Cover Story

Orthopedists start to adopt virtual continuity of care

Mobile apps, video, text systems support increased electronic patient follow-up by orthopedists.

For decades, many medical specialties have used telemedicine, which is the electronic delivery of pictures or radiographs to diagnose and treat patients. The development of newer and more sophisticated technology, such as smart phones and iPads, has supported the increased use of telemedicine in text, as well as video platforms, making it more accessible to physicians and patients as a tool to continue care after the initial office visit or treatment. Although this is not a new concept in orthopedic surgery, the specialty has yet to truly adopt electronic continuity of care and telemedicine for its follow-up of patients.

“I would say that for 90% of orthopedic surgeons in this country, maybe more, electronic follow-up is not a thing,” Orrin I. Franko, MD, a hand surgeon at East Bay Hand Medical Center in San Leandro, Calif. told Orthopedics Today. “They do not do it. They do not get paid for it and they do not have the facilities or the logistical infrastructure to make it happen.”

One reason orthopedists may not use telemedicine is they feel their specialty is too “hands-on” for virtual visits, with orthopedists being unable to determine areas of tenderness and pain or measure range of motion and strength as well through a telemedicine visit as they can in person, according to Joseph P. Iannotti, MD, PhD, who is chairman of the Orthopedics and Rheumatologic Institute at Cleveland Clinic.

“Our specialty is physically based,” Leo T. Kroonen, MD, at Kaiser Permanente in San Diego, said. “We are used to being able to put our hands on our patients and we place a high value on that.”

Leo T. Kroonen, MD
Leo T. Kroonen, MD, said telemedicine and the Kaiser Permanente app have helped him to better care for his patients, many of whom live more than an hour away from his office.

Source: AJ Durfee, PA-C; Kaiser Permanente

The patient experience

Even if a local physical therapist is involved to assist in the physical exam to help improve the patient’s overall health care experience, virtual follow-up can seem less personal, Joseph A. Abboud, MD, professor of orthopedics at Thomas Jefferson University and senior vice president of the Rothman Institute, said. With electronic follow-up, surgeons may miss body language cues from the patient that may convey how the patient is actually doing, he said.

“A lot of the time, observations help you understand the physical limitations of a patient without examining them. How they walk into a room, how they dress, how they put a jacket on or off, and then the nuances of their interaction with their family are also important to your care,” Abboud told Orthopedics Today.

For many patients who decide to undergo major surgery with you, “you know that how they interact with their social network, their spouse, their siblings, their son, their mother, etc., affects some of the social dynamics and their aftercare. You do not necessarily gain an appreciation for that virtually or on the web,” Abboud said.

HIPAA compliance

Orrin I. Franko, MD
Orrin I. Franko

Beyond being unable to fully interact with and read the patient with electronic follow-up systems, orthopedic surgeons should be wary of utilizing applications and other types of virtual follow-up that are not HIPAA-compliant, Franko noted.

“Unfortunately, HIPAA and privacy is not a clear line in the sand,” he said. “There is much interpretation to it.”

According to Franko, although the Facetime app on iPhone has never, to his knowledge, been hacked, it should not be used as a tool for patient follow-up mainly because it is not HIPAA compliant.

“Here you have a system that is probably totally safe to use, but is still illegal simply because of a law that was written before this technology was invented,” he said.

But, not all electronic follow-up platforms are non-HIPAA-compliant.

Iannotti, who embarked on telemedicine for select preoperative and postoperative visits in his upper extremity practice 4 to 5 years ago, told Orthopedics Today he initially did not have a HIPAA-compliant way to use telemedicine. However, he now uses the American Well telemedicine system, which is integrated into the Epic electronic medical record used by Cleveland Clinic.

Forging a connection

Joseph P. Iannotti, MD, PhD
Joseph P. Iannotti, MD, PhD, uses a telemedicine system for patient visits in his upper extremity practice, which is integrated into the Cleveland Clinic electronic medical record.

Source: Cleveland Clinic

Integrating telemedicine into Kroonen’s practice has helped him better connect with patients, many of whom are usually living hours away from his office.

“Our group takes care of the entire county of San Diego, which geographically is big, and it would take a patient potentially an hour or more to drive from one side of the county to another,” he said, noting the Kaiser Permanente trauma system is centralized.

“When I am taking care of ankle fracture – and hip fracture – and wrist fracture type patients, I am taking care of them at our central hospital which is kind of central in our county, but my home office is at the southernmost extent of the county and oftentimes my patients are coming from the northernmost extent of our county,” Kroonen said.

Through the Kaiser Permanente app, Kroonen can “meet” with patients 6 weeks after hip fracture surgery without them having to make the trip to his office.

Tailoring telemedicine to practice

Despite not being able to see the patient in person when electronic follow-up methods are used, Roy I. Davidovitch, MD, Julia Koch Associate Professor of Orthopaedic Surgery at NYU Langone Health in New York, has found these afford surgeons more control of and efficiency with their patients’ preoperative and postoperative treatment and follow-up.

Davidovitch uses a FORCE Therapeutics text-based application that patients sign up for about 1 month before surgery. The practice has reduced the number of phone calls made to patients and generally improved workflow by using push notifications to remind patients of appointments for preoperative and postoperative treatment, according to Davidovitch.

“What it has done is helped us to make the treatment patient and doctor specific, so that whatever I want to happen or whatever message I want to get out to the patient I can get it out to them easily as they progress as opposed to just giving them a big download of discharge instructions,” he said.

“I like the fact I can tailor what the patient hears over time. I am not relying on the hospital giving them some sort of discharge information that they give every patient that may not apply to mine,” Davidovitch said.

Patients can also contact Davidovitch via the app with concerns or questions. Also, urgent matters can be dealt with directly by Davidovitch and his team instead of the patient having to go to the ED. But, orthopedists should be aware that some of their patients may try to take advantage of this kind of a direct connection with the physician.

“[Patients will] message you on the weekend and their expectation is an immediate response even if it is not an urgent matter,” Davidovitch said. “If I get a message on the weekend and it is not an urgent matter, I will not answer it; but, some patients might get upset. Patient expectations must therefore be set ahead of time.”

Virtual follow-up cost savings

Joseph A. Abboud, MD
Joseph A. Abboud

The use of telemedicine has been shown to be financially beneficial, according to Davidovitch, who said it has allowed his practice to stop utilizing home physical therapy and visiting nurse service (VNS), for example.

“I have stopped using VNS and home physical therapy for about 90% of my total hip patients, which is a cost savings of about $4,000 per operation or 15% to 20% savings when considering a bundled payment of $24,000 per episode. Postoperative follow-up visits are minimized due to the increased communication opportunities with the patient. Unnecessary visits to emergency rooms are avoided,” he said.

Beyond being beneficial to hospitals and orthopedic practices in terms of the bottom line, patients too may see the financial benefits from telemedicine and virtual follow-up, according to Abboud.

“It would cost the patients less, from transportation to parking to time commitment [and] time away from work,” Abboud said. Theoretically, patients could complete a virtual follow-up visit on a lunch break, at their office while at work or during a break during the day, he said.

Despite these conveniences and cost savings, Franko said he has concerns about orthopedic surgeons receiving payment for time spent on a virtual follow-up call.

Abboud noted that some insurers will cover the cost of electronic continuity of care.

“There are some insurers that do recognize electronic follow-up as billable follow-up or perioperative care, and we are trying to, in essence through studying it, validate the way we do it,” Abboud said.

May not be for everyone

Roy I. Davidovitch, MD
Roy I. Davidovitch

Telemedicine as a form of postoperative visit may not be beneficial to every practice, Iannotti noted.

Franko, for example, does not see the benefit of using telemedicine as a tool for follow-up in his orthopedic practice. He does, however, appreciate its value as a tool to collect patient-reported outcomes.

“At the patient’s first postoperative visit, they usually get their stitches taken out. You cannot do that by phone or by iPad,” Franko said. “At their second postoperative visit, they often will need a cast. You cannot do that by phone. At many of their postoperative visits, they will often need an X-ray. X-ray is done in my office, so once again, there is no benefit to them staying home,” he said.

Furthermore, many patients are uncomfortable removing their own dressings after surgery and prefer an office visit to have that done, Franko noted.

Abboud also found that to be true when recruiting patients for a study now underway to assess patient and physician satisfaction with virtual visits vs. in-office visits.

“There are patients who have been asked to enroll in this study who have declined because they like to see me. They want me to actually examine them personally and they feel like they are not getting potentially as good of care if I do not physically see them,” Abboud said.

Patient compliance an obstacle

Orthopedic surgeons who are considering telemedicine or an electronic patient follow-up system may be concerned about patient compliance and whether certain patients will be able understand how to work the app. This can be one of the hurdles with this technology, according to Franko.

“You have to guarantee the patient will be available,” he said. “Just because you tell the patient to sit by their iPad by 3 o’clock does not mean they are going to be there.”

In addition, some physicians and patients may be “beyond the age where they are able to understand some of this advanced technology and utilize it,” Abboud said.

Train patients to use virtual systems

Therefore, surgeons who are willing and able to incorporate telemedicine into their practice should confirm with patients that they feel comfortable with and have access to the necessary devices.

Another area to consider is will the patient’s socioeconomic status afford them the ability to access certain technology that would make electronic follow-up possible, Abboud said.

“We assume everyone has access to a smart phone, a laptop, a desktop [computer] and ... Wi-Fi, but not everyone does,” he said.

A way to overcome some of these hurdles and help with patient compliance is to have staff show patients how to use the texting and video platforms, according to Kroonen.

“We have someone call [patients] in advance of the video visit and walk them through the process so they are familiar with it,” Kroonen said.

Telemedicine can offer many advantages when used for follow-up of noninvasive procedures, Franko noted, such as after an injection for carpal tunnel syndrome or trigger finger, as long as the patient has no problems or concerns after his or her treatment.

“What I tell [patients] is if you are doing fine, just cancel your appointment,” he said. “So 90% of the time we could do a quick teleconference and they could say, ‘Just wanted to let you know everything is going fine, no problems, no concerns,’ and that would be perfectly appropriate.”

Technological glitches, upgrades

As with all new technology, telemedicine, electronic follow-up and virtual clinics in orthopedics can experience technological glitches.

“A lot of times, things do not work 100% right the first time,” Kroonen said. “I have tried to do some video follow-ups where I wanted to go over an MRI and we had some glitches in terms of me sharing my screen and I could not get the MRI up.”

Sources told Orthopedics Today they are hopeful the telemedicine apps and systems they now use will eventually offer expanded functionality and other new features, such as HIPAA-compliant Facetime-like communication and a cloud-based process for saving and sending MRIs. They noted it is also important that their telemedicine system offers seamless integration with EMRs.

“These are things that, the more common they become, we will find better ways and patients will get a little more comfortable with the process too; but, we are in the early stages of it,” Kroonen said.

Advice for novice users

For orthopedic surgeons who want to start using telemedicine in their practice, but do not know where to begin, Davidovitch recommends they evaluate several telemedicine systems to determine which one works best for their practice.

“I do not think you want to buy a package where you fit your practice to what the system can do, but rather whatever platform is used can be tailor-made to what you want to do with a direct communication with patients, with the ability to do a picture upload, a link to medical records. Those are the sort of keys to making this easier,” Davidovitch said.

Although orthopedic surgeons should feasibly be able to use telemedicine with nearly all procedures, Davidovitch recommended they initially select a single procedure to try it out on that is repetitive and standardized, such as knee arthroscopy, ACL surgery or single-level anterior cervical discectomy and fusion.

“You can tailor [telemedicine] to what you are doing, but I think in the early going you want to focus on a procedure that has a standardized-type protocol, a group of patients who are easy to follow and study, so you can learn from them and expand it to other procedures,” he said.

In general, Kroonen advises orthopedists to just “start doing it.”

“[Telemedicine] is an important thing for us to be doing in medicine and it does offer a powerful tool to reach patients. Once you start doing it, you will start learning what its place can be and how you can increase your convenience for your patients and how you can, in some ways, increase your convenience for yourself, as well,” Kroonen said. – by Casey Tingle

Disclosures: Davidovitch, Franko, Iannotti and Kroonen report no relevant financial disclosures. Abboud reports no relevant financial disclosures, but Rothman Institute is an investor in FORCE Therapeutics.

Click here to read the POINTCOUNTER, “In what ways will telemedicine change how orthopedic surgeons deliver care in the next 2 to 5 years?

For decades, many medical specialties have used telemedicine, which is the electronic delivery of pictures or radiographs to diagnose and treat patients. The development of newer and more sophisticated technology, such as smart phones and iPads, has supported the increased use of telemedicine in text, as well as video platforms, making it more accessible to physicians and patients as a tool to continue care after the initial office visit or treatment. Although this is not a new concept in orthopedic surgery, the specialty has yet to truly adopt electronic continuity of care and telemedicine for its follow-up of patients.

“I would say that for 90% of orthopedic surgeons in this country, maybe more, electronic follow-up is not a thing,” Orrin I. Franko, MD, a hand surgeon at East Bay Hand Medical Center in San Leandro, Calif. told Orthopedics Today. “They do not do it. They do not get paid for it and they do not have the facilities or the logistical infrastructure to make it happen.”

One reason orthopedists may not use telemedicine is they feel their specialty is too “hands-on” for virtual visits, with orthopedists being unable to determine areas of tenderness and pain or measure range of motion and strength as well through a telemedicine visit as they can in person, according to Joseph P. Iannotti, MD, PhD, who is chairman of the Orthopedics and Rheumatologic Institute at Cleveland Clinic.

“Our specialty is physically based,” Leo T. Kroonen, MD, at Kaiser Permanente in San Diego, said. “We are used to being able to put our hands on our patients and we place a high value on that.”

Leo T. Kroonen, MD
Leo T. Kroonen, MD, said telemedicine and the Kaiser Permanente app have helped him to better care for his patients, many of whom live more than an hour away from his office.

Source: AJ Durfee, PA-C; Kaiser Permanente

The patient experience

Even if a local physical therapist is involved to assist in the physical exam to help improve the patient’s overall health care experience, virtual follow-up can seem less personal, Joseph A. Abboud, MD, professor of orthopedics at Thomas Jefferson University and senior vice president of the Rothman Institute, said. With electronic follow-up, surgeons may miss body language cues from the patient that may convey how the patient is actually doing, he said.

“A lot of the time, observations help you understand the physical limitations of a patient without examining them. How they walk into a room, how they dress, how they put a jacket on or off, and then the nuances of their interaction with their family are also important to your care,” Abboud told Orthopedics Today.

PAGE BREAK

For many patients who decide to undergo major surgery with you, “you know that how they interact with their social network, their spouse, their siblings, their son, their mother, etc., affects some of the social dynamics and their aftercare. You do not necessarily gain an appreciation for that virtually or on the web,” Abboud said.

HIPAA compliance

Orrin I. Franko, MD
Orrin I. Franko

Beyond being unable to fully interact with and read the patient with electronic follow-up systems, orthopedic surgeons should be wary of utilizing applications and other types of virtual follow-up that are not HIPAA-compliant, Franko noted.

“Unfortunately, HIPAA and privacy is not a clear line in the sand,” he said. “There is much interpretation to it.”

According to Franko, although the Facetime app on iPhone has never, to his knowledge, been hacked, it should not be used as a tool for patient follow-up mainly because it is not HIPAA compliant.

“Here you have a system that is probably totally safe to use, but is still illegal simply because of a law that was written before this technology was invented,” he said.

But, not all electronic follow-up platforms are non-HIPAA-compliant.

Iannotti, who embarked on telemedicine for select preoperative and postoperative visits in his upper extremity practice 4 to 5 years ago, told Orthopedics Today he initially did not have a HIPAA-compliant way to use telemedicine. However, he now uses the American Well telemedicine system, which is integrated into the Epic electronic medical record used by Cleveland Clinic.

Forging a connection

Joseph P. Iannotti, MD, PhD
Joseph P. Iannotti, MD, PhD, uses a telemedicine system for patient visits in his upper extremity practice, which is integrated into the Cleveland Clinic electronic medical record.

Source: Cleveland Clinic

Integrating telemedicine into Kroonen’s practice has helped him better connect with patients, many of whom are usually living hours away from his office.

“Our group takes care of the entire county of San Diego, which geographically is big, and it would take a patient potentially an hour or more to drive from one side of the county to another,” he said, noting the Kaiser Permanente trauma system is centralized.

“When I am taking care of ankle fracture – and hip fracture – and wrist fracture type patients, I am taking care of them at our central hospital which is kind of central in our county, but my home office is at the southernmost extent of the county and oftentimes my patients are coming from the northernmost extent of our county,” Kroonen said.

PAGE BREAK

Through the Kaiser Permanente app, Kroonen can “meet” with patients 6 weeks after hip fracture surgery without them having to make the trip to his office.

Tailoring telemedicine to practice

Despite not being able to see the patient in person when electronic follow-up methods are used, Roy I. Davidovitch, MD, Julia Koch Associate Professor of Orthopaedic Surgery at NYU Langone Health in New York, has found these afford surgeons more control of and efficiency with their patients’ preoperative and postoperative treatment and follow-up.

Davidovitch uses a FORCE Therapeutics text-based application that patients sign up for about 1 month before surgery. The practice has reduced the number of phone calls made to patients and generally improved workflow by using push notifications to remind patients of appointments for preoperative and postoperative treatment, according to Davidovitch.

“What it has done is helped us to make the treatment patient and doctor specific, so that whatever I want to happen or whatever message I want to get out to the patient I can get it out to them easily as they progress as opposed to just giving them a big download of discharge instructions,” he said.

“I like the fact I can tailor what the patient hears over time. I am not relying on the hospital giving them some sort of discharge information that they give every patient that may not apply to mine,” Davidovitch said.

Patients can also contact Davidovitch via the app with concerns or questions. Also, urgent matters can be dealt with directly by Davidovitch and his team instead of the patient having to go to the ED. But, orthopedists should be aware that some of their patients may try to take advantage of this kind of a direct connection with the physician.

“[Patients will] message you on the weekend and their expectation is an immediate response even if it is not an urgent matter,” Davidovitch said. “If I get a message on the weekend and it is not an urgent matter, I will not answer it; but, some patients might get upset. Patient expectations must therefore be set ahead of time.”

Virtual follow-up cost savings

Joseph A. Abboud, MD
Joseph A. Abboud

The use of telemedicine has been shown to be financially beneficial, according to Davidovitch, who said it has allowed his practice to stop utilizing home physical therapy and visiting nurse service (VNS), for example.

“I have stopped using VNS and home physical therapy for about 90% of my total hip patients, which is a cost savings of about $4,000 per operation or 15% to 20% savings when considering a bundled payment of $24,000 per episode. Postoperative follow-up visits are minimized due to the increased communication opportunities with the patient. Unnecessary visits to emergency rooms are avoided,” he said.

PAGE BREAK

Beyond being beneficial to hospitals and orthopedic practices in terms of the bottom line, patients too may see the financial benefits from telemedicine and virtual follow-up, according to Abboud.

“It would cost the patients less, from transportation to parking to time commitment [and] time away from work,” Abboud said. Theoretically, patients could complete a virtual follow-up visit on a lunch break, at their office while at work or during a break during the day, he said.

Despite these conveniences and cost savings, Franko said he has concerns about orthopedic surgeons receiving payment for time spent on a virtual follow-up call.

Abboud noted that some insurers will cover the cost of electronic continuity of care.

“There are some insurers that do recognize electronic follow-up as billable follow-up or perioperative care, and we are trying to, in essence through studying it, validate the way we do it,” Abboud said.

May not be for everyone

Roy I. Davidovitch, MD
Roy I. Davidovitch

Telemedicine as a form of postoperative visit may not be beneficial to every practice, Iannotti noted.

Franko, for example, does not see the benefit of using telemedicine as a tool for follow-up in his orthopedic practice. He does, however, appreciate its value as a tool to collect patient-reported outcomes.

“At the patient’s first postoperative visit, they usually get their stitches taken out. You cannot do that by phone or by iPad,” Franko said. “At their second postoperative visit, they often will need a cast. You cannot do that by phone. At many of their postoperative visits, they will often need an X-ray. X-ray is done in my office, so once again, there is no benefit to them staying home,” he said.

Furthermore, many patients are uncomfortable removing their own dressings after surgery and prefer an office visit to have that done, Franko noted.

Abboud also found that to be true when recruiting patients for a study now underway to assess patient and physician satisfaction with virtual visits vs. in-office visits.

“There are patients who have been asked to enroll in this study who have declined because they like to see me. They want me to actually examine them personally and they feel like they are not getting potentially as good of care if I do not physically see them,” Abboud said.

Patient compliance an obstacle

Orthopedic surgeons who are considering telemedicine or an electronic patient follow-up system may be concerned about patient compliance and whether certain patients will be able understand how to work the app. This can be one of the hurdles with this technology, according to Franko.

PAGE BREAK

“You have to guarantee the patient will be available,” he said. “Just because you tell the patient to sit by their iPad by 3 o’clock does not mean they are going to be there.”

In addition, some physicians and patients may be “beyond the age where they are able to understand some of this advanced technology and utilize it,” Abboud said.

Train patients to use virtual systems

Therefore, surgeons who are willing and able to incorporate telemedicine into their practice should confirm with patients that they feel comfortable with and have access to the necessary devices.

Another area to consider is will the patient’s socioeconomic status afford them the ability to access certain technology that would make electronic follow-up possible, Abboud said.

“We assume everyone has access to a smart phone, a laptop, a desktop [computer] and ... Wi-Fi, but not everyone does,” he said.

A way to overcome some of these hurdles and help with patient compliance is to have staff show patients how to use the texting and video platforms, according to Kroonen.

“We have someone call [patients] in advance of the video visit and walk them through the process so they are familiar with it,” Kroonen said.

Telemedicine can offer many advantages when used for follow-up of noninvasive procedures, Franko noted, such as after an injection for carpal tunnel syndrome or trigger finger, as long as the patient has no problems or concerns after his or her treatment.

“What I tell [patients] is if you are doing fine, just cancel your appointment,” he said. “So 90% of the time we could do a quick teleconference and they could say, ‘Just wanted to let you know everything is going fine, no problems, no concerns,’ and that would be perfectly appropriate.”

Technological glitches, upgrades

As with all new technology, telemedicine, electronic follow-up and virtual clinics in orthopedics can experience technological glitches.

“A lot of times, things do not work 100% right the first time,” Kroonen said. “I have tried to do some video follow-ups where I wanted to go over an MRI and we had some glitches in terms of me sharing my screen and I could not get the MRI up.”

Sources told Orthopedics Today they are hopeful the telemedicine apps and systems they now use will eventually offer expanded functionality and other new features, such as HIPAA-compliant Facetime-like communication and a cloud-based process for saving and sending MRIs. They noted it is also important that their telemedicine system offers seamless integration with EMRs.

PAGE BREAK

“These are things that, the more common they become, we will find better ways and patients will get a little more comfortable with the process too; but, we are in the early stages of it,” Kroonen said.

Advice for novice users

For orthopedic surgeons who want to start using telemedicine in their practice, but do not know where to begin, Davidovitch recommends they evaluate several telemedicine systems to determine which one works best for their practice.

“I do not think you want to buy a package where you fit your practice to what the system can do, but rather whatever platform is used can be tailor-made to what you want to do with a direct communication with patients, with the ability to do a picture upload, a link to medical records. Those are the sort of keys to making this easier,” Davidovitch said.

Although orthopedic surgeons should feasibly be able to use telemedicine with nearly all procedures, Davidovitch recommended they initially select a single procedure to try it out on that is repetitive and standardized, such as knee arthroscopy, ACL surgery or single-level anterior cervical discectomy and fusion.

“You can tailor [telemedicine] to what you are doing, but I think in the early going you want to focus on a procedure that has a standardized-type protocol, a group of patients who are easy to follow and study, so you can learn from them and expand it to other procedures,” he said.

In general, Kroonen advises orthopedists to just “start doing it.”

“[Telemedicine] is an important thing for us to be doing in medicine and it does offer a powerful tool to reach patients. Once you start doing it, you will start learning what its place can be and how you can increase your convenience for your patients and how you can, in some ways, increase your convenience for yourself, as well,” Kroonen said. – by Casey Tingle

Disclosures: Davidovitch, Franko, Iannotti and Kroonen report no relevant financial disclosures. Abboud reports no relevant financial disclosures, but Rothman Institute is an investor in FORCE Therapeutics.

Click here to read the POINTCOUNTER, “In what ways will telemedicine change how orthopedic surgeons deliver care in the next 2 to 5 years?