Telemedicine has been a part of physician-patient interaction since the 1970s. Over the years, advances in communications technologies have allowed for exponential growth in the number of applications that telemedicine can provide. For example, practices no longer have to rely on the telephone for scheduling patient appointments and making call backs. Electronic Health Record (EHR) systems and independent vendors also offer online appointment scheduling. More recently, EHRs and dedicated apps have enabled secure email communication with patients, improving access and information sharing.
Potentially the most valuable advancement in telemedicine, however, is a solution that enables physicians to virtually examine patients from thousands of miles away via videoconferencing. In 2010, the U.S. military introduced such a program to increase the number of consultations performed by orthopaedic physicians overseeing U.S. troops. (See "Tailoring Telemedicine to Deliver Optimum Orthopaedic Care," AAOS Now, June 2010). The pilot program utilized a physician assistant to identify possible surgical candidates who then consulted with an orthopaedic surgeon via a video teleconference. However, the early program also identified one important aspect—the need for human intervention or input—that still complicates video consultations today.
Physicians were also deterred from conducting video patient visits due to high costs, difficulty of use, potential liability exposure, geographic barriers with licensing, and conflicts involving HIPAA-compliant healthcare delivery. However, many of these concerns have been addressed as technology has become more sophisticated and efficient. Telemedical research branches among hospitals and universities, and programs such as "MyDoc," a government created HIPAA-compliant software application, have contributed to a rapid increase in the acceptance and use of telemedicine. In addition, concerns over whether patients feel comfortable and competent using telemedicine software to consult with practitioners will likely decrease with the proliferation of smartphone and tablet use among all age groups.
Telemedicine and orthopaedics
Given the growth in communications technologies, applications of telemedicine are blossoming throughout small niches in medicine. The technology boom of the last few years has spawned many telehealth digital technology companies, along with rapidly growing acceptance among patients and primary care healthcare providers. The opportunity exists for specialists—including orthopaedic surgeons—to adapt telemedicine's more sophisticated features to enhance their practices.
To date, however, orthopaedic surgeons have not broadly adopted telemedicine. The logistics of scheduling appointments in a busy orthopaedic practice, combined with the difficulty of integrating the diagnostic studies into the video interface, remain a challenge. Moreover, the orthopaedic consult relies heavily on the physical examination, something that is largely lacking during a video visit. Regulatory issues, such as licensing across state lines, also create hurdles (ie, can a California-licensed physician "see" a patient in New York?).
However, the biggest impediment to the adoption of the video visit in the orthopaedic practice space appears to be reimbursement. As yet, no uniform or widely accepted reimbursement strategy has emerged from Medicare or commercial carriers to allow specialist video visit reimbursements to approach those of an in-person visit. Unlike specialist appointments, moderately priced primary care telehealth visits are relatively easily embraced by cash-pay patients who place a premium on convenient access. The considerably higher cost of the orthopaedic telehealth visit challenges the patient to decide if they are better served going in for a regular (insurance covered) visit, rather than paying for a video consultation. Companies that attempt to keep orthopaedic telehealth visit prices low to encourage their use offer reimbursement rates that are unattractive to orthopaedic surgeons.
On the plus side, orthopaedic telemedicine pilot studies have shown promise. For example, in a study of 229 total knee and hip replacements, 118 patients were randomized to receive telemedical follow-ups and were then interviewed about their experience. Interestingly, researchers found that none of the patients had difficulty grasping the concept of telemedicine, and none complained of difficulties in using the software provided. Patients also reported satisfaction with web-based follow-ups due to less traveling, lower associated costs, and less overall time spent completing their appointment.
Without question, telemedicine has forever changed the way physicians communicate with each other and their patients. As communications technologies progress, the uses for telemedicine in orthopaedic practice have boundless potential. U.S. military surgeons, for example, can already perform surgeries remotely. Ultimately, however, telemedicine's full potential can only be realized if the issues concerning specialist requirements are recognized and addressed.
Nicholas Colyvas, MD, is a member of the AAOS Practice Management Committee. Joey Carbone, BS, is a medical student candidate.
- Marsh JD, Bryant DM, MacDonald SJ, Naudie DDR, McCalden RW, Howard JL, Bourne RB, and McAuley JP: Feasibility, effectiveness and costs associated with a web-based follow-up assessment following total joint arthroplasty. J Arthroplasty 2014;29(9):1723-1728. Epub 2014 Apr 13.
- Daruwalla ZJ, Wong KL, Thambiah J: The application of telemedicine in orthopedic surgery in Singapore: A pilot study on a secure, mobile telehealth application and messaging platform. JMIR mHealth uHealth 2014;2(2):e28. Available at: http://mhealth.jmir.org/2014/2/e28/ Accessed January 27, 2016.