September 21, 2021

How might telehealth alter approaches to surgical patient care?

By: Elizabeth Wood
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Telehealth services grew exponentially in the early days of the COVID-19 pandemic. Overall telehealth utilization for office visits and outpatient care was 78 times higher in April 2020 than in February 2020, according to a McKinsey & Company July 2021 report. Since then, telehealth utilization has stabilized at levels that are 38 times higher than before the pandemic, the report notes.

Psychiatry and substance use disorder treatment comprise the lion’s share of telehealth claims in the McKinsey report, but there are growing opportunities for applications in other specialties, including surgery.

 

Here to stay

Although telehealth usage has dropped from the levels seen during the height of the pandemic, it is widely expected to have staying power, in part because of the reimburseable telehealth codes that the Centers for Medicare & Medicaid Services (CMS) built into the 2021 physician fee schedule. In April 2020, CMS issued 1,135 COVID-19 emergency declaration blanket waivers for healthcare providers that would be effective through the end of the emergency declaration. And coverage for some services via telehealth may be extended until the end of 2023, as per CMS’s 2022 Physician Fee Schedule Proposed Rule.

Joe DeVivo

“In the next 3 to 5 years, healthcare will find the balance between in-person and virtual care,” predicts Joe DeVivo, president, hospital and health systems, Teladoc Health, Inc, headquartered in Purchase, New York. DeVivo sees great potential in the use of telehealth for patients and providers alike.

“There’s a huge opportunity in specialty care,” he says. “Virtual care will be the great democratization of healthcare, allowing for specialty services to be delivered in rural hospitals.” Remote patient monitoring devices can make it easier and more convenient for patients and providers to track postoperative progress. And at some facilities like Cleveland Clinic, anesthesiologists have been conducting virtual preoperative visits instead of traveling in person to each individual clinic to meet with patients. “It’s about convenience—getting more data, efficiency, and better quality of life for the patients and the caregivers,” DeVivo says.

In addition, he notes the use of technology for training purposes. “Telementoring” is allowing clinicians to interact remotely to learn new surgical techniques, and vendors who once frequented ORs can now provide technical assistance remotely instead of in person.

 

Telehealth trends in surgery

Results of a University of Michigan study found an increase in telehealth visits by surgical patients during the pandemic. Using data from 2,588 surgeons who chose telehealth for patient care, the researchers focused on the 1,182 surgeons who used telehealth for new patient visits. They saw a jump in telehealth visits from less than 1% in March 2020 to 34.6% in April 2020.

The researchers used claims data from a large commercial insurer and focused on new adult outpatient visits with a surgeon between January 5 and September 5, 2020. Surgical specialties included in the study were colorectal, general, neurosurgery, OB-GYN, ophthalmology/ENT, orthopedics, plastic surgery, thoracic surgery, and urology.

They established three time periods within the 9-month study period: (1) pre-COVID-19 pandemic, January 5 to March 7, 2020; (2) early pandemic, March 8 to June 6, 2020; and (3) late pandemic, June 7 to September 5, 2020. The mean weekly rate of 16.6% of telehealth use during period 2 dropped to 3.0% in period 3.

“The growth in surgical telehealth during the COVID-19 pandemic mirrors the growth (and eventual decline of telehealth) for other specialties, albeit at slightly lower levels,” the researchers say. That is mainly because clinics reopened for inpatient care, patients who had deferred care came back for in-person care, and surgeons and patients maybe had considered telehealth only a temporary phenomenon.

Even though insurance policies provided some reimbursement, just 25% of surgeons used telehealth for new patient visits, and 59% of surgeons used telehealth in any patient care context.

What is impeding wider adoption? The authors cite these potential barriers:

• concerns that telehealth reimbursement may discontinue after the pandemic; therefore, providers may be reluctant to invest time and resources in changing workflows

• discomfort with assessing patients remotely instead of by physical examination, which is typically how diagnoses and treatment plans are established

• lack of accessibility for patients who are unaccustomed to the technology or unable to secure a private space and internet connectivity for the visit.

“Telehealth, although not a new technology, is being newly used and on a massive scale,” the authors conclude. “Future studies must focus next on whether telehealth truly replaces in-person visits or increases healthcare utilization, and whether it maintains surgical outcomes by specialty given that the quality of surgical care via telehealth in this new era remains unknown.”

The authors of a related commentary echo the researchers’ conclusion: “Ultimately, the surgical patient experience and quality of communication via telehealth remain minimally understood,” say Kapadia et al. “We postulate that perhaps the most difficult aspect of telehealth to overcome is not being able to connect with patients in person. This connection forms the bedrock of the patient-surgeon relationship and lays the foundation for trust.”

 

Considerations for surgical specialties

When it comes to bariatric surgery, telehealth led to a decrease in new patient visits and follow-up visits with surgeons but an increase in follow-up visits with other practitioners, say the authors of a study conducted at a multidisciplinary clinic. Bariatric surgical practices are relatively unique, the authors note, because of the multidisciplinary nature of the care teams and frequent visits before and after surgery. Preoperative care often includes visits with a surgeon, a psychological assessment, and evaluation by a registered dietician. Postoperative care with the multidisciplinary team is lifelong to ensure adherence to lifestyle changes and weight loss maintenance.

Using a pre-telehealth time period (February 19 to March 18, 2020) and a post-telehealth time period (March 19 to April 16, 2020), they analyzed the change in patient visit volume for multiple practitioners. There were a total of 506 visits (162 new patient visits and 344 follow-up visits) in the pre-telehealth period, versus 413 visits (77 new patient visits and 336 follow-up visits) during the post-telehealth period.

Surgeons saw a 75% decrease in new patient visits from the pre- to post-telehealth period, versus only an 8.57% decrease in volume for the psychologist. Similarly, follow-up visits for surgeons decreased by 55.1%, whereas that volume increased by 27.4% for advanced practitioners.

The authors cite several barriers that might account for these results, including:

• the impact of COVID-19 on unemployment and health insurance status has likely led to patients not seeking nonemergent medical care

• technological limitations may prevent some patients from access to telehealth care

• some patients may prefer to wait until they can have an in-person consultation.

The authors believe that clinicians including advanced practitioners, bariatricians, psychologists, and dietitians may transition to telehealth visits for many bariatric surgery patients, whether new or follow-up visits, and that surgeons will continue to use telehealth for follow-up visits.

“These data suggest that other multidisciplinary clinics, including bariatric practices, should strongly consider increased telehealth usage during and at the conclusion of the pandemic,” they say.

Promising results from a randomized study of 122 patients undergoing arthroscopic surgery of the meniscus also favor the use of telemedicine for postsurgical follow-up visits. Researchers at NYU Langone Health in New York City randomly assigned patients to office-based or telemedicine follow-up for 5 to 14 days after surgery.

Surgeons in the telemedicine group assessed patients visually for wound healing, drainage, and swelling. Both groups had low complication rates, and although two patients in each group had swelling that prompted concerns about possible blood clots, Doppler ultrasound scans in these patients found no evidence of venous thromboembolism.

Patient satisfaction ratings on a 0 to 10 scale, based on survey responses, were 9.79 in the telemedicine group and 9.77 in the office-based group. In both groups, about 20% of patients said they would have preferred the other type of visit. The authors say their study is the first to compare postoperative follow-up via telemedicine versus an office visit, and they consider telemedicine to be a “reasonable alternative” for patients undergoing knee arthroscopy.

Plastic surgery is another specialty that has used telemedicine. Before the COVID-19 pandemic, no telehealth consults had been done in the department of plastic surgery at the University of Texas Southwestern (UTSW) Medical Center in Dallas, say the research article authors. But when elective procedures were halted between April 1 and mid-May 2020, five UTSW plastic surgeons used telehealth visits to monitor patients: 195 non-wound care and 145 wound care consultations took place during this period. Of the patients deemed eligible by the surgeons for telehealth consults, 60% agreed to participate, and 40% declined. Consults included breast cancer reconstruction, cosmetic surgery, hand surgery, and other types of surgery.

When phased reopenings of surgery departments occurred after the spring of 2020, the authors note, UTSW began to see a 25% conversion rate from televisits to in-person visits. However, they say that expanding telehealth services allowed providers to see many more new patients—a 22-fold increase from February to April 2020.

Telehealth visits benefit patients by minimizing risk of exposure to pathogens in the clinical setting and in some cases avoiding the hardship of traveling to a facility, the authors say, but there are several legal considerations that play into this model of patient care (sidebar, “Risk mitigation”).

“Although plenty of uncertainty exists over the state of our healthcare system post-pandemic, this medium will remain a useful tool for providing prompt medical care that transcends geographic and socioeconomic barriers,” the authors conclude. “It can be integrated with traditional in-person care to enhance the practitioner-physician relationship and improve patient outcomes.”


Risk mitigation

Misdiagnosis is the biggest liability of using telehealth services, says Peter Reilly, MS, North American healthcare practice leader and chief sales officer of Chicago-based HUB International. A technological glitch can cause misunderstanding, potentially leading to a faulty treatment plan.

Depending on the circumstances, a surgeon may opt to conduct the telehealth meeting with another healthcare professional like a nurse or physician assistant. Or it may be necessary to see the patient in person.

Data security is another major concern. Reilly emphasizes the need for a robust technology platform that is protected with firewalls and updated regularly. “There are checklists and other services that can help outline best practices in data security,” he says. In addition, staff must be trained to understand how to mitigate data security risks and to know when there has been a breach. In the event of a data breach, he says, there should be a breach response plan in place so that the proper authorities are promptly notified and the provider can avoid compliance penalties.

Because of the pandemic, the US Health and Human Services Office for Civil Rights currently is not penalizing physicians for non-compliance with the Health Insurance Portability and Accountability Act if they are acting in their patients’ best interests, say researchers from the University of Texas Southwestern Medical Center in Dallas. But in the post-pandemic world, they note, it will be incumbent on providers to provide a secure technology platform.

References

Cheney C. How healthcare providers can mitigate 3 telehealth risks. HealthLeaders Media. June 4, 2021.

Wamsley C E, Kramer A, Kenkel J M, et al. Trends and challenges of telehealth in an academic institution: The unforeseen benefits of the COVID-19 global pandemic. Asthet Surg J. 2021;41(1):109-118. https://academic.oup.com/asj/article/41/1/109/5875043.

https://www.healthleadersmedia.com/welcome-ad?toURL=/innovation/how-healthcare-providers-can-mitigate-3-telehealth-risks.


On the horizon

The ability to integrate data from the electronic medical record with the data captured from telemedicine visits is ushering in a more consumer-centric approach to healthcare, DeVivo says.

“One thing we’re doing is to contemplate not just the patients’ time in the OR, but who they are beforehand and what their outcomes are afterward,” he adds. This shift to more longitudinal care will help ensure that patients are properly selected and educated before their procedures. Patients, in turn, will have access to their records and more information about their choice of facilities, and many repetitive tasks like filling out multiple forms can be eliminated through better use of technology.

“OR leaders need to be aware that this digitization is happening, and to think about what can be done to enhance best practices and better understand patients to improve outcomes,” he says.

DeVivo will present “The Rise of Telehealth Services in the Hospital, ASC, and OR” on October 21 during the annual OR Manager Conference. To learn more or to register, visit www.ormanagerconference.com. ✥

 

References

Bestsennyy O, Gilbert G, Harris A, et al. Telehealth: A quarter-trillion-dollar post-COVID-19 reality?McKinsey & Company. Published online July 9, 2021. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/telehealth-a-quarter-trillion-dollar-post-covid-19-reality.

 

Brown A M, Ardila-Gatas J, Yuan V, et al. Annals of Surgery. December 2020;272(6):e306-e310. The impact of telemedicine adoption on a multidisciplinary bariatric surgery practice during the COVID-19pandemic. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7668342/.

 

Chao G F, Li K Y, Zhu Z, et al. Use of telehealth by surgical specialties during the COVID-10 pandemic. JAMA Surgery. Published online March 26, 2021. https://jamanetwork.com/journals/jamasurgery/fullarticle/2778017.

 

Hakim A A, Kellish A S, Atabek U, et al. Implications for the use of telehealth in surgical patients during the COVID-19 pandemic. The American Journal of Surgery. 2020;220(1):48-49. https://www.americanjournalofsurgery.com/article/S0002-9610(20)30231-2/pdf.

 

Herrero C P, Bloom D A, Lin C C. Patient satisfaction is equivalent using telemedicine versus office-based follow-up after arthroscopic meniscal surgery. Journal of Bone and Joint Surgery Am. Published online March 15, 2021. https://pubmed.ncbi.nlm.nih.gov/33720907/.

 

Kapadia M R, Kratzke I M, Sugg S L. The rise and fall of surgical telehealth—Can lack of patient connection be blamed? JAMA Surgery | JAMA Network. Published online March 26, 2021. https://jamanetwork.com/journals/jamasurgery/fullarticle/2778018.

 

Wamsley C E, Kramer A, Kenkel J M, et al. Trends and challenges of telehealth in an academic institution: The unforeseen benefits of the COVID-19 global pandemic.Aesthetic Surgery Journal. 2021;41(1):109-118. https://academic.oup.com/asj/article/41/1/109/5875043.

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