Good Comes From Evil: COVID-19 and the Advent of Telemedicine in Orthopedics

Introduction

The consequences of the COVID-19 pandemic continue to affect many facets of our lives. One consequence has been the integration of web-based videoconferencing platforms into both the professional and personal lives of many people worldwide. Social distancing mandates, implemented to prevent the spread of the virus, prompted many health care institutions to transition rapidly from in-person to remote patient encounters via various telehealth platforms for most clinical care episodes [21,42]. This collective pivot to telehealth was important for musculoskeletal care providers including orthopedic surgeons, primary care physicians, physiatrists, and physical and occupational therapists; it allowed them to care for patients with conditions deemed non-essential for in-person consultation but still warranting evaluation and treatment [21,42]. Furthermore, it provided a safer alternative in caring for patients who are at high risk for complications related to SARS-CoV-2 infection, including patients older than 65 years and those with certain comorbidities [39]. Although the utilization of telemedicine had increased over the past few decades within certain medical disciplines, including primary care medicine, radiology, and dermatology, it had not been widely implemented among musculoskeletal care providers [11,13,52,66]. Barriers to implementation have included doubts that a reliable physical examination could be performed and a lack of experience and comfort in providing patient care via videoconferencing platforms. Other concerns that have prevented the widespread adoption of telemedicine include a lack of reimbursement from multiple payers including the Centers for Medicare and Medicaid Services (CMS), legal concerns regarding medical licensure law and personal health information (PHI) protection, and socioeconomic barriers [13].

As guest editors of this special issue of HSS Journal on the use of telemedicine in musculoskeletal care, we have been impressed by the dedication of clinicians in adapting their practices to accommodate the needs of their patients. While the rapid adoption of telemedicine in musculoskeletal care came out of necessity in response to the COVID-19 pandemic, clinicians’ experiences with this method of care delivery have provided valuable insights into how we can better use these technologies in a post-pandemic world. In this article, we provide a brief overview of the current role of telemedicine in orthopedics and describe how the COVID-19 pandemic has led to its rapid implementation within our field [3,12,25,37,38,46].

Rapid Implementation of Telemedicine in Orthopedics: A Timeline

In December 2019, the World Health Organization (WHO) received reports of pneumonia with an unknown cause, and it was soon determined that a novel virus (SARS-CoV-2) had caused these cases [3]. In response to the spread of this virus throughout the world, the WHO declared a global pandemic on March 11, 2020. From March 13 to 16, 2020, states of emergency were declared throughout the United States [42], and various state and local governments issued “stay-at-home” or “shelter-in-place” orders [21]. In response to these mandates, health care systems across the country immediately pivoted to delivering patient care for most non-emergent and non-COVID-19-related issues via telemedicine. Most patient encounters shifted from traditional in-person appointments to virtual visits, conducted mainly via web-based videoconferencing platforms or telephone [42]. To facilitate this abrupt, large-scale transition to telemedicine, clinical staffs were rapidly trained to provide care remotely [42]. These measures helped to reduce the spread of SARS-CoV-2 transmission within outpatient offices and medical centers, protecting patients and health care workers alike [42,60]. The CMS began to temporarily provide reimbursements for telemedicine encounters, and most states either eased provider licensing requirements or administered temporary licenses for telemedicine [3,21]. Although these measures were initially intended to be temporary, as we continue to gather data supporting improved patient access to care, similar or better patient satisfaction rates, and reduced health care costs, it is becoming increasingly likely that CMS and other payer support of telemedicine and provider licensing will continue when we return to a new normal following the resolution of the COVID-19 pandemic [2,6–8,22,28,31,40,50,56,57,59,67].

Telemedicine Utilization Pre-COVID-19

The WHO defines telemedicine as the remote delivery of services by health care professionals by using communication technologies to exchange information for the diagnosis, treatment, and prevention of disease, injuries, research, and evaluation, in the interests of advancing the health of individuals and their communities [33]. Telehealth visits can be synchronous, or real-time interactions between the patient and provider, or asynchronous [60]. The first documented episode of telemedicine occurred more than 50 years ago [65]. More recently, the use of telehealth has been increasing throughout the United States, Canada, and Europe, most notably in the fields of radiology, dermatology, psychology, cardiology, and general surgery [45]. Prior to the COVID-19 pandemic, telemedicine had largely been used to deliver health care to remote areas where transportation may be difficult and for patients with socioeconomic limitations which make in-person visits difficult [44]. Barriers to the widespread implementation across other medical disciplines have included low rates of physician buy-in, medicolegal concerns, a lack of reimbursement models by insurance companies and CMS, questions regarding value to the health care system, and patient access to requisite technologies [1,3,53]. Telemedicine has had a limited role in orthopedic surgery [11,52,66]. The U.S. Army began to use telemedicine for orthopedic care in 2007 for soldiers deployed overseas [4]. Previously published studies on telemedicine in orthopedics prior to the COVID-19 pandemic demonstrated that most remote patient interactions were actually asynchronous, with patients sending images of wounds or representative photos of joint range of motion to their provider for interpretation and guidance [8,17,26,32]. More recent advances in web-based videoconferencing platforms have allowed for synchronous, real-time remote interactions, facilitating a more personal approach to patient encounters that more closely resemble traditional in-person visits [41].

The Hospital for Special Surgery Telehealth Experience

In 2018, the Hospital for Special Surgery (HSS) introduced a telehealth platform called HSS@Home, which initially served as an alternative to traditional home rehabilitation services following total joint arthroplasty (TJA). This program facilitated face-to-face rehabilitation sessions with physical therapists, which allowed for real-time patient education, progress assessment, and remote monitoring of surgery-related complications such as extremity swelling or wound healing issues [21]. This program improved access to care, with patients typically first seen within 24 hours of discharge, while also helping to decrease unnecessary re-admissions by allowing for timely detection of postoperative issues [18]. When restrictions on non-essential, in-person clinic visits were put in place at HSS in March 2020, the clinician and administrative workflows that were already in place for the HSS@Home virtual rehabilitation program were scaled up and used throughout the institution. In an effort to continue providing outpatient musculoskeletal care while maintaining appropriate social distancing protocols, HSS began the institution-wide utilization of telehealth [21]. Between March 16 and May 29, 2020, HSS performed 15,461 outpatient telehealth visits. Similar initiatives took place within the department of physical therapy. Other institutions reported similar massive increases in remote patient visits, with 1 institution in California reporting a 400% increase in telephone visits and a 900% increase in video visits [42].

Benefits of Telemedicine

Telemedicine visits have been shown to allow for the delivery of timely and convenient patient care across a variety of medical disciplines [14,43]. Telemedicine also improves access to health care by removing geographic and economic barriers [21,47]. As there is a lack of access to subspecialized orthopedic care in rural settings across the United States, with this disparity projected to worsen over the next decade, telemedicine can serve as a means of providing necessary care to these patients [5,30,34]. When compared with in-person visits, telemedicine has been shown to decrease travel times and result in significantly lower costs to patients [10]. Lower costs result from reduced travel expenses, less time lost from work, and lower child care costs when compared with in-person visits [6]. Overall, telemedicine has been shown to be cost-effective in the delivery of orthopedic care in the United States and other countries [22,28,31,40,50,59,67]. Additional benefits include flexibility for physicians and patients to arrange visits outside of traditional clinic hours at times that may be more convenient for working patients and surgeons [3,21]. For postoperative patients and elderly patients who may have limited mobility, telemedicine visits may minimize the likelihood of falls and decrease the amount of time spent in health care facilities, an important consideration during the COVID-19 pandemic [3].

Telemedicine may also improve patient satisfaction, with 1 recent meta-analysis suggesting that patients who have had previous telehealth visits are 1.5 times more likely to prefer it for subsequent appointments when compared with in-person visits. Randomized controlled trials (RCTs) investigating patient satisfaction among orthopedic patients with telemedicine showed no differences when compared with in-person visits [6,7]. Other studies investigating specific orthopedic subspecialty populations including pediatric and adult trauma [8,56], spine [57], and sports medicine [2] have reported good patient outcomes and satisfaction rates. Among studies that assessed functional outcomes including range of motion and quality of life, no differences were found when comparing telemedicine and in-person visits [6,7,20,29,54,55,63]. Furthermore, no differences in management plans were observed when comparing in-person and telemedicine visits, suggesting that telemedicine does not hinder the ability to diagnose or manage orthopedic conditions [62].

We have found telemedicine to be particularly useful for follow-up visits in which imaging or other diagnostic studies are reviewed with patients. Before our institutions adopted telemedicine at the onset of the COVID-19 pandemic, the results of such diagnostic studies were often communicated to patients via a phone call in which the imaging study was not visible to the patient. However, during a virtual visit using a web-based videoconferencing platform, the provider is able to share their screen and demonstrates pertinent findings in real-time. Subsequently, the provider and patient can discuss a treatment plan. Both patients and clinicians have generally expressed satisfaction with the convenience associated with these types of virtual visits. Other applications of telehealth include new patient visits, in which the initial consultation serves as a triage mechanism [21]. During this initial consultation, the provider can determine the need for additional diagnostic testing or imaging, medication, physical or occupational therapy, an in-person visit for further evaluation, or referral to another provider [60]. This format can be particularly beneficial to patients living in remote areas, those with limited means of transportation, poorly mobile patients, or for individuals unable to visit the clinic during normal hours. Studies have demonstrated that when telehealth is used in this way, it can reduce unnecessary follow-up appointments [31], lower health care system costs [9], and improve physician workflow and satisfaction [48,68]. As our experiences with telemedicine continue to increase, future studies will investigate and better delineate the most appropriate roles for telemedicine in orthopedics.

Limitations of Telemedicine

Although the rapid adoption of telemedicine in response to the COVID-19 pandemic has improved access to care and has shown telehealth to be a viable option for orthopedic care, there are some limitations. While Internet access is generally accessible for most patients and providers, there are concerns that health care disparities may widen among patients without readily available Internet connectivity [27]. Furthermore, even among patients with Internet access and compatible electronic devices, connectivity issues frequently arise and often warrant phone calls to patients to help them connect to their remote visit. These issues have arisen due to problems with the web-based programs themselves and user errors, as many patients and providers have not yet become facile with the use of these programs [53]. Technical support staff must be available to troubleshoot these issues, an added cost to the health care system. Continued improvement to and increasing familiarity with these technologies will be necessary to deliver effective care while preserving patient satisfaction levels [50].

Beyond issues related to the various web-based videoconferencing platforms, other challenges include accommodating patients with sensory disabilities such as blindness or deafness, difficulties in integrating interpreter services, and accommodating patients with cognitive deficits [60]. As the use of telemedicine continues to expand, it will be essential to make interpreter services and other assistive technologies available to individuals with disabilities and other underserved patient populations [60]. Certain aspects of in-person care are also inherently lost with telemedicine [3]. Some patients have been reluctant to engage in telemedicine visits, especially for initial visits with a new provider. This may be in part due to concerns about building a physician-patient relationship via a videoconferencing platform, a concern that many surgeons have also raised [3]. As discussed below, an in-person physical examination offers a more comprehensive ability to perform a musculoskeletal assessment when compared with a virtual visit. Ultimately, as we return to a new normal following the resolution of the COVID-19 pandemic, the benefit of telemedicine in preventing spread of the virus will become less relevant. At that point, perhaps the greatest barrier to providing these services will be a reluctance among both patients and providers to adopt telemedicine. As such, the aforementioned limitations of providing orthopedic care via telemedicine must continue to be investigated and improved upon [50].

Is Telemedicine an Effective Method for Patient Care? The Data

A 2015 Cochrane review which investigated the efficacy, cost, and acceptability of telemedicine across multiple medical disciplines included 93 RCTs and found that telemedicine was equivalent to usual practice for the management of chronic health conditions [19]. However, most of these RCTs pertained to heart disease and diabetes, and most interventions pertained to the monitoring and treatment of these chronic conditions. Among postoperative patients following organ transplant or urological surgery [15,16,35], the review found no difference in patient outcomes when comparing telemedicine and in-person visits. Previous studies have also specifically investigated telemedicine in orthopedic patients [23,64]. These studies have demonstrated no differences in patient satisfaction when comparing telemedicine and in-person visits. However, some studies have suggested that telemedicine visits can result in additional testing being ordered when compared with in-person visits [23,64]. In a recent systematic review of telemedicine in orthopedics, 12 of 13 included studies reported no significant difference in patient satisfaction with telemedicine compared with in-person office visits, along with a reduction in health care–associated costs with telemedicine [41]. In fact, 1 study demonstrated increased patient satisfaction with telemedicine visits which was attributed to shorter wait times [23,64]. In another study, 97% of patients who were surveyed after a telemedicine encounter preferred subsequent telemedicine rather than in-person visits, whether as initial or follow-up appointments [24]. One recent study of telemedicine in sports medicine similarly reported a high quality of care and patient satisfaction across a wide range of ages, with high satisfaction for both new and follow-up encounters [60]. One study suggested that providers were comfortable delivering care via telemedicine by their fourth encounter [60]. Ongoing and future studies, including larger randomized studies with longer term follow-up that directly assess orthopedic patients, will aim to validate and improve upon the increased use of telemedicine seen since the onset of the COVID-19 pandemic.

Telemedicine Physical Examination

The challenges of remote physical examination include determining an accurate range of motion, strength, stability, and neurovascular testing, all considered obstacles among orthopedic surgeons to telemedicine. While several articles in this special issue of HSS Journal describe modifications of various aspects of the in-person musculoskeletal physical examination to allow it to be performed remotely, there is no doubt that an in-person physical examination allows for a more comprehensive assessment with fewer limitations than a virtual examination. Furthermore, the “laying on of hands” that occurs during the physical examination may provide the patient with an additional level of comfort and confidence in their provider, especially during an initial visit with a new provider. While it is impossible to replace the ability of a trained provider to perform a comprehensive and accurate physical examination, many aspects of the physical examination can be effectively and efficiently performed remotely. One recent study provided an overview of the musculoskeletal physical examination for telemedicine visits [58]. An RCT compared telemedicine and in-person consultations, finding that physicians rated their abilities to examine patients as “good” or “very good” in 98% of telehealth visits, with no between-group differences or adverse events [7]. Previous studies have demonstrated that clinicians can successfully use telemedicine to perform a standard examination for patients with mild low back pain [61], non-articular lower limb pain [51], and knee pain [49]. A major limitation of the virtual musculoskeletal physical examination is that the sensitivities, specificities, and diagnostic accuracies of most examination maneuvers have not yet been validated when performed by a patient or by an untrained remote examiner and interpreted by a clinician. However, 1 recent study compared the diagnostic effectiveness of the telemedicine shoulder examination with an in-person examination for the diagnosis of rotator cuff tear, finding no significant differences in the overall diagnostic effectiveness [5]. Recognizing the current limitations of the remote musculoskeletal examination, we recommend that treatment plans are only formulated when findings of the virtual examination corroborate the patient’s history and imaging studies—conflicting findings should prompt an in-person evaluation prior to clinical decision making [29]. Future studies will aim to develop a standardized remote physical examination along with validated measurements that will allow for widespread, reliable use by providers of musculoskeletal care.

Future Directions

Despite its devastating consequences across the globe, the COVID-19 pandemic has served as a catalyst for the widespread expansion of telemedicine [3]. While telemedicine will not entirely replace in-person orthopedic care, it can offer advantages including cost-effectiveness, safety, convenient access, and high patient satisfaction [5,41,60]. Barriers to widespread adoption include the limited availability of technology for some patients and the challenges in performing an adequate remote physical examination for clinicians. Continued expansion of telemedicine and validation studies may minimize these barriers [60]. As orthopedists care for patients with a wide variety of conditions, we must not take a one-size-fits-all approach to remote orthopedic care [5]. Rather, future studies specific to each of these patient populations will help to better delineate the most appropriate roles for telemedicine in orthopedics [5]. While early studies have demonstrated great promise, larger and longer term studies will be necessary to assess the safety, efficacy, and cost-effectiveness of telemedicine in orthopedics [36].