Telemedicine and Plastic and Reconstructive Surgery

Lessons From the COVID-19 Pandemic and Directions for the Future

Noah H. Saad, M.D.; Husain T. AlQattan, M.D.; Oscar Ochoa, M.D.; Minas Chrysopoulo, M.D.


Plast Reconstr Surg. 2020;146(5):680e-683e. 

Summary: Telemedicine holds vast amounts of potential in changing the way outpatient plastic and reconstructive surgery is practiced. Before the coronavirus disease 2019 (COVID-19) pandemic, video conferencing was used by a small fraction of medical specialties. However, since the start of the pandemic, the Centers for Medicare and Medicaid Services and the largest private health insurance companies have relaxed regulations to allow the majority of specialties to use video conferencing in lieu of in-person visits. Most importantly, video conferencing minimizes patient and physician exposure in situations such as these, and decreases risk in the immunocompromised population. Video conferencing, which has been shown to be just as safe and efficacious in treating patients, offers the ability to follow up with physicians while saving travel time and travel-related expenses. This in turn correlates with increased patient satisfaction. Video conferencing also allows physicians to expand their reach to patients in rural areas seeking advanced professional advice. Incorporating video conferencing into existing practices will make for a more efficient practice, improve patient satisfaction, and decrease cost to patients and the health care system.

Telemedicine, available as an adjunct for health care providers since the early 2000s, has grown over time. It now allows patients access to their electronic medical records in real time, and to participate in video conferencing in lieu of face-to-face office visits. Although video conferencing has been most used by primary care practitioners, other specialties have been increasingly using video conferencing. The coronavirus disease 2019 (COVID-19) pandemic has highlighted the importance of video conferencing and the vast untapped potential that can change the face of outpatient follow-up in medicine.

Before the pandemic, video conferencing had many regulations that limited which practices were able to fully use its capabilities.[1,2] Regulations mandated that patients live in federally underserved areas, and be able to travel to a medical facility to get telemedicine services from physicians in remote locations. Patients were not allowed to video conference from their homes.[1,3] Beginning March 6, 2020, under the Coronavirus Preparedness and Response Supplemental Appropriations Act and Section 1135 of the Social Security Act, the Centers for Medicare and Medicaid Services eased its restrictions, allowing patients and physicians to video conference without having to leave their homes.[1,3,4] In addition, cost-sharing expenses for these video conferencing visits would be reduced or waived. The five largest private health care insurance companies then followed suit and allowed video conferencing to be used in lieu of face-to-face office visits.[5–9]

Video conferencing offers a host of benefits, most importantly, minimizing patient exposure as in our current pandemic, even the seasonal flu, and especially among the immunocompromised. Video conferencing offers flexibility of the patient's schedule, which may increase the presence of the patient's support team, ultimately resulting in improved patient compliance during their recovery. Patient satisfaction has been shown to be equal to or better than face-to-face visits because of decreased cost and time spent on travel.[10,11] Moreover, it is possible that neither patients nor their support will need to miss work for clinic visits, theoretically increasing workforce productivity. Video conferencing also offers patients the opportunity for remote consultations, which is especially important for those living in rural areas without access to subspecialties. Jue et al. have shown that use of video conferencing allowed their group to expand their reach across Florida for patients in need of complex oncologic operations, while also saving patients over $150,000 in a 2-year period, amounting to $507 per patient.[12]

Numerous studies have looked at the efficacy and safety of video conferencing across a number of medical specialties.[11–15] Dullet et al. analyzed the impact telemedicine had on travel-related expenses on more than 11,000 patients across 30 specialties. Patients saved an average of 284 miles traveled and 235 minutes, resulting in a total savings of $2.8 million equaling $156 per patient.[13] Similarly, Zheng et al. analyzed the impact of telemedicine in endocrine surgery patients, saving them on average 123 miles traveled and 144 minutes. In addition to the time and money patients saved, physicians were able to schedule more patient visits because of the increased efficiency.[14]

Specifically in plastic and reconstructive surgery, there have been numerous studies that analyzed video conferencing: consultations between a rural hospital and a tertiary care center, using store and forward capabilities, and trauma consultations by means of video conferencing.[16–21] To our knowledge, there have been no studies analyzing the use of video conferencing for routine office visits in plastic and reconstructive surgery patients. Van Dillen et al. found that there was a high degree of correlation between face-to-face and video conferencing for wound assessment and their necessary treatment, which physicians agreed on 94 percent of the time.[16] Likewise, Engle et al. also found a high correlation when assessing inpatient free flaps between face-to-face visits and remotely by photograph. Free flaps assessed in person were accurate 98.7 percent of the time, whereas those assessed remotely were accurate 94.1 percent of the time; accuracy increased to 97.4 percent when photographs deemed uninterpretable were excluded.[17]

Since the onset of the pandemic, our practice has transitioned to video conferencing for new consultations and follow-ups with exceptions for patients truly needing in-person evaluation (e.g., possible infection, hematoma, flap compromise, or drain removal). Before the pandemic, our seven-physician practice averaged 115 clinic visits per week. On March 26, 2020, the transition to video conferencing was implemented; over the subsequent 2-week period, our video conferencing encounters have been reduced to 20 per week. We have found that our clinic and patient follow-up have become more efficient. We anticipate being able to see more patients without exposing them to risk of coronavirus as social distancing restrictions continue and patients become more familiar with the video conferencing platform. Pertinent CPT codes used in our practice are listed in Table 1.

The COVID-19 pandemic has been a trying time for our health care system, and we would be remiss to not extract every ounce of potential good from this experience. There are myriad issues that need to be addressed regarding regulations for telemedicine once this pandemic ends. Currently, both physician and patient are allowed to conduct video conferencing visits from their respective homes; however, this may not be the case once social distancing guidelines have been relaxed. It may benefit some patients to conduct these visits from home, provided that they are Health Insurance Portability and Accountability Act compliant. In addition, clarification is needed for coding in this setting to avoid fraud, but to also appropriately reimburse physicians' time and expertise, and visit type. Privacy is of the utmost importance, and as we have seen during this pandemic, hackers have been able to infiltrate Zoom conferences. Currently, the government is not enforcing penalties for use of non– Health Insurance Portability and Accountability Act–compliant technology for video conferencing use.[22] Surely, this regulation will be reinforced after the pandemic is over, and presently there are a host of Health Insurance Portability and Accountability Act–compliant platforms (Table 2). The length of time that the restrictions for telemedicine are lifted are dependent on each individual insurer; the Centers for Medicare and Medicaid Services has given no definitive end-date, only stating that the restrictions remain lifted until the pandemic is over. Use of video conferencing should be considered in any situation where social distancing would be beneficial, and when in-person clinic visits are problematic such as during periods of inclement weather, transportation difficulties, or remote patient locations. Incorporating video conferencing into plastic and reconstructive surgery practices will make for a more efficient practice, improve patient satisfaction, and decrease cost to patients and the health care system.