Telehealth, in its essence, is the ability to deliver healthcare at a distance. It is the concept of providing an equivalent or even better level of care regardless of the patient’s physical location.
In the early days of medicine, virtually all care happened in the presence of the patient: exams, visits, operations. With advancements in scientific understanding and technology, test results could be evaluated in laboratory settings; radiological exams could be interpreted after they had been recorded.
With advancements in transportation and communication technology, many of the peripheral healthcare services could now be performed at locations tens or hundreds of miles away. Blood samples could be flown to specialized labs and reports sent back by secure electronic messaging. EKGs could be taken in one location and then faxed to a cardiologist for review. X-Rays could be digitized and sent to Radiologists on a different continent.
Nowadays, of course, the term telehealth mostly evokes video visits and for some even the possibilities of “Remote Physiological Monitoring”, or RPM. A natural evolution from the early beginnings of healthcare’s augmentation through technology, albeit now accelerated by the Covid-19 health crisis.
The Clinical and Financial Efficacy of Telehealth
Over the past years I have written extensively about Telehealth’s benefits to increase access to care or to make it more convenient for the Modern Healthcare Consumer.
What has been more challenging to cover accurately is the actual clinical efficacy of telehealth and, in the context of our shift away from fee-for-service care toward value-based care, the financial sustainability of telehealth.
In this first of a series of articles over the next months, I plan to feature evidence that telehealth indeed proved to be at least as good as the traditional in-person care model of the past. And if there are contraindications — circumstances, under which telehealth cannot deliver the same results — I will cover and highlight those as well.
The purpose is to educate, so that clinicians can use telehealth as what it is: a clinical tool that, like any other medical tool, should only be used under the right circumstances.
Telehealth Efficacy in Surgical Planning
The first example of telehealth efficacy (and the limitations of telehealth) comes from the world of surgery.
When I first started in telehealth I thought that surgeons and dentists would probably one of the last to use telehealth, yet as early as 2013 remote surgeries were performed on a regular basis and in 2016 I was even approached by two orthopedic surgeons who were excited about offering diagnostic telehealth services, but were still a little ahead of their time.
Today’s evaluation of telehealth efficacy focuses on surgical planning conducted via a virtual visit which subsequently was confirmed (or changed) during an in-person evaluation. The results from this type of clinical are especially interesting because many opponents to telehealth claim that a virtual visit can not be a substitute for an in person visit because of the lack of an ability to properly examine the patient.
Study: Telemedicine visits generate accurate surgical plans across orthopaedic subspecialties
The study I’m referencing was conducted retrospectively on 303 patient visits that led to surgery. The study’s authors were interested in understanding how often the surgical plan that was developed after the virtual visit was updated after subsequent in-person visits. Across the different types of procedures, the rate of changes was quite low:
- Overall no change in the surgical plan for 292 of the 303 patients (96%)
- Hip & Knee Arthroplasty: no change for 77 out of 77 (100%)
- Foot & Ankle Surgery: 11 out of 11 (100%)
- Sports Surgery: 77 out of 80 (96%)
- Upper Extremity/Shoulder Surgery: 73 out of 76 (96%)
- Spine Surgery: 54 out of 59 (92%)
As the authors summarize it: “surgical plans generated for orthopaedic patients across all the elective orthopaedic subspecialties are rarely changed by in-person evaluation.”
The Art of Virtual Exams
What I like about the authors’ approach is that they also analyzed to which extent the surgeons asked the patient to perform one or more maneuvers for further evaluation.
As they laid out in their study, they found a great degree of variation across subspecialties but also across institutions to which extent maneuvers were integrated into the virtual exam e.g., for upper extremity & shoulder surgery about 50% of virtual exams included three or more maneuvers whereas about 20% did not include any maneuver.
The good news is, that as with anything in medicine: if a diagnosis cannot be made confidently (e.g., based on a physical exam), then further tests or examinations are needed. Thus, if a virtual visit exam is not sufficient, further visits or tests are needed.
Behind the closed walls of an exam room, most physicians are left to their own training and experience to perform examinations as they see best fit. Since few if any clinicians had such an education on the proper use of maneuvers during a virtual exam, it is for now potentially most prudent to rely on the proven practice of “curbside consults” albeit not necessarily specific to one patient, but rather on the best approach to this “diagnostic service”.
The Need for Clinical Virtual Care Guidelines
One way to systematize this process is to facilitate the discussion of clinical guidelines on how to best conduct a virtual visit or, in this case a virtual exam. We are currently working with a number of clients across a number of clinical specialties and behavioral health services to develop some in-house clinical guidelines to share and compare best practices.
This shift toward embracing virtual care first and foremost calls for clinical leadership to set the course for the clinicians to develop ways to get the most value and clinical accuracy out of virtual visits. As the authors of the study speculate, the variability across institutions may very well be reflective of the institution’s or the leadership’s embrace of virtual care services (or lack thereof).
On the other hand, the authors also make a good point with “given the significant breakthroughs in advanced imaging, technology, and communications systems, it is not clear that the physical exam itself is as important as it once was for most orthopaedic diagnoses.”
In other words, telehealth may not have had the upper hand 10, 20 years ago, but these days fewer and fewer specialists have to rely on a physical examination in order to make a diagnosis and develop a treatment plan. Which further reduces the need for an in-person encounter.
Conclusion
Even though telehealth has been around for decades, we are just beginning to tap into the full potential of what virtual care can offer. The innovative technologies are already here and it is now upon courageous clinical leaders to lead their colleagues into this new paradigm of care delivery, without a compromise in the quality of care.
Have you come across a research paper or article that features the clinical or financial efficacy of telehealth? Send ‘em my way and I’ll write about it in one of the upcoming installments of “#TelehealthEfficacy”.
To receive articles like these in your Inbox every week, you can subscribe to Christian’s Telehealth Tuesday Newsletter.
Christian Milaster and his team optimize Telehealth Services for health systems and physician practices. Christian is the Founder and President of Ingenium Digital Health Advisors where he and his expert consortium partner with healthcare leaders to enable the delivery of extraordinary care.
Contact Christian by phone or text at 657-464-3648, via email, or video chat.
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