Telemedicine in the Wake of the COVID-19 Pandemic

Increasing Access to Surgical Care

Paige K. Dekker, BA; Priya Bhardwaj, MS; Tanvee Singh, MPH; Jenna C. Bekeny, BA; Kevin G. Kim, BS; John S. Steinberg, DPM; Karen K. Evans, MD; David H. Song, MD, MBA; Christopher E. Attinger, MD; Kenneth L. Fan, MD

Disclosures

Plast Reconstr Surg Glob Open. 2021;9(1):e3228 

In This Article

Discussion

Telemedicine has seen rapid expansion in the wake of the recent pandemic. Telehealth refers to the broad use of health-related digital services, including monitoring wearables or patient education videos.[30] Telemedicine refers to remote diagnosis and treatment using digital technology. Before COVID-19, telemedicine's expansion was curtailed due to several factors relating to reimbursement, licensure, and infrastructure. Medicare narrowly defined applications to select rural populations. Payments under Medicaid were defined by individual state legislation. Only 10 states (Arkansas, Delaware, Georgia, Hawaii, Kentucky, Minnesota, Missouri, New Mexico, Utah, and Virginia) have laws on true payment parity between telemedicine and in-person visits, whereas 16 states have a provision on the payment structure.[31,32] When 104 health care organizations were surveyed, 50% of them reported reimbursement as a significant cause of limitation to deployment.[30] There were also limitations in cross-state licensure, limiting providers' ability to utilize telemedicine to conduct visits with patients outside of their own state.[33] As a result of these obstacles to licensure and payment, there was little investment in infrastructure by health providers and organizations alike.

On March 6, 2020, Medicare expanded telehealth services as a temporary and emergency effort under 1135 waiver authority and the Coronavirus Preparedness and Response Supplemental Appropriations Act. Telehealth services were previously limited to designated rural areas.[34] In these provisions, Medicare telehealth visits for new and established patients are considered the same as in-person visits and are reimbursed at the same rate in all areas of the country for all settings.[34] Furthermore, most states have relaxed licensure requirements for physicians with out-of-state licenses who wish to practice telehealth.[35]

Broadly speaking, the Centers for Medicaid and Medicare Services categorizes virtual services into 3 main types: televisits, virtual check-ins, and e-visits. Medicare televisits involve interactive audio and telecommunication systems with healthcare providers for new and established patients. Virtual check-ins are 5- to 10-minute communications conducted via telephone or other communication modalities (secure text messaging and email). These are scheduled in response to specific patient concerns that are not related to a medical visit within the previous 7 days or do not result in a visit within the following 24 hours. Although virtual check-ins are generally initiated by patients, providers can educate patients on the availability of these services. Similarly, e-visits are communications that are initiated by established patients through an online portal and are intended to save patients' trips to physician offices.

The rapid expansion of telemedicine has created a natural experiment on access to care in the vulnerable population. Access to care, as defined by Shi and Singh, "can be defined as the ability to obtain needed, affordable, convenient, acceptable, and effective personal health services in a timely manner."[36] Prior examination of the benefits of telemedicine has demonstrated improvements in access to care for rural patients across multiple healthcare specialties.[37,38] Recent research also indicates that telemedicine increases access to care for patients with acute illness in socially disadvantaged populations, which more appropriately distributes healthcare resources.[39] However, few studies examine the impact of telemedicine in the surgical subspecialties, especially in the face of the national pandemic.

Despite general improvements in healthcare in America, avoidable access issues are pervasive amongst disparate populations.[40] In the previous office-based model, patients of higher SVI were more likely to miss their appointments. The results of this study demonstrate that expansion of telemedicine in the COVID-19 pandemic resulted in improved reach of new and established surgical patients. Anecdotally, patients have been very satisfied with the new format. People who were unable to take "off from work" or arrange childcare, or have difficulties in mobility and arranging transportation are now being seen at greater rates. These finding are in line with a study on the CVS MinuteClinics telehealth program.[41] In these visits, physician and patients communicate through 2-way audio and video, and diagnoses are made through history and physicals, and via digital audioscopes and otoscopes. Amongst surveyed patients, 94% reported being very satisfied with the experience, with over half citing the absence of waiting time as their primary motivator for use. Similar high levels of satisfaction were achieved in underserved, rural plastic surgery patients in Vermont and New Hampshire.[42]

Telemedicine has also proved to have benefits on patient outcomes. One study examining utilization of telemedicine by a wound specialist in conjunction with home health nurses found improved rates of healing, faster healing time, decreased number of home health visits, and fewer hospitalizations for wound complications after telehealth implementation.[43] A high level of correlation between in-person and photograph evaluation for the diagnosis and treatment of wounds has been confirmed in the literature.[44,45] Systematic review indicates telemedicine increases efficiency, decreases cost, and increases access of microsurgical monitoring, burn evaluation, and cleft lip/palate consultations.[42,46]

Despite the potential benefits in patient experience and outcomes that may be offered by telemedicine, there are also challenges that must be addressed. Although not statistically significant, we have found that elderly patients and those with limited access and understanding of technology still have difficulty accessing our established online portal. Creative solutions, such as use of FaceTime, the patient's video conferencing application of choice, or text message, have had to be employed in many instances. It will be critical to establish easy-to-use, HIPAA-compliant technologies to scale. Furthermore, there are limitations in assessing surgical incisions and wounds with current telemedicine platforms. Picture and video quality can be poor, especially if online networks are strained. Patients have to be coached to show the involved body part for context. Commonly, we receive pictures of areas of interest they deem important. This is particularly germane in new patient consults, as a patient–provider relationship is established with transmission of the image.[45] The provider assumes legal responsibility, without having met the patient. In the absence of a home health aide, we have to rely on patient's assessment of warmth, which can be limited. This is particularly salient in the wound population, where decline in warmth can indicate a threatened extremity. Other issues identified in the literature include misdiagnosis, inefficient use of provider time due to technological difficulties, and delays in diagnosis.[45]

Limitations of this study include the limited number of providers practicing in an urban, academic setting. Our findings may not be generalizable to different localities, including community or rural environments. Furthermore, outcomes such as complications arising from telemedicine use were not directly examined. It is unknown whether the completed telemedicine visits in more vulnerable patients are equitable from a quality perspective. Future study will require an in-depth evaluation of provider and patient factors, barriers to use, reliability of diagnosis and treatments recommended, patient satisfaction, and the workflow of the telemedicine visit, with a focus on elderly and disadvantaged patients.

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