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With the increase in February 2020 of COVID-19 cases and the need for social distancing practices, telehealth became a CDC-recommended format for health care providers and facilities to use for clinical services.

Research published in the Morbidity and Mortality Weekly Report showed the number of telehealth visits increased by 50% in the first quarter of 2020 compared with the same period in 2019. However, from June 26 to Nov. 6, 2020, researchers reported the number of telehealth visits decreased by 35.8% to 26.9% and the number of weekly telehealth visits also declined when COVID-19 cases decreased and then plateaued when the number of COVID-19 cases increased.

Alfred Atanda Jr., MD, said telehealth delivers health care through a beneficial and impactful experience that saves patients time and money.

Source: Nemours Children’s Health System

Despite such fluctuation in the use of telehealth, sources told Orthopedics Today they expect telehealth will continue to be used in orthopedics beyond the COVID-19 pandemic.

“With telehealth, you can deliver care in such a way that is going to be most impactful and beneficial to the patient,” Alfred Atanda Jr., MD, director, center for sports medicine service and chief of clinician experience at Nemours/Alfred I. duPont Hospital for Children, told Orthopedics Today. “In the traditional, in-person setting, it is all uniform and generalized, which is fine, but it does not get you to that higher level and echelon of care that telehealth can.”

One of the biggest advantages of telehealth is it reduces the need for patients to travel to the physician’s office, saving them time and money. A 2018 study by Atanda and colleagues showed patients who scheduled a telehealth visit saved 85 miles of driving and $50 in costs per visit. These patients also experienced shorter clinic visit and wait times compared with patients who attended in-person visits.

“Now, you can get the care you need from the comfort of your home,” Atanda, who uses telemedicine via the Nemours app, said. Telehealth allows patients to check in with their doctors remotely for medical advice without taking off from work, driving or taking their children out of school, he said.

Care anytime, anywhere

Not only can patients see their physician from anywhere, but physicians can also see patients from their home office instead of at the clinic, which, in turn, may allow physicians to extend the distance of their practice, according to Vikas V. Patel, MD, executive vice chair executive of the department of orthopedic surgery at the University of Colorado.

“[Telehealth] allows physicians to broaden the distance of their practice as well,” by allowing them to see patients who live further away from the practice, as well as to expand their practices to patients who need a second opinion, said Patel, who uses Vidyo in his telehealth practice.

Vikas V. Patel

Having fewer patients visiting the office may potentially lead to the need for less clinic space and staff, he said.

Fewer in-person visits allow providers and clinicians to save room on their schedules for more complicated cases that need a physical examination, according to Atanda.

“We can minimize resource utilization and costs and waste, especially during COVID. You have fewer people who are potentially infecting one another, but even outside of COVID, just having fewer people in your waiting area is good, in general, in terms of infectious disease,” Atanda said.

Adam S. Levin, MD, associate professor of orthopedic surgery at Johns Hopkins University, said postoperative telehealth follow-up visits may increase patient satisfaction and have helped make physicians and practices more efficient without losing patient care touchpoints.

“[Telehealth] has been a big satisfier for patients and, with that, has shown that providers are more comfortable letting patients out of their grasp, out of the hospital quicker, at times,” Levin said.

Changes in regulations

Although some physicians have the desire, interest and ability to perform telehealth visits with orthopedic patients, several challenges still remain, sources said.

One of the biggest is whether the government and other regulators will continue to allow telehealth as a feasible alternative to an in-person visit, according to Levin.

Adam S. Levin

“There had been restrictions, particularly regarding the site of service, where the patient is sitting at the time of the encounter, that greatly limited [with whom] we could [use] telemedicine,” he told Orthopedics Today. “With the public health emergency, a lot of those restrictions got lifted by CMS … and that allowed us to be able to do [telehealth visits] on patients that we were restricted from being able to do it with in the past.”

Medicolegal ramifications associated with the telehealth use, including licensure, reimbursement and medical malpractice, are areas physicians and practices need to work through regarding telehealth visits.

Licensure issues

Although licensure-related ramifications of telehealth only occur when crossing state lines, David M. Glaser, JD, health care attorney with Fredrikson Byron, said these can happen often, especially for orthopedic surgeons who practice in an area of a state that borders another state.

“From a practical perspective, … if you are seeing an established patient, the [legal] risk is probably low” concerning a telehealth licensing issue, said Glaser, who is an Orthopedics Today Editorial Board Member. “If you have seen someone in your office and this is a follow-up visit and … [the patient] has crossed the border, the risk is low, but it is not zero.”

Physicians should check whether the patient’s insurer will provide reimbursement for telehealth visits.

David M. Glaser

“With Medicare, the answer is, during the public health emergency, yes,” Glaser said. “Following the public health emergency, we are not yet sure. There is promise that through the end of 2021, even if the public health emergency ends, they are going to cover most telehealth, but we do not know about the future for Medicare.”

Reimbursement depends greatly on private insurers, with only some providing detailed information on how telehealth visits are handled. However, whether the physician has a contract with a private insurer has a lot to do, as well, with the reimbursement status for telehealth visits, according to Glaser.

“If you have a contract, the contract is going to control this. If the insurer says we are not going to cover telehealth, then you will have a problem,” Glaser said. “If you do not have a contract, then industry norms control. I think you have a good argument that right now, the industry norm is telehealth is permitted,” he said.

He suggested sending a certified letter notifying the insurer you are using telehealth, which limits the insurer’s ability to seek recoupment for the telehealth visits you perform.

Keep it confidential

Concerning risk of medical malpractice, it is not known whether there is a higher risk of medical malpractice with a telehealth visit vs. an in-person visit, Glaser said. Physicians and patients need to keep confidentiality in mind by being aware of where they are conducting the telehealth visit and if the platform they use is secure.

“So far, the government has been fairly flexible on [platform use] with Zoom and some of the other platforms, but that is an open question,” Glaser said. “Some of the different platforms — and a lot of places try to use a secure telehealth-specific platform — as time goes on, that security will probably become more important.”

To mitigate some of the legal risk associated with telehealth visits, physicians should use common sense and be transparent with patients, Glaser said.

“Be honest with the patient. Ask them if they are comfortable. If they have any misgivings about the telehealth visit, you might want to suggest they come in,” he said. “But, one of the realities is there is risk associated with having patients come in. People can get COVID. So, everything has risk, and we are all about balancing them.”

The virtual exam

Sources who spoke with Orthopedics Today said physicians must navigate how to perform an exam virtually and determine which patients would benefit most from a virtual visit.

Established patients may be the best candidates for telehealth visits, according to Nolan M. Wessell, MD, assistant professor in the department of orthopedic surgery and division of spine surgery at the University of Colorado School of Medicine.

“Particularly for return patient visits or postoperative follow-up, it is easier to conduct those visits via telehealth, which saves patients a substantial amount of driving and often we can coordinate things like follow-up imaging studies through the patient’s primary care provider and have those sent to us electronically to offer a complete visit,” Wessell told Orthopedics Today.

Nolan M. Wessel

He said one group that he finds benefits from follow-up telehealth visits are patients who receive targeted spinal injections.

“It is straightforward for us to have a discussion via telehealth regarding the outcomes after those injections and then we can spend time talking about future risks and benefits associated with surgery,” Wessell said.

Atanda said telehealth visits would also be effective for second-opinion visits.

“These patients have been seen, they have been evaluated, they have imaging and they just want to know what another surgeon thinks of their situation,” Atanda said. “It is not necessarily that I have to examine them, per se. In a lot of instances, they just want me to review their MRIs and talk to them about potential surgical options.”

Telehealth also works well for provider-to-provider consultations, he said.

New patient telehealth visits

Patients who are new to the practice may be a challenge to examine and diagnose via telehealth, according to Atanda.

“For brand new patients that you do not know, [telehealth] does not work well because we need to examine them, we need to put our hands on them and range joints and palpate joints and do different things,” Atanda said. “So, there is a big drawback and limitation to telehealth for brand new patients or patients who have not been seen or evaluated by anybody.”

However, telehealth can be beneficial for new patients who do not need a physical examination but can be diagnosed instead via imaging, such as patients with arthritis, according to Levin.

In addition to some hip and knee conditions, Patel noted patients with spinal stenosis or disc herniations may be good candidates for a telehealth visit. However, the technology can make it difficult for physicians to differentiate a patient with a simple diagnosis from one with a more complex condition, he said.

“If I could say all of the patients who have hip arthritis who had not had previous joint replacement and have typical symptoms were going to be in my clinic, then that would be easy,” Patel, who is an Orthopedics Today Editorial Board Member, said. “But the difficulty is that you cannot always pre-screen those patients and pre-diagnose them to make sure that they are appropriate for telehealth.”

Experience is less personal

Telehealth presents challenges in relationship building because it may result in a less personal experience for physicians and patients compared with an in-person visit, Patel said.

“Perhaps there is … less of a bond between the physician and patient,” Patel said. “It certainly feels less personal, so that may limit the depth of the interaction between the physicians and the patients.”

Physicians may also be hesitant to transition to telehealth in some cases because they may not feel they have an accurate assessment of the patient without direct physical contact, according to Wessell, who said an unreliable or unstable internet connection can also lead to a patient visit that is less than ideal.

“Not every patient has a reliable, high-speed internet connection which makes video-based visits a significant challenge. I think it is an equal frustration on the part of the provider as it is for the patient,” he said. “In those circumstances, you are reliant completely on a telephone conversation, which is even less ideal than a virtual visit.”

Innovative use of telehealth

Despite these challenges, telehealth may provide physicians with innovative ways to care for patients.

Richard A. Berger, MD, assistant professor of orthopedic surgery at Rush University Medical Center, said not only does he spend more time with patients virtually than he would be able to in the office, but it provides such added advantages as being able to conference in family members who live elsewhere and better understand the patient’s living situation.

“[I have patients] take their phone, walk around their house and show me what environment they are going back into,” Berger told Orthopedics Today.

Richard A. Berger

With the ability to see the layout of the patient’s house, Berger can determine what needs should be addressed prior to the patient returning home after surgery, such as navigating a flight of stairs or rearranging furniture to reduce fall risks.

The capabilities of telehealth can also be expanded beyond the direct-to-consumer model to include provider-to-provider consultations, according to Atanda. In particular, sports medicine physicians can conduct provider-to-provider consultations with athletic trainers on the sidelines of sporting events, which he said allows physicians to cover more games across different sports and levels.

Telehealth helps streamline patient care by allowing specialists to help manage patient transfers from a primary care provider’s office or the ED and as facilitation of physician teleconferences with a patient and their physical therapist during a physical therapy session, Atanda said.

“By doing things virtually, it just helps us spread and disseminate knowledge quicker and easier in such a way that is not burdensome to the physician.”

Make telehealth a priority

For physicians interested in implementing telehealth within their practice, Patel said they should make it a priority and take the time to learn and understand it.

“If they are going to use it and do it, they have to dedicate some time and effort to getting it set up, to setting aside time to see patients with telehealth, to integrating it into the practice, to making sure that patients know that it is an option and are offered the option of the telehealth visits, and then, again, having dedicated time for those telehealth visits as opposed to trying to sprinkle [them] in through an otherwise busy in-person clinic where those telehealth patients can get lost or dropped,” Patel said.

He said it is important for physicians to understand their insurance contracts regarding reimbursement for telehealth visits and the need to use HIPAA-compliant software and technology accessible to both the physician and patient.

In addition, physicians should keep up to date on changes in regulatory requirements and restrictions because these change frequently, according to Levin. Physicians should also determine how they want to incorporate telehealth into their practice workflow, whether through a separate telehealth-only clinic or as an augment to the overall clinic.

“[Telehealth] is a resource-lite meaning that it does not require a lot of resources on top of what physicians already need to run their practice and it expands what they can do in their practice,” Levin said.

Berger said physicians must realize the technology to use telehealth in their practices is already available.

“Everything you need is here today. Having some 3D hologram of the patient in front of you would, of course, be better than Zoom, but not that much,” Berger said. “You are not going to get any more information. Everything you need, you already have.”

Click here to read the Point/Counter to this Cover Story.

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