Telemedicine visits generate accurate surgical plans across orthopaedic subspecialties

Archives of Orthopaedic and Trauma Surgery https://doi.org/10.1007/s00402-021-03903-2 ORTHOPAEDIC SURGERY Telemedicine visits generate accurate surgical plans across orthopaedic subspecialties Alexander M. Crawford1 Andrew K. Simpson2 · Harry M. Lightsey1 · Grace X. Xiong1 · Brendan M. Striano1 · Andrew J. Schoenfeld2 · Received: 25 January 2021 / Accepted: 8 April 2021 © The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021 Abstract Introduction The role of telemedicine is rapidly evolving across medical specialties and orthopaedics. The utility of telemedicine to identify operative candidates and determine surgical plans has yet to be demonstrated. We sought to assess whether surgical plans proposed following telemedicine visits changed after subsequent in-person interaction across orthopaedic subspecialties. Materials and methods We identified all elective telemedicine encounters across two academic institutions from March 1, 2020 to July 31, 2020. We identified patients indicated for surgery with a specific surgical plan during the virtual visit. The surgical plans delineated during the telemedicine encounter were then compared to final pre-operative plans documented following subsequent in-person evaluation. Changes in the surgical plan between telemedicine and in-person encounters were defined using a standardised schema. Regression analysis was used to evaluate factors associated with a change in surgical plan between visits across specialties, including the number of virtual examination manoeuvres performed. Results We identified 303 instances of a patient being indicated for orthopaedic surgery during a telemedicine encounter. In 11 cases (4%), the plan was changed between telemedicine and subsequent in-person encounter. No plans were changed amongst patients indicated for joint arthroplasty and foot and ankle surgery, whilst 4% of plans were changed amongst sports surgery and upper extremity/shoulder surgery. Surgical plans had the highest rate of change amongst spine surgery patients (8%). There was notable variability in the conduct of virtual examinations across subspecialties. Conclusion Our results demonstrate the capability of telemedicine to support development of accurate surgical plans for orthopaedic patients across several subspecialties. Our findings also highlight the substantial variation in the utilisation of physical examination manoeuvres conducted via telemedicine across institutions, subspecialties, and providers. Description of study type Level IV, retrospective cohort study. Keywords Telemedicine · Telehealth · Surgical planning Introduction The role of telemedicine is rapidly evolving in all medical specialties, including orthopaedic surgery. Advanced imaging, technological growth, communication platforms, and the near ubiquitous access to home and mobile communications * Alexander M. Crawford 1 Harvard Combined Orthopaedic Residency Program, 55 Fruit St, Boston, MA 02114, USA 2 Department of Orthopaedic Spine Surgery, Brigham and Women’s Hospital, Harvard Medical Schools, 75 Francis St, Boston, MA 02115, USA devices have created a connectivity ecosystem of substantial potential [1, 2]. Nonetheless, reimbursement barriers from payers, lack of integration into electronic medical records platforms, and limited patient acceptance of telehealth have prevented the widespread adoption of these platforms in the United States [3]. The recent pandemic catalysed the growth of telemedicine by driving payer reimbursement and forcing health systems to adopt and integrate telecommunications platforms to serve patients and remain financially viable. The rapid pace of telemedicine adoption has left orthopaedic practices and health systems unsure how to best leverage these technologies, despite availability [3, 4]. In particular, the utility of telemedicine to identify operative orthopaedic 13 Vol.:(0123456789) Archives of Orthopaedic and Trauma Surgery surgery candidates and determine surgical plans is an area of active interest. The primary limitation of telemedicine is the inability to perform a traditional in-person physical examination, which has long been taught to be paramount to the accurate diagnosis and treatment of musculoskeletal pathologies. As such, much of the recent clinical telemedicine literature within orthopaedics has focused on addressing and adapting to this limitation, with innovative virtual alternatives to traditional exams [5–10]. Nonetheless, these virtual exams have yet to be validated and standardised. Rather than focus on creating telemedicine functions to substitute for the in-person evaluation, our group chose to evaluate a different question, which is how telemedicine might affect the ultimate disposition of patients. In other words, if telemedicine interactions produce the same surgical plan and outcome for an orthopaedic patient’s disposition, the nuances and granular components of the interaction may be less important. With these considerations in mind, our group recently performed a pilot investigation in spine patients at a single institution to determine whether surgical plans proposed following telemedicine visits changed after in-person evaluation [11]. We found that surgical plans for 94% (31/33) of patients did not change; furthermore, in the two patients where surgical plans were modified, the changes were based on further review of previous imaging, rather than additional information gained from in-person examination [11]. In this context, we sought to expand the scope of our initial query to encompass all elective orthopaedic subspecialties across multiple institutions. Specifically, our primary objective was to assess whether surgical plans proposed following telemedicine visits changed after subsequent inperson interaction and to explore these changes across subspecialties. The secondary aim consisted of characterising the extent and types of virtual exams across providers. Based on our prior research [11, 12], our hypothesis was that surgical plans made via telemedicine would rarely change after in-person examination. Materials and methods Institutional investigational review board approval was received prior to the start of this research effort. We obtained data from the clinical registry of Mass General Brigham (MGB). MGB is the parent healthcare corporation of the two institutions (Massachusetts General Hospital and Brigham and Women’s Hospital, both in Boston, MA) where this research was performed. Created in 1991, the means through which data are captured and made available through the MGB clinical registry have been described in detail in previous work [13, 14]. In brief, the registry links with billing and electronic health records from MGB subsidiary institutions 13 to capture sociodemographic and encounter data for all inpatient and outpatient events, by international classification of disease and current procedure terminology code (...truncated)