Telemedicine and virtual consultations are becoming increasingly prevalent in spine care, as healthcare providers seek to adapt practices amid the pandemic. A recent Scoliosis Research Society (SRS) webinar, moderated by Suken A Shah (Wilmington, USA), explored leveraging technology in the era of COVID-19, touching on the deployment of telemedicine within the spine care field, in terms of its current applications and potential limitations.
Opening the session, SRS president Paul Sponseller (Baltimore, USA) briefly addressed the need to be “creative” in responding to the pandemic, which has had far reaching effects upon all areas in healthcare. “Shakespeare wrote King Lear whilst he was quarantined for the plague,” Sponseller remarked. “We are now stimulated to be creative in our field.”
Joshua Pahys, an orthopaedic surgeon at Shriners Hospitals for Children (Philadelphia, USA) offered an overview of the impact the pandemic has had on spinal surgery as well as current guidance around which procedures should be prioritised , and those that should be curtailed. “As orthopaedic and spine surgeons, our biggest concern has been what needs to go to the operating room. Initially, it was a bit more nebulous but now guidance is starting to come out from the Academy [American Academy of Orthopaedic Surgeons (AAOS)] and other bodies. There is a list of what constitutes a surgery that needs to go,” he said.
Pahys detailed how current guidance from the AAOS and American College of Surgeons (ACS) presents procedures in a hierarchy structured upon the urgency of the surgery, and applied based upon the extent of the COVID-19 response within an individual centre. Phase II denotes a centre where there is an increasing number of COVID patients being treated at an individual institution. At this point surgeons must consider which procedures it is suitable to carry out. If an institution reaches Phase III, where the majority of resources are being directed towards COVID-19 patients, only emergency procedures including spine trauma, neurologic deficit, or epidural abscess should be considered, he explained. “Every country, region and institution is different. You need to follow your moral compass and do what is right for your patients and your colleagues. The regions that have been proactive rather than reactive have been the ones that we have found to be much more successful in this fight.”
Suken A Shah, division chief, Spine and Scoliosis Center at Nemours/Alfred I duPont Hospital for Children introduced the role that telemedicine has to play in the spine surgery setting against the backdrop of COVID-19. “Prior to the crisis, many of you may not have used it [telemedicine] before,” he commented, adding, “It took us a crisis to get here. We have to keep our patients safe and we have to keep ourselves and our staff safe”. The perfect solution, Shah said, is to bring telemedicine and virtual care into the current arena.
During his presentation, Shah outlined some of the hardware and software options available to healthcare providers considering the employment of telehealth services in their practice, including more advanced platforms or simple computer and smartphone-based options.
Detailing the kinds of patients that are best eligible for the application of telemedicine, Shah noted that postoperative consultations and follow-ups “are a good place to start”. Expanding on this, he said: “A patient that you already know and have a good rapport with, or who is tech-savvy, is going to love this kind of application. It is perfect.”
In terms of the types of digital consultation that surgeons should be looking to carry out, Shah elaborated: “Quick checks of the incision, whether their pain is controlled, and gross neuro exams andrange of motion checks. When you are seeing out of town patients with rare diagnoses who have travelled for your care, telemedicine is the perfect way to stay engaged with them without them travelling to come back and see you.”
Offering practical advice of the use of telemedicine in a paediatric care-setting, Burt Yaszay, associate clinical professor at Rady Children’s Hospital (San Diego, USA) commented that many of the principles that apply during a physical examination will still be relevant during a digital consultation. He said, “We do a lot of this intuitively when we are examining the patient in the room. We are looking for asymmetry; we are looking naturally at the skin either for spinal dysraphisms or other neurologic issues. There is a lot that we do intuitively on a regular exam that we have to focus on a bit more to make sure we are doing that full assessment.” In fact, he added that there are some additional key pieces of information that can be gleaned through a virtual consultation, that may not be possible if patients are coming into the clinic for an appointment. “Look past the bones. This is a rare view into a patient’s home and you might see things that you might otherwise not gain from a social aspect, a safety aspect, and other things like that.”
Rajiv Sethi, executive director of Spine Center of Excellence Programs at the Virginia Mason Medical Center and professor of health services research at the University of Washington (Seattle, USA), offered some insight into the practicality of virtual examination of adult spinal deformity patients from his institution. Sethi commented that establishing trust between patient and physician is important when consulting virtually, something that is typically harder to do than in a face-to-face setting. “You have to establish trust with the patient. You really have to get to know them and understand their concerns” he said. Echoing Yaszay’s comment about witnessing a patient in their home environment, Sethi said, “You can actually do that with an adult too. What activities can they do, what can they not do now? Trying to assemble a neurological picture is very key especially in situations where patients are being put on elective surgery waitlists.”
In wrapping up the session, Shah discussed the various rules and regulatory aspects of telemedicine. Counselling that there are state by state variations and licensure issues, much of the guidance for billing and compliance comes from the Centers for Medicare & Medicaid Services (CMS); however, with the COVID-19 crisis, many of the rules have been relaxed during the extent of the public health emergency to increase access to care and remove barriers. Additonally he discussed practical aspects to implementing this strategy in your practice and answered questions from the audience. “Use this time to get comfortable with telemedicine and your patients, some of this may be here to stay.”
Telehealth may become a building block of healthcare systems after the crisis – but only if we design an inclusive infrastructure, which takes the heterogeneity of patients’ and doctors’ needs very seriously. https://www.youtube.com/watch?v=mbKpaCpKNNE&t=157s