February 27, 2019

My first experience with using telemedicine in orthopedics was in August 2015. I had performed an anterior cruciate ligament reconstruction on a 17-year-old male named Tom, who lived about 90 miles from our hospital. A week later, during a casual conversation with his father, I learned that Tom was doing well recovering at home, but was having trouble adjusting his postoperative brace. Tom’s dad asked if I could “FaceTime” with Tom and show him how to adjust it.
I agreed, and after showing Tom how to use the brace, we talked for a few minutes. I asked Tom about his pain, and he bent his knee and let me see his wound through the phone’s camera. At the end, Tom said he would see me later that week for his in-person, postoperative appointment.
But I soon realized that it wasn’t necessary for Tom and his father to drive 90 miles for me to do in person what I had just done on FaceTime. He seemed comfortable, he had reasonable range of motion, and his wound looked great. I could just email or fax him the necessary paperwork, and we’d be done.
During that same year, our hospital created a telemedicine division within its innovation center. This administrative initiative encouraged physicians, physician assistants, nurse practitioners, and nurses to use telemedicine to evaluate and treat patients whenever possible. Telemedicine, as they explained it, used information technology such as videoconferencing to make it possible to provide healthcare remotely.
I quickly realized that many other patients could receive the same kind of care I provided Tom. I wanted to learn how I could use telemedicine technology to treat more of my patients. I met with the telemedicine coordinator to get set up, and I have been delivering service remotely ever since.

For Established Patients

Most people probably think of telemedicine in an on-demand sense, such as the technology popularized by apps like AmWell, Teladoc, MDLive, and Doctor on Demand. In contrast, I primarily use telemedicine for established, scheduled patients. Typically, I already have a relationship with the patient and examined them several times in the past, which means that a physical exam is often not necessary.
Telemedicine works very well to evaluate patients for encounters focused on information transfer. Simple follow-ups, routine ¬postops, surgical discussions, wound checks, and MRI/lab result reviews can all be handled through telemedicine. I rarely use telemedicine to evaluate brand-new patients, unless they have already been seen and physically examined by a provider in our practice.
Telemedicine visits are scheduled within an electronic medical record in the same way that in-person visits are scheduled. I can integrate visits within my regular clinic hours or schedule them early in the morning or later in the evening, when children are home from school and parents are done working. This provides extra flexibility, unlike in-person visits that can only occur when the clinic is open and staff is available.
Our hospital has two telemedicine platforms. The first is similar to FaceTime and can be used for videoconferencing between two individuals. As a provider, I can invite patients to download the app and link them into my “video chat room.” This platform not only enables me to evaluate patients but also to invite participation by other providers such as primary care doctors, athletic trainers, and physical therapists. This is helpful because I can evaluate patients while they are at physical therapy or in their training room at school and get real-time feedback from their therapists and trainers about their progress.
The second platform is formally integrated into our clinic template and can only be used to interact with scheduled patients. It requires that patients enter insurance and demographic information and is very helpful at administrative tasks such as co-pay collection.
Between these two platforms, I have the flexibility to evaluate patients and interact with providers in various clinical scenarios. I personally prescreen all telemedicine patients to ensure their appropriateness for this type of visit. Once they agree, they are consented for the visit and scheduled with our normal orthopaedic scheduler.
For both patients and providers, the only hardware requirement for telemedicine visits is a device with Internet access, a camera, and a microphone. Laptops, desktops, tablets, phones, and carts/kiosks can be used. Devices with these requirements are very common, ensuring access for most patients.

Pros and Cons

Two years ago, we published a report detailing our experience with telemedicine. Our study showed that telemedicine has two major benefits for patients: convenience and significantly less waiting time. In our department, an in-person visit takes an average of 68 minutes per patient, from check-in to check out. The patient spends almost half of that time waiting. On the other hand, the average telemedicine visit takes only 17 minutes from log-on to log-off, with virtually no waiting time. It takes approximately 2 minutes to download the app and log-in.
In addition, basically all of the time during a telemedicine visit is spent with the provider. This contrasts with an in-person visit, during which the patient spends only approximately 10 of the 68 minutes with the provider. In addition, telemedicine offers the following patient benefits:
  • no travel time or expense
  • no parking hassles or fees
  • less time missed from work or school
  • less contact with other sick individuals
Hospitals and departments also benefit when patients are served via telemedicine. These benefits include lower direct labor costs (no staff is needed to evaluate the patient) and lower resource utilization (such as paper, clinic space, or electricity). As an innovative technology, telemedicine also presents unique marketing and research opportunities.
However, we have noted a few drawbacks to telemedicine. Patients who are not “tech savvy,” for example, may find the technology somewhat challenging to use. In addition, some patients simply prefer face-to-face interactions with their providers. And, the biggest concerns for hospital systems and orthopaedic departments tend to be billing and legal issues, as well as the staff learning curve. Policies governing telemedicine reimbursement vary by state and payor, and I would encourage practices to do their homework before performing telemedicine visits. In addition, bear in mind that, if the telemedicine visit crosses state lines (the patient in one state and the provider in another state), the provider must be licensed in the state in which the patient is physically located at the time of the encounter.

The Future is Now

Although I don’t think telemedicine will replace traditional, in-person clinical visits anytime soon, I do believe that it can be used to augment traditional health care and streamline the patient experience. Looking toward the future, I can envision other uses for telemedicine, including the following:
  • sports sideline coverage and virtual training rooms
  • virtual patient triage and pre-screening
  • virtual patient navigation
  • virtual coverage of urgent care and emergency departments
  • on-demand orthopaedic consultations with physical therapists, athletic trainers, and primary care doctors
As the healthcare landscape continues to evolve and the emphasis on value and satisfaction continues to grow, telemedicine may be used by providers to control costs and resource utilization, while keeping patients satisfied and delivering quality care. Most patients spend a tremendous amount of time getting what they need on mobile devices. It’s only a matter of time before health care is routinely delivered in that fashion as well.

Getting Involved with Telemedicine

The following steps can help you get started with telemedicine visits.
  • Discuss telemedicine with your department head and/or hospital administrator. Point out the benefits and be ready to answer questions about costs and implementation.
  • Ask billing questions. Do your research on Medicare and commercial payor rules, and familiarize yourself with state reimbursement and other guidelines for telemedicine visits. Be sure you know all of the requirements that must be met and followed.
  • Evaluate hardware options. Do you primarily use a desktop, laptop, or tablet? How easy would it be to add telemedicine to your current programs?
  • Evaluate different platforms. Look for one that has the features you need, is easy for the patient to use, offers training for your staff, and provides adequate security to meet current patient privacy regulations.
  • Examine your patient population. Would your patients be amenable to telemedicine visits? Are most of them comfortable with the technology? Do they have access to mobile devices in their homes?
  • Establish a pilot program. Develop a set of guidelines defining patient populations for whom telemedicine is a viable option. Collect feedback from patients and use the data to adjust your guidelines and operations.
*The views and opinions expressed by our guest bloggers are those of the authors, and do not necessarily reflect the views of KarenZupko & Associates, Inc.

 

Author - Alfred Atanda Jr., MD
Alfred Atanda Jr. is a pediatric orthopedic surgeon who specializes in sports medicine at the Alfred I. duPont Hospital for Children in Wilmington, Del., where he is the director of the Center for Sports Medicine. He performs arthroscopic surgery of the knee, elbow, ankle, and shoulder as well as general orthopedic and trauma surgical procedures. A graduate of the University of Pennsylvania School of Medicine, he completed an internship and an orthopedic surgery residency at the University of Chicago Medical Center. Dr. Atanda also completed fellowships in pediatric orthopedic surgery, at Alfred I DuPont Hospital for Children, and in sports medicine surgery, at the Rothman Institute at Thomas Jefferson University. His research interests are in overuse injury prevention and general orthopedic trauma. Recently, he has developed an interest technology and innovation by routinely using telemedicine in his sports medicine practice. His future aspiration is to create an app-based platform to utilize telemedicine technology to triage, navigate, evaluate, and treat orthopedic patients.
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