Telemedicine in Surgery—Beyond a Pandemic Adaptation | Surgery | JAMA Surgery | JAMA Network
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July 14, 2021

Telemedicine in Surgery—Beyond a Pandemic Adaptation

Author Affiliations
  • 1Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
  • 2Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
  • 3Department of Neurology, Biological Sciences Division, University of Chicago, Chicago, Illinois
  • 4Center for Healthcare Delivery Science and Innovation, University of Chicago, Chicago, Illinois
  • 5Division of Pediatric Surgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
JAMA Surg. Published online July 14, 2021. doi:10.1001/jamasurg.2021.2052

The rapid transformation of the health care delivery system and surgical services across the US as a result of the COVID-19 pandemic was unprecedented. To limit COVID-19 exposure and transmission between patients and clinicians, millions of elective surgical procedures were suspended and necessity compelled surgeons to adopt telemedicine for preoperative, follow-up, and emergent surgical care visits. By summer 2020, surgical care gradually started returning to business as usual, but with the resurgence of COVID-19 cases in the fall and winter, suspension of elective surgery was reinstated in some states with surgical outpatient care continuing to be delivered by telemedicine.

Substantive changes in regulations permitting telemedicine clearly facilitated the dramatic shift to telemedicine during the pandemic. Arguably, the most important of these regulations is that of the US Centers for Medicare & Medicaid Services (1135 Waivers) making reimbursement of in-person and telemedicine visits equal in March 2020.1 Other third-party payers quickly followed. As a result, hospitals and surgical departments repositioned available technology to initiate widespread delivery of care by telemedicine. These institutions used primarily synchronous (eg, videoconference telemedicine visits) and asynchronous (eg, text messages, email, patient portal) telemedicine modalities.2 The third modality, remote patient monitoring, which uses technology such as wearable devices to monitor patients outside conventional clinical settings, was least used.

Approval of several effective COVID-19 vaccines and initiation of vaccination programs should, in time, mitigate the need to reduce in-person health care visits. While some proclaim that the pandemic finally surmounted long-standing resistance to the adoption and integration of major digital and technological advances into health care delivery,1 recent national data suggest that the matter may be more nuanced. In a Commonwealth report, Mehrotra and colleagues3 analyzed 50 million outpatient visits (up to October 1, 2020) and found a rebound of in-person, outpatient visits to pre–COVID-19 levels with a concomitant decline in telemedicine visits. In fact, in-person surgical visits were higher compared with the prepandemic period with telemedicine visits only accounting for 2% to 3% of all visits. This resurgence of in-person surgical care may signal that telemedicine may not be a satisfactory or sufficient replacement. While the COVID-19 pandemic highlighted the feasibility of using telemedicine to deliver some aspects of surgical care, the Commonwealth report3 suggests that it may be viewed, by both patients and clinicians, as a temporary adaptation rather than a permanent substitute for in-person visits, even with expanded reimbursement.

A telemedicine visit primarily hampers a surgeon’s ability to accurately assess surgical physical findings, including vital signs, and diminishes personal communication and interaction with patients.3 Yet this modality of health care delivery is unlikely to be abandoned when the COVID-19 pandemic ends. Telemedicine has some distinct advantages, and can potentially lead to improved access, continuity of care, and reduced disparities.2 It can take place immediately if needed, minimizes travel costs for patients, and is decoupled from a specific location so that the surgeon and patient can be anywhere. These advantages were evident long before the COVID-19 pandemic and have been leveraged particularly for surgical follow-up visits.4 However, the extent to which telemedicine will replace or, more likely, supplement in-person visits on a wide scale will depend on 3 main factors.

First, with interpersonal relationships being a core attribute of high-quality surgical care,3 perhaps more targeted implementation of telemedicine is required. For example, established patients may offer an attractive subset of patients to be initially offered telemedicine for postoperative visits or routine follow-up. It took more than 20 years to introduce and fully integrate electronic health records, although this did not fundamentally change patients’ health care experience.5 On the other hand, introduction of telemedicine has rapidly transformed the health care delivery experience for both patients and surgeons, allowing little time for adaptation. As a result, patient and surgeon expectations of telemedicine need to be better calibrated and tools to establish trust are needed. Detailed guidelines have been developed for use of telemedicine, but they address mainly technical aspects of telemedicine visits, such as mitigating connectivity issues and ensuring proper posture and lighting.6 Recommendations have also been developed to enhance the patient-clinician virtual connection, such as by the Academy of Communication in Healthcare, but these may need to be adapted to surgical patients.3 Additional efforts are also still needed to overcome other challenges, such as patient concerns about privacy, when using telemedicine.

Second, substantial technological innovation is still needed to enhance surgical diagnostic capacity of telemedicine, for example, postoperative complications, such as wound infections. With current synchronous and asynchronous modalities, telemedicine may function most effectively for postoperative follow-up visits for low-risk patients. While these 2 modalities may themselves be improved, combining them with remote monitoring will significantly enhance the capabilities of telemedicine and mitigate some of its limitations. Consumer-grade wearables (for example, the Fitbit [Fitbit Inc]) have sensors that reliably and passively capture fundamental changes in longitudinal health measures (eg, heart rate, electrocardiogram, posture, sleep time, physical activity) and transmit data in real time. Such data collected continuously on patients in the postoperative period provide trends of patient recovery that may aid the surgeon in making more informed clinical decisions when examining the patient during a telemedicine visit. This is exemplified by the use of a wearable device in patients with heart failure and the continuous capture of patients’ heart rate, respiratory rate, cardiac rhythm, and physical activity. Wearable data, in conjunction with telemedicine, better predicted the need for rehospitalization.7 Integration of wearable data from Apple Health and Fitbit into electronic health records systems is underway at 16 health care systems.8 Processing of these data in clinically meaningful and easily presentable ways should accelerate their use in clinical practice.

Third, given the direct relationship between insurance coverage and adoption of health care innovation, continued coverage for telemedicine services and further refinement to the existing policies are needed to sustain this mode of health care delivery. At the federal level, virtual care has gained bipartisan support, and the Biden administration has pledged to increase federal grants for such care. However, several large health insurers are already rolling back their coverage for telemedicine visits that are not related to COVID-19, thus raising concerns regarding the extent to which telemedicine will thrive in the future. This extent will certainly be affected by the payment model for telemedicine. Strict fee-for-service payment models have not traditionally led to high adoption of telemedicine services because of the lower reimbursement associated with such encounters. Centers that are part of an integrated delivery network or participate in value-based payment models are far more incentivized to use telemedicine services. Alternatively, including telemedicine as part of a bundled payment structure could lead to wider use.9 Such payment models may result in more aligned incentives by being less burdensome to insurers and yet provide surgeons more flexibility to use, for example, either telemedicine or in-person visits for postoperative follow-up visits to evaluate their patients.

In conclusion, telemedicine was quickly adopted by surgical services as part of wider health care system forced adoptions due to the COVID-19 pandemic, but a return to in-person health care visits has been observed lately. This should not indicate that telemedicine has failed. Rather, this nascent transformation of health care delivery using telemedicine provides an alternative modality to engage with patients and proved invaluable during the COVID-19 pandemic. However, routine integration into surgical clinical workflow needs further refinement and customization with very targeted implementation strategies and sustainable reimbursement models.

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Article Information

Corresponding Author: Hassan M. K. Ghomrawi, PhD, MPH, Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, 633 N St Clair, 20th Floor, Chicago, IL 60611 (hassan.ghomrawi1@northwestern.edu).

Published Online: July 14, 2021. doi:10.1001/jamasurg.2021.2052

Conflict of Interest Disclosures: None reported.

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Mehrotra  A, Chernew  M, Linetsky  D, Hatch  H, Cutler  D, Schneider  E. The impact of the COVID-19 pandemic on outpatient care: visits return to prepandemic levels, but not for all providers and patients. Accessed March 16, 2021. https://www.commonwealthfund.org/publications/2020/oct/impact-covid-19-pandemic-outpatient-care-visits-return-prepandemic-levels
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