Adoption of Telemedicine: A Debrief for the Orthopedic Practitioner

Introduction

The COVID-19 pandemic has brought numerous challenges to the safe and effective delivery of health care worldwide. The cancelation of non-essential surgeries and redistribution of health care resources have contributed to a widespread adoption of telehealth practices. Physicians and patients alike should be prepared to continue to use telehealth for the foreseeable future, as current estimates suggest that “social distancing” practices may persist into the year 2021 and beyond [28].

Within the past decade, telehealth has grown rapidly in conjunction with ongoing advances in telecommunication devices and applications. Several health care sectors, including education, innovation, and clinical services, have increasingly utilized telehealth services for the delivery and advancement of efficacious and cost-effective health care [7,10]. Within musculoskeletal medicine, providers have used telehealth for consultations, outpatient follow-up care, and rehabilitation, with early success [13,18,25,35].

Recent large-scale changes in health care policies and reimbursements have decreased barriers to accessing telehealth. These amendments, albeit temporary, coupled with continued social distancing practices, suggest that telehealth may remain a useful means of health care delivery for the foreseeable future. While ultimately beneficial for providers and patients, these rapid policy changes may create a confusing landscape. In this primer, our aim is to provide the orthopedic surgeon with an overview of the presently available telehealth services and platforms and offer suggested best practices of how to smoothly integrate these methods.

Definition: Telehealth versus Telemedicine

The Federation of State Medicine Boards (FSMB) defines telehealth as “the practice of medicine using electronic communications, information technology, or other means between a licensee in one location and a patient in another location with or without an intervening health care provider” [1]. Under this framework, telemedicine refers to the use of information communication technology to deliver remote clinical care services [15]. Although used interchangeably, telehealth more broadly encompasses several services, including patient-doctor consultations, online health education resources, and even remote monitoring of patients via wearable or broadcasting devices.

A (Brief) History of Telehealth

Modern telehealth practices emerged in the 1970s; a partnership between NASA and the Indian Health Services (IHS) utilized remote communication technologies to provide primary care services to a rural Native American tribe [11]. By the end of the 20th century, telehealth practices had expanded to include anesthesiology, emergency medicine, and acute care surgery. Digital stethoscopes, glucometers, and goniometers have gone so far as to allow for portions of a standard physical examination to be performed via telehealth, allowing for remote consultations and evaluations [34]. Similarly, portable telemedicine workstations have connected inpatient staff to outside consultative services, including trauma, vascular, or even neurological surgery [30].

Within orthopedic surgery, telehealth utilization has yielded promising results. Early studies comparing telehealth visits to traditional, in-person visits for orthopedic care have shown high patient satisfaction with no apparent adverse events [6]. Traumatologists, arthroplasty surgeons, and even pediatric orthopedic surgeons have reported the benefits of telehealth for follow-up visits for both fracture management and post-operative rehabilitation [25,26]. These early findings suggest that musculoskeletal care also stands to benefit from telehealth platforms.

Regulatory Environment

Perhaps the most complex and confusing aspect of modern-day telehealth is its ever-changing regulatory environment. Since its advent, the Food and Drug Administration (FDA) has grappled with the safety, legality, and cost-effectiveness of telehealth practices. Early Centers for Medicare and Medicaid Services (CMS) regulations supported only real-time audio and video platforms; wearable heart monitors, remote glucometers, and mobile apps that tracked and transmitted patient data have been regarded as more controversial. The FDA has noted that they would not be accountable for regulating Medical Device Data Systems (MDDS), identified as “anything that transfers, stores converts or electronically displays medical device data.” The few attempted regulations for these technologies fell under the umbrella of “guidance documents,” released in conjunction with the FDA Safety and Innovation Act of 2012 [20]. Support for telehealth innovation improved with the 2017 Digital Health Innovation Action Plan, the goal of which was to monitor product performance, advancements, and safety and introduce pathways to pre-certify health care software and technologies [5]. Despite these advancements, concern still exists with regard to the legality and privacy of telehealth services across all specialties, given the vast array of services that it authors [36].

Telemedicine Reimbursement and Coverage

In 2001, reimbursements for telehealth services were first incorporated into the Social Security Act. However, an early barrier to the expansion of telehealth was the disproportionate insurance coverage in rural versus non-rural communities, as well as distinct regulatory environments. In the past decade, Medicare began reimbursing comprehensive Telehealth programs without geographic restrictions and loosened requirements on originating sites. In addition, CMS began offering reimbursements for real-time telehealth services and consultations and loosened restrictions on remote collection of patient data [8]. More recently, all 50 states and Washington DC now offer telemedicine services to some degree. However, there remains significant variability with regard to policies for reimbursements, coverage, originating sites, and provider credentialing and patient location requirements [2,17,19].

In light of the COVID-19 pandemic, the U.S. Department of Health and Human services has loosened regulations for the implementation of telehealth [3]. As of March 2020, CMS telehealth policy changes increased patient access to care. These emergency waivers for reimbursement and coverage have significantly expanded telehealth coverage beyond rural communities across the nation. In addition, some states have removed originating sites allowing patients to establish care from the safety of their home. Previously non-HIPAA complaint platforms have now been deemed acceptable for physician and patient use under the principle of good faith [33]. New patient visits may be established through a telehealth visit, as opposed to prior guidelines requiring evidence of prior clinician-patient relationships [2,3,31]. Medicare has also waived co-pays and deductibles for all telehealth services, from virtual conferencing to remote patient monitoring (RPM) and e-visits.

Telehealth Platforms

Currently, there exists a multitude of virtual health care options that vary based on the features that they provide. Provider-to-provider telehealth platforms involve communications between members of the hospital/practice staff, while provider-to-patient platforms connect patients directly with physicians. Key to effective telehealth services is the ability to share protected health information (PHI) such as imaging or medical history, as well as the type of media utilized, namely audio, video, digital messaging, or a combination thereof. Selecting the appropriate telehealth platform requires a thorough understanding of the extent to and efficacy with which this information can be shared, as well as its security and regulation, in order to effectively utilize telehealth in one’s practice.

Telehealth platforms utilize both synchronous and asynchronous technology into their software. Synchronous telehealth, that is, live video, refers to real-time conferencing between a provider and patient. Asynchronous telehealth involves electronic communication of information, including messaging or patient data, such as labs, imaging, or other PHI [17,18]. These services allow for fluidity in patient care; for instance, a physician may carry a videoconference with a patient, review pertinent X-rays or other imaging, and document in the chart.

Videoconferencing

The bulk of virtual health care revolves around the utilization of videoconferencing. A 2015 Telehealth Index Survey through the American Orthopaedic Association (AOA) found that 84% of providers felt that platforms with video features would allow for the most accurate diagnostic ability in the remote setting [35]. Videoconferencing platforms may be divided into those that are already integrated into an electronic health record (EHR) system (enterprise-based solutions) or stand-alone applications. These 2 options vary significantly in their security, regulatory compliance, cost, customizability, and ease of use and integration. Table 1 lists the specifications of popular videoconferencing applications.

Table 1.

Examples of Available Telehealth Platforms.

Platform	Cost	Compatibility	Capabilities	Benefits	Limitations	Privacy and security	Connectivity
Enterprise level
American Well	$500/mo for up to 5 providers $500/mo for each additional provider $49 per visit patient cost	iOS: iPhone 4S/iPad 2, Air, Mini, or later iPod touch 5th generation Android phone (Gingerbread v2.3.3 or above) Android Tablet	Multi-way live video and text chat EMR integration Apple Health remote monitoring Carts, kiosks, and remote instruments Scheduling and patient waiting rooms Controlled reimbursement White-labeled technology	White-labeled software available for additional cost Quick access to catalog of physicians Support for integrations Seamless billing and payments	No unpaid tier or free trial for patients Less simple interface No screen-recording capabilities	“Reasonable” measures to help protect information Does not guarantee HIPAA compliance or encryption	Wi-Fi and cellular network compatible
Doxy.me	Free introductory version	PC or Mac Operating system: Windows 10 or macOS Catalina iOS iPhone/Tablet Linux Chromebook	Live video and text chat Screen sharing on premium plan Photo capture, some screen-recording functions Multi-provider practice Patient waiting room	Simple interface and software No need for patients to download software or create account Pre-call Test function Paid tier: collect patient payments directly	Video quality varies Lack of secure document sharing Lack of scheduling capabilities No EMR/EHR integration	Point-to-point NIST-approved AES 128-bit encryption HIPAA compliant	Wi-Fi and cellular network compatible
VSee	Basic VSee Clinic at $49/month	PC or Mac Operating system: Windows 10 or macOS Catalina iOS 11+, iPhone/Tablet Android 5.0+	Live video and text chat Screen sharing Call recording Document sharing MyVitalz remote patient monitoring EMR integration with scheduling, notes, billing, and e-prescription Workflow/patient waiting room	Simple interface and software Demos and pre-meeting tests available	Rated as lower quality video/sound Lack of live customer service No screen-recording capabilities	Point-to-point encryption Offers HIPAA-required BAA HIPAA compliant	Wi-Fi and cellular network compatible
Updox	$35-60/mo per doctor No upfront fee	PC or Mac Compatible with several earlier generation operating systems iOS iPhone 7+ Samsung: Galaxy s7 and up One Plus 3t and up Google: Pixel 3+	Live video and text chat EMR integration Fax capability Scheduling and patient reminders	Easy to setup and use Reasonable pricing Aimed at small private practices	Software learning curve Delays syncing information to EMR Variable connection/compatibility with mobile phones No screen-sharing capabilities	Standard AES 256 encryption, SHA-2 hashing standard TLS when transmitted over internet HIPAA compliant	Wi-Fi and cellular network compatible
Web based
Zoom	Basic: Free Pro ($14.99) Business ($19.99) Enterprise ($19.99)	Operating system: Windows 10 or macOS Catalina Linux (including Ubuntu) PC or Mac iOS iPhone/Tablet Android Blackberry	Multi-way live video and text chat Screen sharing Screen recording	Easy navigation Breakout rooms/waiting rooms High-quality sound and video	No document sharing Concerns regarding chat feature Security concerns	Audio, video, and screen-sharing data encryption New end-to-end encryption in paid tier (2020) HIPAA compliant (“Enforcement discretion”) Meeting access Password-protected	Wi-Fi and cellular network compatible
Skype for Business	Free with Microsoft Office Account	Operating system: Windows 10 or macOS Catalina PC or Mac iOS Android IP phones USB and personal peripherals Google Chrome, Safari, and Firefox	Multi-way live video and text chat Screen sharing Document sharing	High-quality video and lag-free audio Document sharing	Interface is less simple than Zoom Security concerns	Audio, video, and screen-sharing data encryption Meeting access password-protected	Wi-Fi and cellular network compatible
Google Hangouts	Free	Chrome, Safari, and Firefox PC Linux Android macOS/iOS	Multi-way live video and text chat Screen sharing	Easy access to meetings	Both parties require Google Hangout account Must establish new meetings for each patient Cannot record, save, or share video	Audio, video, and screen-sharing data encryption Customers subjected to HIPAA guidelines must complete BAA prior to use (“Enforcement discretion”)	Wi-Fi and cellular network compatible
FaceTime	Free	Apple device/software and account iOS macOS	Multi-way live video and text chat Screen recording (without audio)	User friendly Unlimited (free) calls between Apple devices	Access to Apple products Patients gain access to personal number Cannot record or share video with audio	Phone number End-to-end encryption	Wi-Fi and cellular network compatible

See https://www.itcentralstation.com/products/comparisons/skype-for-business_vs_zoom

EHR electronic health record, BAA Business Associate Agreement, EMR electronic medical record, AES Advanced Encryption Standard, SHA Secure Hash Algorithm, TLS Transport Layer Security.

Enterprise-Level Solutions

Prior to regulatory changes surrounding the COVID-19 outbreak, EHR-integrated videoconferencing was becoming an increasingly popular means of providing virtual health care services in a variety of settings, including post-operative care and consultative services [9,25]. Certain telehealth platforms, such as Teladoc Health and American Well, allow patients to initiate health care visits with a range of providers even if they do not have a pre-existing relationship with a physician. In addition, programs “white-label” their software so that hospitals and subscribing institutions can customize their own teleconferencing interface, specific to their practice or hospital system. Of note, while enterprise-based solutions are enticing, these complex software features may be limited by similarly complex learning curves for both patients and providers [27].

Videoconferencing Applications

While many of the names and models of aforementioned telehealth enterprises are less well known, several social media-based applications are more familiar. Careful, compliant implementation of these seemingly ubiquitous applications has demonstrated early utility within telehealth. A 2015 pilot study evaluating the impact of WhatsApp use among orthopedic surgery residents as a communication tool demonstrated its utility as an intradepartmental tool for (asynchronous) provider-to-provider communication [16]. As over 80% of Americans own a smartphone and commonly use applications such as Zoom, Skype, FaceTime, and Google Hangouts, the implementation of these programs for videoconferencing provides a cost-effective and easily accessible option [17]. With the rapid, large-scale need for remote patient services, many providers have turned to these solutions as means of quickly converting to telehealth practices. The Office of Civil Rights (OCR) has temporarily waived regulations regarding previous HIPAA-noncompliant platforms to allow for utilization of popular applications with videochat capabilities, noting the need for “enforcement discretion” for providers using these applications in good faith [33]. This waiver allows providers to more easily connect with patients using computers or smart devices with cameras, rather than having to purchase an enterprise-level telehealth platform for their practice.

The convenience and cost-effectiveness of using these platforms has been offset by concerns regarding cybersecurity and technical difficulties [14]. In conjunction with the recent rapid surge in web-based videoconferencing in the educational and health care sectors, there too have come several reports of privacy-related incidents, from information-hacking to harassment. In efforts to improve security, Zoom and other teleconferencing applications have released more secure versions of their basic software, adapted and upgraded for the purpose of protecting health information.

Remote Patient Monitoring

Asynchronous RPM systems also have a diverse repertoire of platforms, which have gained new attention with COVID-19. RPM technologies have been utilized for improving patient outcomes in chronic illness and post-operative care, including post-operative arthroplasty patients. Ramkumar and colleagues monitored post-operative total knee arthroplasty patients via an automated knee sleeve, paired to an RPM app [29]. Patients and their physicians were able to track daily steps, range of motion, patient-reported outcome measures (PROMs), opioid consumption, and exercise compliance. Although the authors were concerned that older patients may struggle technically with app-based care, they found that all patients were able to complete the study and that 22 of 25 patients felt “motivated and engaged” via wearable technology [4,12,22]. Similar outcomes demonstrating the efficacy and utility of remote goniometry were demonstrated in other joint evaluations, including the elbow [21], hand interphalangeal joints [37], as well as the shoulder and knee [23,24]. The implementation of these technologies to monitor patient progress has signified increasing physician trust and reliance upon telemedicine.

Institutional Practices

Our institution utilizes a commercially available videoconferencing platform, directly integrated into our existing EHR for telehealth visits. New or established patients may request a remote evaluation through online or telephone registration. For the visit, we recommend that patients dress in comfortable clothing; they may set up in the comfort of their own home, in a location that is private but allows mobility. Patients may establish a telehealth visit via our institution’s online portal. This website contains key information on “what to expect” of their telehealth visit, as well as scheduling and preparation guidelines to ensure that the visit proceeds smoothly. We note that the remote nature of the visit may make patients more skeptical of their care; therefore, these online services become crucial in maintaining their confidence in our level of care. Increased advertising of telemedicine, through our institution’s website and other social media platforms (Instagram, Twitter, Facebook) helps reinforce new or established telehealth care offered by our physicians. In addition, our portal offers a variety of adjunct telehealth services aside from virtual primary orthopedic care; these include on-demand home exercise videos, therapy programs, and wellness infographics.

When conducting a telehealth visit, patients may use a smartphone, tablet, laptop, or desktop computer with a camera to connect with their provider. In our experience, a smartphone is often most effective; it is portable, has front- and rear-facing cameras, and optimizes continuity via cellular reception or Wi-fi, limiting connectivity issues. We emphasize that it is crucial to be very vocal throughout the telehealth visit; teleconferencing has the potential to break down the physician-patient relationship in the absence of face-to-face rapport [32]. Continuous commentary and feedback throughout the visit helps maintain this connection. Best practices for performing a remote physical examination remain to be elucidated; however, this is out of the scope of this review.

Conclusion

The COVID-19 pandemic has drastically affected the delivery of musculoskeletal care. As musculoskeletal providers segue to a “new normal” of practice management, telehealth provides a convenient, compatible, and cost-effective platform for continuing to provide high-quality care. Navigating this novel clinical environment requires knowledge and awareness of telehealth options and technicalities in order to establish best practices. We hope that this narrative provides a focused overview for the orthopedic surgeon, rheumatologist, or other musculoskeletal care practitioner beginning to utilize telehealth.