Post COVID-19: Is Orthopaedic Telemedicine Here to Stay?

During the COVID-19 pandemic, the role of orthopaedic virtual visits and telemedicine developed rapidly out of necessity. Because many surgeons were not able to evaluate patients in office, the field was forced to develop new communication tools to optimize the workflow and quality of evaluations in an online setting. Although the pressing need for virtual options has thankfully subsided with the pandemic, the development of orthopaedic telemedicine has left patients continuing to expect the convenience of such online medical services.

Benefits of telemedicine
The need for telemedicine has always been present, particularly in minimizing travel or time away from work or school for patients, where evidence shows the use of online services can be extremely effective. Numerous studies since the onset of the pandemic have demonstrated the efficacy of orthopaedic telemedicine, with high levels of patient satisfaction. This success has been attributed to conveniences such as decreased travel and wait times for appointments and reduced costs of care.

Similarly, physicians have reported high satisfaction rates with orthopaedic telemedicine. Studies have demonstrated that video consultations for follow-up care after orthopaedic and trauma surgery can result in cost savings through reducing personnel costs while increasing productivity for clinics. In addition, telemedicine has demonstrated good validity and excellent reliability for assessments of pain and swelling, range of motion, muscle strength, and balance, making it a safe and useful tool in the management of orthopaedic patients.

Optimizing virtual visits
Telemedicine for new patient evaluations in an orthopaedic practice may be employed in a narrow capacity, with care taken to set expectations regarding the limitations of a virtual visit. Initial telemedicine evaluation by a clinician can allow for earlier availability, facilitating triage of more urgent patients. Orthopaedic surgeons should be careful not to make assumptions or provide full diagnoses in cases that require hands-on evaluation. However, the virtual process can improve the efficiency of patient care, including preparation for the first in-person visit, such as appropriate imaging and necessary records.

Postoperative management has been shown to be an effective use of telemedicine visits, with studies demonstrating noninferiority compared to in-person visits following total knee arthroplasty. Other studies have demonstrated comparable pain relief and greater range of motion and strength with telemedicine-based versus in-person rehabilitation, possibly due to convenience and increased compliance with the exercises. These and other types of visits that require relatively uncomplicated evaluations, such as range-of-motion assessments, can also be ideal for the virtual setting.

As the virtual examination requires adequate set-up, including standardized camera perspectives for valid assessment of symmetry and angle measurements, pre-visit communication for appropriate preparation by the patient remains critical for optimal efficiency and effectiveness of the virtual visit. Prior to appointments, patients should be reminded that the virtual visit will involve a physical evaluation. They should review the instructions for the visit, including wearing appropriate attire (e.g., shorts for knee evaluations) as well as having the appropriate space and camera set-up for optimal visualization during evaluation.

Lastly, visits consisting primarily of discussion, whether for clinical decision making or surgical education, continue to be a useful indication for telemedicine visits. These visits tend to have the most value for telemedicine without the current limitations associated with physical examinations. The capability to screenshare to review imaging during follow-up visits increases the utility of telemedicine compared with telephone calls. Additionally, surgical discussions with the use of visual aids, such as knee models, can also be useful communication tools in this setting.

Challenges
New challenges since the pandemic have included the expiration of the waiver that had allowed for the use of telemedicine for provision of care, with few exceptions. As of this year, many states require a license in the patient’s state for a physician to practice telemedicine. However, some states make exceptions for certain types of visits; therefore, those who are considering utilizing telemedicine for out-of-state patients should confirm the laws specific to each state and communicate this with their patients. In general, reported exceptions include the settings of established medical problems or ongoing workups, patient screenings for complex referrals, as well as follow-up after travel for surgical or medical treatment. Clinicians should avoid initiating care for out-of-state patients with new problems and additionally should ensure an appropriate local backup plan in the event that it is needed.

As telemedicine expands, the field will face ongoing challenges, including ensuring that all populations of patients have access to and familiarity with computer-based technology. These factors may be related to age or socioeconomic status, which are known to serve as barriers to virtual care. Continued efforts are needed to identify such patients and take measures to ensure equal opportunities for communication and access when providing services via telemedicine.

The greatest limitation of virtual visits at this time continues to be in the ability to perform an orthopaedic examination that is comparable to an in-person visit. Numerous studies since the onset of the pandemic have described new techniques for virtual examinations with good reproducibility; however, dynamic and specialized physical examination and testing remain challenging in this setting, and such limitations should be communicated to patients appropriately.

Future directions
With the rapid development of telemedicine and virtual orthopaedic examination protocols during the pandemic, incorporation of technological advances to improve virtual visualization will determine future directions. Although the development of augmented reality–based joint tracking is still early, the utility of computer vision–based rehabilitation programs and smartphone-based apps for postoperative care aims to increase the convenience of virtual orthopaedic care. Similarly, the potential integration of wearable technology for tracking and biofeedback in the setting of postoperative and rehabilitative care remains an exciting and promising avenue to communicate closely with patients.

Although the field initially adopted telemedicine out of necessity, the orthopaedic community has embraced and enhanced the benefits of online communication. Working with patients to set expectations regarding the visits, continually developing standardized practices that allow for reproducible assessments, and incorporating new technological avenues of communication will allow orthopaedic surgeons to continually improve the way they offer remote medicine and optimize its benefits for their patients and their respective practices.

Miho J. Tanaka, MD, PhD, FAAOS, is the director of women’s sports medicine at Massachusetts General Hospital and an associate professor of orthopaedic surgery at Harvard Medical School in Boston.

References

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