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Telemedicine and Orthopaedic Surgery

The COVID-19 Pandemic and Our New Normal

Nathan S. Lanham, MD Abstract

» Telemedicine can serve as a medium for patient evaluation,
Kyle J. Bockelman, DO
monitoring, and interpretation of diagnostic imaging and other tests.
Brendan J. McCriskin, MD
» Advantages of telemedicine include improved access to care, cost-
Downloaded from http://journals.lww.com/jbjsreviews by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 01/19/2021

effectiveness, and efficiency.

Investigation performed at Martin
» Challenges remain regarding more widespread adoption of tele-
Army Community Hospital, Fort
Benning, Georgia medicine and involve reimbursement as well as regulatory support.

» The coronavirus disease 2019 (COVID-19) pandemic has led to a

paradigm shift in telemedicine that is here to stay.

» Patient satisfaction is a key component of telemedicine and will drive

its evolution.

Written work prepared by employees of the
Federal Government as part of their official
duties is, under the United States Copyright
Act, a ‘work of the United States Government’
forwhichcopyrightprotectionunderthatActis
not available. As such, copyright protection
does not extend to the contributions of
employees of the Federal Government
prepared as part of their employment.
O
ver the past several decades,
there has been a rapid
emergence of technological
advances that have facili-
tated health-care delivery at a distance1.
Multiple forms of telemedicine have
enabled providers to evaluate patients,
monitor follow-up, and interpret diagnos-
tic imaging and other tests. This has led to
improved access to care, cost-effectiveness,
and efficiency. The coronavirus disease
2019 (COVID-19) pandemic and the
response that it has engendered have dis-
rupted health-care systems around the
world. Initiatives such as telemedicine have
been encouraged and employed in order to
limit this disruption and combat the spread
of COVID-192.
Orthopaedic surgery is a dynamic
multifaceted specialty that is high-volume
and technology-dependent. Therefore,
efforts to improve efficiency and leverage
technology through telemedicine could
benefit patients and providers in the field of
orthopaedic surgery under any circum-
stances. This review article is intended to
define and provide a framework for tele-
medicine classification, summarize positive
Disclosure: The authors indicated that no external funding was received for any aspect of this work.
The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the
article (http://links.lww.com/JBJSREV/A621).
and negative findings in the literature per-
taining to telemedicine and orthopaedic
surgery, and provide a few pragmatic steps
that can be taken to begin implementing
telemedicine in a practice.
Defining Telemedicine
Telemedicine has been defined as patient
care that is provided at a distance using
information technology, including cell
phones, computers, or other electronic
devices1. The U.S. Centers for Medicare &
Medicaid Services (CMS) defines tele-
medicine, or telehealth and related terms, as
the exchange of medical information from
1 site to another through electronic com-
munication to improve a patient’s health.
This electronic communication must
include an audio and a video component
in order to be considered a telehealth
encounter by CMS. More broadly, the
World Health Organization (WHO)
defines telemedicine as the delivery of
health-care services at a distance, using
electronic means for the diagnosis, the
treatment, and the prevention of disease
and injury, as well as for research and eval-
uation and the education of health-care

JBJS REVIEWS 2020;8(7):e20.00083 · http://dx.doi.org/10.2106/JBJS.RVW.20.00083 1

 | Te l e m e d i c i n e a n d O r t h o p a e d i c S u r g e r y
providers in order to improve the health
of their patients1.
Classification
Telemedicine may be classified accord-
ing to the nature of the interaction and
the type of information that is being
transmitted3. Synchronous and asyn-
chronous telemedicine are the 2 major
classifications that characterize tele-
medicine as it relates to the timing of the
provider-patient interaction. Synchro-
nous telemedicine, often called real-time
telemedicine, employs videoconferenc-
ing and other technologies to facilitate
provider-patient interaction. Asynchro-
nous telemedicine, often called store-
and-forward telemedicine, involves
generating images or data and trans-
mitting them electronically for later
review4.
The CMS recognizes 3 types of
telemedicine services that can be pro-
vided to patients: telehealth visits, vir-
tual check-ins, and electronic (E)-visits.
Telehealth visits are considered virtual
encounters between the provider and
the patient for services that usually occur
in-person at a clinic or a hospital. The
provider must use an interactive audio
and video telecommunications system
that permits real-time communication
between the distant site and the patient
at home for the encounter to be recog-
nized and reimbursed as a telehealth
visit5.
The CMS also reimburses virtual
check-ins, or brief communications
with technology-based services, which
allow for patients to communicate with
their providers and avoid unnecessary
trips to their provider’s office or hospital.
These virtual check-ins are intended for
patients who have an established rela-
tionship with a provider and when the
communication is not related to a
medical visit that has occurred within
the previous 7 days and does not lead to a
medical visit within the next 24 hours5.
Lastly, established patients may
have non-face-to-face patient-initiated
communications, or E-visits, with their
providers by using online patient por-
tals. This E-visit service only can be
2 JULY 2020
reported when the billing practice has an
established relationship with the patient.
The patient must generate the initial
inquiry, and communication can occur
over a 7-day period. This 7-day period
may involve multiple messages between
the patient and the provider and is billed
according to the amount of time that is
required to satisfy the patient’s inquiry5.
Telemedicine Encounters
Prior to the initiation of a telemedicine
encounter, the staff or the provider
should inform and educate the patient
about the nature of the telemedicine
service compared with in-person care.
This information can be presented in
writing or verbally and should include a
discussion of record-keeping, schedul-
ing, privacy and security, potential risks,
mandatory reporting, follow-up, and
contingencies if the encounter is dis-
rupted6. Each of these items may be
included in an all-encompassing
waiver consent form that may be
electronically signed. Most impor-
tantly, patient-specific concerns about
the telemedicine encounter should be
addressed accordingly.
The patient encounter should
reflect the level of assessment that is
required to manage a patient, taking into
consideration the information that can
be elicited remotely. Audio-based eval-
uation may be used solely for consulta-
tion if the evaluation, the diagnosis, and
the treatment can be reliably made with
a complete medical history and is con-
sistent with established standards of care
and state and federal laws and regula-
tions, especially as they relate to the
prescribing of medications.
Preparing and standardizing the
conditions of the virtual physical exam-
ination can help to optimize the quality
and efficiency of the telemedicine
encounter. As part of this preparation,
patients can be sent a pre-encounter
checklist containing certain positives
and negatives that are relevant to the
chief concern, in addition to diagrams
for the localization of pain and sensory
abnormalities. Patients also should
confirm that the camera and the micro-
phone on their electronic device are
functioning appropriately prior to the
encounter. Specific tools that can aid
virtual physical examination include
web-based goniometers, which have
been noted to be compatible with most
telemedicine applications7. In addition,
some physical examination tests that
require manual resistance can be simu-
lated by having the patient grasp an
object of a known size and weight.
Additional evaluation of strength and
neurologic status can be achieved with
patient-demonstrated activities, such as
having patients sit back in a chair and
then rise without using their arms for
assistance. In the absence of provocative
testing, discrete palpation, and stability
testing, some authors have advocated for
increased utilization of advanced imag-
ing studies such as magnetic resonance
imaging (MRI)7.
Following each patient encounter,
documentation should be provided and
maintained in a secure Health Insurance
Portability and Accountability Act
(HIPAA)-compliant form and location.
This includes assessment and discussion
with the patient about pertinent diag-
nostic tests, imaging or laboratory
results, and treatment options6.
Advantages
The purported advantages of tele-
medicine include cost-effectiveness,
improved access to care, patient satis-
faction, and efficiency. Buvik et al.
performed an economic evaluation
based on a randomized controlled trial
of 389 patients who had been referred
for an orthopaedic outpatient consul-
tation8. One group was randomized to
receive a video-assisted remote con-
sultation, while the control group
received standard care with an outpa-
tient consultation at the hospital. The
remote consultation involved trained
nurses who set up the videoconfer-
encing at the remote site. The nurses
assisted during the consultation and
performed physical tasks, such as
changing casts or removing stitches.
Digital radiographs also were made at
the remote sites if needed and were
· VOLUME 8, ISSUE 7 · e 20.00083

shown to patients during consulta-
tions with the orthopaedic provider to
help inform patients about their
pathology. The authors found that the
video-assisted orthopaedic consulta-
tions were cost-effective provided that
the number of consultations per-
formed per year was .1838. Another
study evaluating cost data obtained
from a randomized controlled trial
showed that telemedicine was less
costly than conventional care if the
number of evaluated patients was .80
per year; however, if the distance to
specialist care was reduced from
160 km to 80 km, the number of
patients needed in order to realize
the same cost benefit increased to
approximately 200 per year9.
Harno et al. prospectively evalu-
ated the costs of videoconferencing and
outpatient clinic appointments for 225
patients who had been referred to
orthopaedic surgeons and found that the
use of telemedicine reduced direct costs
by 45% and was cost-effective10. In
another study, first-time telemedicine
appointments with orthopaedic oncol-
ogy specialists for patients with sus-
pected bone tumors were found to
decrease health-care costs between 12%
and 72% when compared with con-
ventional face-to-face appointments.
The cost analysis performed by the
authors considered the cost of trans-
portation as the primary variable that
was responsible for telemedicine’s cost-
savings11.
Despite the evidence in support of
telemedicine’s cost-effectiveness, other
authors have identified weaknesses and
have recommended additional studies to
consider alternative economic evalua-
tions12. Some of these include how
studies define costs, which can involve
1 or a combination of factors that are not
uniform across all studies and therefore
make cost comparisons difficult11.
Multiple studies have found that
telemedicine increases access to care for
patients in remote locations. Aarnio
et al. prospectively evaluated orthopae-
dic telemedicine consultations that were
performed in which the locations of the
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Te l e m e d i c i n e a n d O r t h o p a e d i c S u r g e r y
patient and the provider were approxi-
mately 240 km apart13. Two-thirds of
the patients who were evaluated with
videoconferencing were afforded defin-
itive treatment, and the videoconfer-
encing obviated the need for these
patients to travel for an in-person
appointment13. A randomized trial
comparing telemedicine with standard
outpatient appointments found that
patients in the telemedicine group were
offered a follow-up appointment more
often. In addition, telemedicine led to
fewer tests being ordered and increased
patient satisfaction when compared with
standard outpatient consultation14.
Buvik et al. performed a randomized
controlled trial comparing video-assisted
remote orthopaedic consultations and
standard outpatient consultations in an
orthopaedic clinic for patients living in
remote locations15. The telemedicine
consultations were rated as “good” or “very
good” in 98% of cases and were found to
be non-inferior to the standard in-person
evaluations15.
The United States Army found
that its telemedicine program, which
consisted of email consultations from
health-care providers in austere settings
of deployment to subspecialty ortho-
paedic consultants, limited the number
of unnecessary medical evacuations16.
Rogers et al. equipped 4 rural hospital
emergency departments with real-time
videoconference technology to facilitate
consultation with 3 trauma surgeons at
level-I trauma centers17. Telemedicine
consultations in the study were with
more severely injured patients than the
general trauma population that was
admitted to the level-I trauma center.
These findings were attributed to the
increase in capability of the rural hospi-
tals, which leveraged the level-I trauma
surgeons’ expertise to perform patient
care. More than 80% of the rural refer-
ring providers believed that telemedi-
cine improved trauma care and was
lifesaving on multiple occasions17.
Not only has telemedicine been
shown to decrease cost and improve
access to care, it has also been shown
to improve provider efficiency and
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decrease patient wait times for clinical
evaluation. Clegg et al. found that real-
time telemedicine reduced the wait time
for wound-care consultations in rural
locations from 48 hours to ,24 hours
when compared with in-person consul-
tations18. Another study found that tel-
eradiology for remote orthopaedic
consultation diminished the need for in-
hospital consultation and reduced the
average time for decision-making by
more than half19.
Gamus et al. evaluated the remote
care of lower-extremity ulcers over a
12-month period and compared tele-
medicine with face-to-face consulta-
tions20. The telemedicine evaluation
was performed with synchronous vid-
eoconferencing, and a nurse-assisted
setting was implemented during all
treatment sessions for both groups. No
difference in healing was found between
the groups, and the telemedicine group
had a substantially reduced number of
visits (4.36) when compared with those
who had face-to-face care (6.32)20.
Similarly, another study evaluated the
efficiency and orthopaedic surgery spe-
cialty care wait times of patients in remote
locations using telemedicine. The authors
found that nearly 70% of patient consul-
tations were resolved after 2 telemedicine
evaluations, and wait times for referrals to
orthopaedic subspecialty care decreased
from 201 to 40 days21.
Challenges and Barriers
Despite multiple studies demonstrating
telemedicine’s efficacy, widespread im-
plementation faces multiple barriers,
including regulatory support, reim-
bursement, liability, and the technology
itself.
Establishing a patient-provider
relationship using telemedicine subjects
the provider and the practice to all of the
usual regulatory considerations. The
provider needs to be licensed at the site
of origin, and the video and medical
record transmission should be HIPAA-
compliant1. Although many state licen-
sure statutes have provisions for inter-
state consultations and have enacted
special “telemedicine licenses,” these are
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 | Te l e m e d i c i n e a n d O r t h o p a e d i c S u r g e r y
not uniformly present in all states.
In addition, The Joint Commission
requires that physicians practicing with
telemedicine technologies be creden-
tialed in the hospital where they are
transmitting17. Additionally, the Ryan
Haight Act prohibits the prescribing of
controlled substances without a valid
prescription and requires at least 1 in-
person evaluation. Although there are
exemptions granted for telemedicine,
providers must meet specific criteria,
and these vary from state to state. The
current public health emergency is 1 of
the exemptions to the Ryan Haight Act
and was granted by the U.S. Drug
Enforcement Administration (DEA) in
March 2020 to help curtail the spread of
COVID-1922.
The next challenge is reimburse-
ment. Medicare only pays for video
consultation if the patient lives in a
designated rural Health Professional
Shortage Area, and reimbursement by
private payers varies5. Thus, under the
current payment models, reimburse-
ment is limited. However, during the
COVID-19 pandemic, several insur-
ance companies as well as the CMS, with
the support of multiple regulatory bod-
ies, made necessary changes to their
policies that enabled providers to engage
patients with telemedicine and bill for
their services5.
Malpractice insurance and liability
for providers who are engaged in tele-
medicine also have raised concerns17,18,23.
Some institutions have attempted to
resolve these concerns by covering
providers in the same fashion as an in-
person visit, and they require the use
of a separate consent form for tele-
medicine encounters 17 . In addition,
each telemedicine encounter is vid-
eotaped and kept as part of the per-
manent medical record for each
patient encounter 23 . Other liability
concerns have been raised in which
a referring provider could be held
liable for not obtaining a telemed-
icine consult if the service was
available 17 .
Clegg et al. noted technological
difficulties with the implementation of
4 JULY 2020
their telemedicine system, such as orders
and progress notes that were not inserted
into the chart after the consultation had
been completed18. Similar challenges
were noted by Rogers et al.17. On mul-
tiple occasions, the hospital and the
trauma surgeon were not able to connect
using the videoconferencing system.
Additional technical failures included
loss of remote camera control and non-
functional audio17.
Baruffaldi et al. compared asyn-
chronous and synchronous real-time
teleconsulting for orthopaedic second
opinions24. The authors found that
asynchronous teleconsulting was pre-
ferred in the majority of cases, although
there were issues with the lack of infor-
mation or the low quality of the infor-
mation that had been received from the
referring sites. The authors found that
clinicians’ confidence in their diagnosis
was lower in asynchronous consulta-
tions, and clinical complexity and orga-
nizational requirements were noted to
be the main factors affecting the choice
of the consulting procedure24. Although
videoconferencing has been found to be
feasible for the examination of ortho-
paedic outpatients when randomized to
telemedicine, there have been problems
examining these patients. There are
instances where the diagnosis and sub-
sequent treatment are contingent on
specific physical examination findings or
inspection can be impeded with poor-
quality audio-video or imaging tech-
nology. Therefore, some authors
endorse the remote evaluation of
orthopaedic patients only when reliable
and high-quality audio-video or imaging
technology is not critical for developing
a treatment plan25.
Finally, the costs of implementation
and maintenance have been cited as
barriers to the widespread adoption of
telemedicine. The cost of installing the
required surveillance equipment to
complete remote wound consults
through videoconferencing has been
noted to be substantial18. This finding
has been echoed in other studies, with
starting costs ranging from $10,000 to
$17,0008,17. These costs do not include
maintenance or service subscription
fees, which can add additional costs.
Telemedicine encounters that are re-
corded and archived as part of the per-
manent medical record necessitate large
data storage capability, which also can
increase costs.
Nevertheless, there are lower-cost
alternatives in the form of videoconfer-
encing software and mobile applications
(apps) that can be easily downloaded
onto computers, tablets, and smart-
phones. Zoom for Healthcare, GoTo-
Meeting, and Skype for Business are a
few examples of the products that pur-
port HIPAA-compliant videoconfer-
encing capability26. The WhatsApp
Messenger is another example of a
relatively inexpensive nonmedical
mobile app that has been shown to
effectively facilitate orthopaedic care in
multiple clinical settings27,28. The cost-
effectiveness and ubiquitous presence of
these technologies should be balanced
against their requirements of patient
resources and fluency with technology.
Presuming that all patients possess the
necessary technology and understand-
ing of this technology to effectively
leverage it for telemedicine may disen-
franchise certain groups of patients.
Therefore, consideration of lower-cost
alternative forms of telemedicine cannot
ignore the patient factors that may
compromise their efficacy.
Implementation
Despite multiple challenges and bar-
riers, telemedicine possesses several
advantages and can serve as a valuable
tool to reduce costs, increase access, and
improve patient satisfaction and effi-
ciency. Providers who are interested in
developing a telemedicine service-line in
their practice should set clear goals that
reflect the needs of their patient popu-
lation and practice. This begins with
determining which telemedicine plat-
form capabilities would enable effective
telemedicine consultations. Some of
these platform capabilities include, but
are not limited to, the ability to screen
share and review imaging with patients
while also simultaneously maintaining
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TABLE I Telemedicine Resources

Resource Description

Center for Connected Health
Policy (CCHP)*
National Consortium of
Telehealth Resource Centers
(TRC)†
National Telehealth Technology
Assessment Resource Center
(TTAC)‡
American Telemedicine
Association (ATA)§
Nonprofit organization originally established by the California Health Care
Foundation
Serves as the National Telehealth Policy Resource Center
Resources dedicated to national and state-specific telehealth policy
Federally funded with charter from the Office for the Advancement of
Telehealth
Provides assistance, education, and information to individuals and
organizations interested in providing health care at a distance
Regional telehealth resource center hub
Grant funded with support from the Office for the Advancement of Telehealth,
Health Resources and Services Administration, U.S. Department of Health and
Human Services (HHS)
Based out of the Alaska Native Tribal Health Consortium (ANTHC)
Offers a variety of services in the areas of technology assessment and selection
for providers
Nonprofit association that is headquartered in Washington, DC
Seeks to accelerate the adoption of telehealth
Promotes policy and provides education and resources to include
telemedicine clinical practice guidelines

*cchpca.org. †telehealthresourcecenter.org. ‡telehealthtechnology.org. §americantelemed.org.

videoconferencing. Other examples
include audio-only platforms and
asynchronous texting or emailing.
While patient satisfaction has been
demonstrated in both synchronous
and asynchronous telemedicine
platforms, studies citing patient sat-
isfaction with asynchronous tele-
medicine have primarily involved
older patient populations 29. There-
fore, the capability to deliver multi-
modal telemedicine services allows for
a more efficacious patient-centered
approach.
Additionally, there must be an
analysis of the projected cost impact
and a review of state regulations to
ensure that a patient-provider rela-
tionship can occur using telemedicine.
The Center for Connected Health
Policy (CCHP) is 1 of many resources
that can help providers understand
many of the policies and regulations
pertaining to telemedicine (Table I).
Reviewing telemedicine vendors and
options in addition to ensuring HI-
PAA compliance with secured en-
crypted transmissions for personal
health information should then follow
(Table II). Many of the larger elec-
tronic medical record (EMR) compa-
nies provide telemedicine options
that interface with their EMR. Thus,
providers currently using an EMR
system should consider engaging
their EMR’s representatives. Lastly,
verifying state licensure rules and
policy compliance along with re-
viewing malpractice considerations
with your malpractice insurance
carrier can mitigate medicolegal
liability.

TABLE II Telemedicine Vendor Considerations*

Determine upfront and maintenance/subscription cost(s)

Assess platform capabilities (screen sharing, uploading outside images)
System compliance with HIPAA and medical boards
Type of services provided (synchronous “real-time” videoconferencing versus asynchronous “store-and-forward”)
24/7 service and technical support
Integration with current practice and electronic health record
Support for insurance claims/billing

*https://www.aaos.org/quality/practice-management/telemedicine/. HIPAA 5 Health Insurance Portability and Accountability

Act.

JULY 2020 · VOLUME 8, ISSUE 7 · e20.00083 5

 | Te l e m e d i c i n e a n d O r t h o p a e d i c S u r g e r y
Future Directions
The use of telemedicine is likely to
increase in the United States. A 2017
survey of 184 health-care executives
conducted by the American Telemedi-
cine Association found that 88% of the
executives believed that they would
invest in telemedicine in the near future,
and 98% believed that it offered a
competitive advantage. However, 71%
believed that lack of coverage and pay-
ments were barriers to implementation1.
A more recent survey of .800 physi-
cians in the U.S. found that 48% are
now using telemedicine in their prac-
tices as a consequence of COVID-19,
which is up from 18% in a similar survey
that had been conducted in 201830.
Another survey of .600 private prac-
tices and 140 billing companies found a
35% decline in patient volume during
March 2020. The survey also found that
41% of respondents had begun offering
telemedicine options to patients, up
from 22% in a previous 2018 survey31.
Despite telemedicine’s tremen-
dous upside, traditional research
methods may be challenging with tele-
medicine, given the rapidly increasing
utilization of health technology among
patients and health-care systems, espe-
cially during the COVID-19 pandemic.
Thus, the traditional methods of ran-
domized controlled trials to evaluate the
efficacy of an intervention or a change in
care delivery may not be feasible. Some
authors have instead suggested more
pragmatic methods that balance the
traditional research paradigms and the
ever-changing landscape of telemedicine
and its many facets32. In addition, future
research regarding telemedicine must
more clearly and uniformly define cost
analysis and cost savings in order to
enable comparison among studies. Bar-
riers to regulatory support and reim-
bursement that have required specialty
society involvement in the form of
evidence-based practice guidelines and
political advocacy have largely been
eliminated during the COVID-19
pandemic. Nevertheless, sustained
coordinated efforts among providers,
researchers, insurance carriers, and pol-
6 JULY 2020
icymakers will be necessary if telemedi-
cine is to continue to grow in practice
and scope.
Overview
Telemedicine is a multidimensional
rapidly evolving modality that is capable
of improving access to quality cost-
efficient health care for patients needing
orthopaedic specialty services. The
COVID-19 pandemic has compelled
providers to negotiate a myriad of chal-
lenges that have brought telemedicine to
the forefront of health care. With the
support of the CMS and other insurance
carriers, telemedicine initiatives were
quickly supported and enacted in order
to continue providing health care to
patients during the pandemic. Patient
satisfaction is a key component of tele-
medicine and will drive its evolution.
Beyond the COVID-19 pandemic,
telemedicine will undoubtedly serve an
increasing role as our new normal in
orthopaedic surgery.
Nathan S. Lanham, MD1,
Kyle J. Bockelman, DO2,
Brendan J. McCriskin, MD1
1Department of Orthopaedic Surgery,
Martin Army Community Hospital,
Fort Benning, Georgia
2Department of Orthopaedic Surgery,
William Beaumont Army Medical Center,
El Paso, Texas
Email address for K.J. Bockelman:
kbockelman@gmail.com
ORCID iD for N.S. Lanham:
0000-0003-3641-9367
ORCID iD for K.J. Bockelman:
0000-0002-5627-3695
ORCID iD for B.J. McCriskin:
0000-0003-2941-9983
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