U.S. military teleorthopaedic program utilizes VTC, specially trained PAs

Technology could soon change the way U.S. soldiers stationed in Bavaria, Germany, receive orthopaedic care. Based on the success of a telemedicine pilot project, injured soldiers could be assessed locally under the watchful eye of an orthopaedic surgeon stationed hundreds of miles away.

The Tele-Ortho telemedicine solution utilizes live video-teleconferencing (VTC) and physician assistants (PAs) to perform surgical consults remotely over the Internet, eliminating the 3- to 4-hour trip to Landstuhl Regional Medical Center (LRMC) or Heidelberg Health Center normally required to meet with a surgeon. A 90-day pilot program of the technology was recently conducted at the U.S. Army Health Clinic in Vilseck, a training camp in Germany.

“Our remote clinics are staffed by primary care physicians; we don’t have specialty care set up in these locations,” explained LTC Jeffrey S. Morgan, MD, MC, U.S. Army. “We needed a solution for delivering military-specific orthopaedic care to our soldiers.”

PAs plus VTCs equal success
As Dr. Morgan pointed out, telemedicine is not a new concept. It has been used stateside for decades to provide rural patients increased access to specialty health care. In Germany, implementation of a U.S. military traumatic brain injury telemedicine program is currently underway. Dr. Morgan was able to use some of the technology already in place to develop a solution appropriate to the needs of military orthopaedic patients who may require surgery.

A unique aspect of the program was that it utilized orthopaedic-trained PAs to perform all aspects of nonsurgical patient management.

“During the pilot program, it was the PA’s responsibility to review the surgery consults that came in from the primary care providers and identify patients who may require surgery,” Dr. Morgan said. In the event of complex issues, an orthopaedic surgeon was always available for back-up by telephone or via the VTC.

When the PA identified a patient as a potential surgical candidate, a VTC consult with the orthopaedic surgeon was then scheduled. During the consult, the surgeon was able to view all relevant patient images—radiographs, magnetic resonance imaging scans, and computed tomography scans—stored in the picture archive communication system.

“Although I physically couldn’t put my hands on a patient, I could watch the PA perform, for example, a Lachman test on a patient with a suspected anterior cruciate ligament (ACL) tear,” Dr. Morgan explained. “I wouldn’t expect a primary care physician to have a feel for that and to be able to tell if the ACL is out or not—but I do expect that from an orthopaedic-trained PA.”

When the patient arrived at the hospital for surgery, the surgeon repeated the PA-performed physical exam to verify the VTC findings before proceeding to the operating room. In 100 percent of the cases, the VTC findings were confirmed.

The Tele-Ortho pilot program’s success can be attributed largely to its experienced orthopaedic PA, says Dr. Morgan. “David Melaas is a strong orthopaedic PA who showed what PAs can do with the appropriate support behind them and with a system designed to make them successful.”

During the pilot program, Mr. Melaas saw 167 orthopaedic patients and recommended 28 (23 surgical, 5 nonsurgical) VTC consults. Of the 23 potential surgical candidates, 61 percent received or scheduled surgery. Postoperative appointments were also performed remotely via VTC.

“Given this was a 3-month pilot program, I was very pleased with the 61 percent surgical rate,” said Dr. Morgan. “We believed it was prudent to be overly cautious during the pilot as we worked out all the various possibilities and problems. We didn’t want to miss anything during this pilot program.”

A hit with soldiers
What do the soldiers think about the Tele-Ortho program? According to Sgt. Jacob Bacahui, the non-commissioned officer in charge of the project in Vilseck, patients were very pleased with the program.

“Soldiers are confident with military orthopaedic care, especially when they can see and converse with their surgeon pre- and postoperatively without having to travel to a hospital several hours away,” he said. Eliminating unnecessary trips to the hospital also kept soldiers off the dangerous German autobahn and decreased their time away from work.

The program also boosts the productivity of the orthopaedic surgeons. “By allowing the PAs and primary care providers to manage patients’ nonsurgical care, I can spend less time in the clinic and more time in the operating room,” said Dr. Morgan. “I’m increasing the number of soldiers I’m helping return to the force.”

Based on the Tele-Ortho pilot program’s success, the military plans a full roll out to increase military orthopaedic services throughout the European Regional Medical Command (ERMC). Shaka M. Walker, MD, will take over as clinical director of the Tele-Ortho program in ERMC; Dr. Morgan is returning to the states to earn an MBA in health sector management at Duke University and to practice in Fort Bragg, N.C.

It’s important to note, said Dr. Morgan, that although telemedicine differs from traditional treatment techniques, the Tele-Ortho program does not affect the standard of orthopaedic care the U.S. military provides. In fact, it maintains the same surgical quality of care and the same support structure (such as occupational and physical therapy) while increasing patient and physician satisfaction.

“We are committed to, and pride ourselves on, providing our soldiers the highest caliber of orthopaedic care,” Dr. Morgan stressed.

Partial funding for the Tele-Ortho project was provided from the Army Medical Department Advanced Medical Technology Initiative. The project was developed in collaboration with the University of Nebraska, Omaha, Tele-medicine Research Center.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org