AAOS Now

Published 11/30/2019
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Daniel Schlatterer, DO, FAAOS; Alfred Atanda Jr, MD, FAAOS

Telemedicine in Orthopaedics: Risks Versus Benefits

Editor’s note: This article is part one of a two-part series on telemedicine (TM). Part one provides a historical background and presents TM’s potential role in orthopaedics. Part two will discuss liability and compensation concerns TM providers may face and will appear in the January 2020 issue of AAOS Now.

Telemedicine (TM) is relatively new. In the early 2000s, it was used in seven rural Mississippi emergency departments (EDs). In 2008, Duchesne et al., reported their experience with trauma patients initially treated at local community hospitals in those same seven rural EDs before being transferred to trauma centers. In 2017 and 2018, reports were published about TM in a pediatric sports medicine practice setting (Table 1).

TM can be traced back to the 1950s, when closed-circuit systems delivered innovative surgical procedures from surgeons to participants at regional and national conferences. Those teleconferences often were sponsored by industry, which later supported Hospital Satellite and Cable Health Network (CHN) in the 1980s. Lifetime Medical Television was the final version of CHN. In the 1990s, the American Medical Association launched American Medical Television for physicians.

TM bridges the physical gap between patients and clinicians. The most illustrative examples are space programs and military installations worldwide, both of which have relied on TM for decades.

Considering TM for orthopaedics

Innumerable questions arise when the field of orthopaedics considers TM. First, orthopaedic surgeons rely on radiographs to further define musculoskeletal complaints. Equally important in all medicine are history and physical examination. Certainly, a history can be obtained via TM, but can a diagnosis be reached without a “hands-on” physical examination?

Alfred Atanda Jr, MD, FAAOS, is a pediatric orthopaedic surgeon in Maryland who has experience with TM; he described his experience in a phone interview with Daniel Schlatterer, DO, FAAOS. Dr. Atanda found TM helpful in pre- and postoperative patient visits. He also found that during his TM visits, the office staff could perform other tasks related to patient care. A TM visit, whether pre- or postoperative, is primarily centered on information exchange and less dependent on physical examination, according to Dr. Atanda.

Furthermore, because a postoperative TM visit is within the global period, billing is a nonissue. The ideal patient for a TM visit is a reliable and established patient and/or family with whom rapport has been previously established, Dr. Atanda said. For example, by the second or third postoperative visit, a patient with scoliosis doesn’t need wound checks or radiographs. Much of what can be communicated during a direct encounter can be achieved via TM. If necessary, a family member can direct the camera to an area of concern—the surgical site for example.

Table 1 Reported benefits of a telemedicine (TM) program in a pediatric sports practice, according to Alfred Atanda Jr, MDSource: Atanda Jr A: Using Telemedicine for Orthopaedic Follow-Up. Available at: www5.aaos.org/aaosnow/2017/Jun/ Clinical/Clinical08. Accessed November 7, 2019.

Could TM help triage patients from outlying EDs or urgent care centers? In Dr. Atanda’s experience, pediatric patients don’t always need to be transferred to higher-level centers. He has found that more than 50 percent of patients transferred to pediatric hospitals could have been seen in a pediatric orthopaedic office the next day without generating transportation expenses. What most patients need, according to Dr. Atanda, is knowledge transfer, not physical transfer.

For example, a specialist on a TM line may provide treatment recommendations or activity restrictions until the patient can be seen in a specialist’s office. In other words, a TM visit can mimic an office visit after a prior visit to an ED, an urgent care center, or a pediatrician’s office. The time and money saved when a patient is seen by TM are significant. In addition, TM consultation accelerates an eventual office visit because most questions have been addressed and the history has been completed. TM improves efficiency, which helps busy patients and caregivers, as well as clinicians.

Patient satisfaction from TM encounters is usually favorable. Dr. Schlatterer has personally experienced patients transferred to his trauma center with reported unstable and operative pelvis or acetabular fractures. Upon review of radiographs and CT scans, he often finds that the injuries were overstated. Transferred patients often live hours away from the trauma center, so getting them back home delays discharge. In general, any and all pelvis fractures in patients at peripheral, rural, and community centers raise concerns that could be alleviated with a 10-minute TM consultation.

This article was supported by the AAOS Medical Liability Committee.

Alfred Atanda Jr, MD, FAAOS, is a pediatric orthopaedic surgeon based in Wilmington, Del. He can be reached at aatanda@nemours.org.

Daniel Schlatterer, DO, FAAOS, is a member of the AAOS Medical Liability Committee and an orthopaedic trauma surgeon based in Atlanta, Ga. He can be reached at danschlatterer67@gmail.com. He has established TM consultation services in orthopaedic trauma and stroke.

References

  1. Duchesne JC, Kyle A, Simmons J, et al: Impact of telemedicine upon rural trauma care. J Trauma 2008;64:92-7.
  2. DeBakey, ME: Telemedicine has now come of age. Telemedicine J 1995:1:3-4.
  3. Atanda Jr A: Using Telemedicine for Orthopaedic Follow-up. Available at: https://www5.aaos.org/aaosnow/2017/Jun/Clinical/clinical08/. Accessed November 7, 2019.
  4. Atanda Jr A, Pelton M, Fabricant PD, et al: Telemedicine utilisation in a paediatric sports medicine practice: decreased cost and wait times with increased satisfaction. J ISAKOS 2018;3:94-7.

AAOS Medical Liability Committee addresses critical orthopaedic practice concerns

AAOS is committed to safe, accessible, cost-effective, and high-quality patient care. However, the structure of the current medical liability system limits physicians’ ability to provide the highest-quality patient care, and systematic medical liability reform is necessary to improve the overall healthcare system. AAOS believes that broad reforms are necessary to compensate negligently injured patients promptly and equitably, enhance patient-physician communication, facilitate improvement of patient safety and quality of care, reduce defensive medicine and wasteful spending, decrease liability costs, and improve patient access to care. The AAOS Medical Liability Committee monitors all trends regarding professional liability and tort reform and develops and prioritizes AAOS activities related to the medical liability crisis. The committee is charged with continuing to advocate for medical liability reform and educating AAOS members on this important issue.

Committee members include:

  • Bob Slater, MD, FAAOS (chair)
  • Christopher Kontogianis, MD, FAAOS
  • Stuart Green, MD, FAAOS
  • Craig Mahoney, MD, FAAOS
  • Gary Pushkin, MD, FAAOS
  • William Ritchie, MD, FAAOS
  • David Romness, MD, FAAOS
  • Alan Routman, MD, FAAOS
  • Daniel Schlatterer, DO, FAAOS