underwent standard in-person consultation. Video consultations were noninferior; 98% of video visits were rated as “good” or “very good” by providers.
Studies Demonstrating Cost-Effectiveness
Harno et al 2001	Prospective study consisting of 419 patients demonstrating 45% savings in direct costs per patient for teleconsultation versus outpatient clinic visit.
Ohinmaa et al 2002	Randomized trial consisting of 145 patients demonstrating societal cost-savings with telemedicine at a threshold workload of more than 80 patients/year.
McGill and North 2012	Analysis of 27 videoconference fracture clinics and resultant cost savings; 21 transfers were avoided overall and in the final 5 months of the study, there was an overall savings of $11,334.
Buvik et al 2019	Randomized trial consisting of 389 patients demonstrating costeffectiveness of video-assisted remote consultations versus in-person care as long as total consultations more than 151/year. Annual cost savings amounted to &U20AC;18,616 ($20,869) for 300 consultations/year.
Sinha et al 2019	Nonrandomized study consisting of 116 patients comparing real-time video consultation (101 patients) with conventional outpatient clinic visits (66 patients) for pediatric fracture care. Telemedicine visits significantly decreased indirect and direct costs.
Studies Demonstrating Patient Satisfaction
Good et al 2012	As mentioned previously, 93% of patients surveyed preferred Skype for follow-up due to convenience and cost savings.
Sharareh and Schwarzkopf 2014	Prospective study of 78 total joint arthroplasty patients, 34 of whom underwent telemedicine postoperative follow-up versus 44 patients undergoing standard follow-up. Telemedicine patients rated their postoperative care significantly higher than the nontelemedicine group and reported that Skype sessions increased their postoperative satisfaction.
Sathiyakumar et al 2015	Randomized pilot study consisting of 17 patients, 8 of whom had telemedicine follow-up and 9 of whom had in-person follow-up in an orthopaedic trauma setting. There was no significant difference in patient satisfaction. Furthermore, no patients in the telemedicine group took time off of work compared with 55.6% of patients in the control group.
Gilbert et al 2017	Systematic review of four qualitative studies. All studies demonstrated that the use of videoconferencing is “acceptable” to patients in an orthopaedic setting.
Sinha et al 2019	As noted previously. No significant difference was found in the overall quality of care provided and overall consult experience. Eight of 101 telemedicine patients preferred in-person follow-up as a next visit.
Buvik et al 2019	As noted previously. No difference was found in patient-reported satisfaction between video-assisted and standard consultations; 86% of videoconferencing patients preferred video-assisted consultation as their next visit.

Practitioner Reticence Prior to COVID-19

In 2016, a live poll during the American Orthopaedic Association Annual Meeting sought to investigate orthopaedic surgeons’ use of and opinions on telehealth.²¹ Although 96% of respondents believed in telehealth’s clinical utility, only 42% and 38% reported using telephone or email correspondence to communicate with patients, respectively. Furthermore, although most providers chose video as their preferred mode of telecommunication, 27% of respondents expressed concerns over Health Insurance Portability and Accountability Act compliance and lack of training and 23% of respondents had questions regarding clinical appropriateness
and reimbursement. A concern with successful backing and implementation was apparent; 42% of surgeons thought that their colleagues would be disinterested and 61% of surgeons thought that creating a coalition of providers willing to regularly use telehealth would take work.

Surgeon concern also stemmed from a fundamental limitation of the telehealth platform: inability to perform a physical examination. In a specialty wherein examination of musculoskeletal and spinal systems has traditionally been upheld as a key component of a complete patient assessment, the prospect of missing this information or performing limited virtual examinations was disconcerting. Such limitations also contributed to concern about increased medicolegal exposure. Additionally, with evidence to support the importance of the doctor-patient relationship in avoiding malpractice suits,²²,²³ the idea of trying to develop this bond with virtual examinations discouraged surgeons.

Technologic Inefficiencies and Barriers to Implementation

Inefficiencies with telemedicine introduced through technology and its users served as additional deterrents to telehealth adoption. Difficulty connecting parties and unstable audiovisual streaming often result in frustrating and time-consuming delays. Furthermore, lack of familiarity with this technology by both practitioner and patient led to additional delays and avoidance. With the traditional system centered around face-to-face interactions and examinations, telehealth was deemed to be generally inefficient and unnecessary.

Tangible barriers to telehealth implementation have also complicated its appreciation. Prior to the pandemic, successful telehealth programs required substantial investment. Developing the infrastructure to support hardware while identifying and paying for software that satisfied security compliance, was integrated into existing electronic medical record systems, and had the capacity to archive encounter recordings was prohibitively expensive for most hospital groups and practices. These barriers, coupled with provider and patient apprehension, significantly contributed to telehealth’s underutilization.

TELEHEALTH IN ORTHOPAEDICS: DURING COVID-19

The coronavirus pandemic necessitated rapid implementation of telehealth modalities in order to maintain a functioning health care system. Federal and state mandates comprehensively overturned legislative restrictions within their domains and private models largely mirrored these actions²⁴,²⁵,²⁶ (Table 2). In this unprecedented period, the US healthcare system adjusted to a new era of telehealth. Medicare increased covered services through various modalities and waived limitations on providers and patients. Medicaid established more state-level autonomy; for example, no federal approval was required for state programs to offer reimbursement parity.²⁷ Private insurers acted in kind; several payers began covering telehealth services at no cost to members.²⁸,²⁹,³⁰ Outside of the insurance realm, other government agencies adjusted policies to promote telehealth and continuity of care. The Drug Enforcement Administration permitted registered practitioners to issue prescriptions for controlled substances without in-person medical

evaluations pending satisfaction of certain criteria.³¹ The Office for Civil Rights redefined qualifications for Health Insurance Portability and Accountability Act violations to enable health care providers to use popular online communication technologies, including FaceTime or Skype.³²

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