The COVID-19 pandemic had a transformational effect across medicine. One of the most notable changes wrought by the virus was widescale adoption of telemedicine for patient visits. Although not new, telemedicine as a true substitute for in-person appointments had been mostly a niche offering among selected practices and for relatively few patients. Largely out of necessity, and with the entry and blessing of government regulators and major payers, many medical practices formalized the implementation of televisits to the point where they now constitute a significant portion of patient contacts.
Although early implementation was often done on the fly, with some latitude allowed by regulators and payers, as telemedicine has become formalized, practices that adopt it now must invest time and resources to construct and operate a telehealth system that is efficient for physicians and staff, patient-friendly, and compliant with the same regulations and standards of traditional in-person care.
At an Instructional Course Lecture (ICL) at the 2022 AAOS Annual Meeting, panelists offered guidance on implementing and operating a full-fledged telehealth service, while sharing lessons learned from the early days when COVID-19 catalyzed the widespread adoption of televisits.
Robert A. Gallo, MD, MHA, FAAOS, of Penn State Hershey Bone and Joint Institute, who served as chair of the session, gave a primer on telemedicine, covering how and when it is most suitable for use, technical and logistical considerations, advantages for patients and physicians, disadvantages and limitations, and practical pearls and pitfalls.
First, Dr. Gallo observed, “Without coronavirus, we are not having this discussion.” His presentation focused on “synchronous telemedicine,” which he said is “typically what we mean when we discuss telemedicine” and involves real-time interactions between patients and physicians or other professionals. Synchronous telemedicine occurs during telephone conversations or video visits. Telemedicine also may extend to remote monitoring, allowing for continuous evaluation, as with a Holter monitor for heart rhythm. It also may involve direct video monitoring and remote status monitoring, which have found favor among some arthroplasty surgeons to track postoperative progress in place of some office visits.
The primary challenges with telemedicine, as with any aspects of practice, are “time and money,” Dr. Gallo said. He noted that implementing telemedicine may be “harder for a private practice than a big academic center because of economy of scale.” Another difficulty is buy-in from staff, especially practice managers. “Some people just don’t want to do it,” he said, “and I’m not sure you will convince those people.”
The advantages of telemedicine can be persuasive. Among them are significant time savings for physicians and staff members. “I’m so much more efficient with telemedicine than in person,” Dr. Gallo said. Not only can telemedicine allow for optimized scheduling, but “on-screen, people tend to get to the nuts and bolts, and there is less fluff in a visit.”
Dr. Gallo also extolled telemedicine’s benefit of easier access to care, which may be especially valuable in larger, nonurban “catch” areas, such as his practice in southern Pennsylvania, where a patient may drive an hour each way for an office appointment. For his rural patients, “Telemedicine makes sense when it means a five- to 10-minute visit from home versus driving two hours. It can be satisfying to offer that convenience.”
He pointed to an ongoing trial of rural videoconference fracture clinics. Twenty-seven clinic sessions were held, which ultimately saved 21 patient transfers, which would have cost $1,269 for each adult and $2,134 for each child. With each clinic costing $1,285, the savings over five months totaled more than $11,000.
Another study evaluated cost-effectiveness of telemedicine versus in-clinic visits. The researchers compared 199 patients receiving 302 telemedicine consultations with 190 patients who received 257 in-person outpatient consultations. They concluded that, after accounting for startup and operational costs, telemedicine yielded savings when the number of patients was greater than 151 and visits greater than 183.
Telemedicine also has advantages in timeliness, specifically the time a clinic patient spends in radiology, as demonstrated by an analysis conducted at Dr. Gallo’s institution. “We get bottlenecked in X-ray, which can add 40 minutes to a visit,” he said. “To have a patient drive an hour, then wait a half-hour for an X-ray, to spend 10 or 15 [minutes] with a provider doesn’t make sense, whereas telemedicine wait time is about 10 minutes, and that’s counting when they log in, not appointment time. My wait time is probably a minute or two,” he said, noting that patient wait time in a traditional setting is longer than the time spent with a physician—“But in telemedicine, it reverses.”
Dr. Gallo also pointed to a study gauging patient satisfaction. It found that of those who wish to use telemedicine, 92 percent reported satisfaction. Of those patients, 71 percent had no need for a subsequent in-person visit; the primary reasons for in-person visits were need for a physical examination or poor communication. Only 7 percent had difficulties using telemedicine or following advice given during their visits. Regarding those who had difficulties, “We need to figure out who those people are and why they had a problem,” Dr. Gallo said. “And you need to make sure they have a way to get into clinic if they need to.”
A randomized, controlled trial that measured patient satisfaction found that 99 percent of both clinic-visiting and telemedicine patients rated the experience as satisfactory or very satisfactory, and 86 percent preferred video-assisted care for the next consultation. No difference in patient-reported health was seen at 12 months.
A study at NYU Langone Health looked at patients who underwent arthroscopic meniscus surgery and had a postoperative visit within two weeks of surgery. It found that patient satisfaction with postoperative care was equivalent for those who came to the office and those who completed a televisit.
Data suggest that the level of care was also equivalent, with no subsequent or missed complications in the telemedicine group and no concerns introduced from the surgeons regarding adequate evaluation of patient progression.
In other words, Dr. Gallo said, “Most patients preferred the modality that they had chosen. Importantly, they seemed to have similar complication rates, so [the surgeons] probably didn’t miss the complications.” He noted that if deep vein thrombosis is suspected in a telemedicine patient, the patient can be referred to care locally.
Finally, a study at Rothman Orthopaedic Institute examined satisfaction with telemedicine on the part of the provider versus the patient. Overall patient satisfaction was high—about 91 percent—although some 60 percent of patients still preferred in-person visits, with the most commonly cited reason related to the level of care received. Those experiencing a technical difficulty had a higher rate of dissatisfaction—26.7 percent versus 3.3 percent. Provider satisfaction with the platform was 4.8 out of 10, and the providers’ perceived level of care was 5.2/10, with 10 being the same as an in-person visit.
In the session, Dr. Gallo also covered other facets of implementing telemedicine, including the provider’s room setup; workflow, scheduling, and billing issues; patient selection; various challenges, including technical difficulties; reimbursement; and the myriad legal issues associated with telemedicine.
Lessons learned from his experience, Dr. Gallo said, were:
- Certain patients and visit types work well with telemedicine.
- Allow enough time.
- Be patient with the system—“there will be issues.”
- Not everyone wants telemedicine.
- Patient and physician preparation is important.
The other panelists in ICL 106, “Telemedicine after COVID-19,” were Richard C. Mather III, MD, MBA, FAAOS, and Miho Jean Tanaka, MD, FAAOS.
Terry Stanton is the senior medical writer for AAOS Now. He can be reached at email@example.com.