Telehealth in Plastic Surgery

A Veterans Affairs Hospital Perspective

Stephanie Douglas, MD; Erik Geiger, MD; Andrew McGregor, MD; Amanda Norwich, MD; Deena Abbate, RN; Henry Hsia, MD; Deepak Narayan, MD

Disclosures

Plast Reconstr Surg Glob Open. 2018;6(10):e1840 

In This Article

Discussion

The incorporation of new technology mandates the medical community evaluate its impact on the quality of health care delivery. Multiple studies have examined the legitimacy of telemedicine, assessing topics such as diagnostic accuracy, disease management, and patient outcomes. The intent of our study was to disseminate the effectiveness of our pilot project using telemedicine in plastic surgery for pre- and postoperative visits for a patient population likely to otherwise incur significant inconvenience associated with an in-person visit. We also aimed to assess patient attitudes toward this new modality of delivering care to plastic surgery patients, which was shown to be favorable to traditional methods. Finally, we propose a substantial amount of time was saved by streamlining the logistics of care and limiting the number of in-person visits for preoperative and postoperative care (Figs. 2, 3). We conclude this can save patients significant travel time and expense. Tadros et al.[20] reviewed 300 patients referred to a plastic surgery department for evaluation of suspected skin cancers using a secure electronic referral system that transmitted high quality digital images of the patients' lesions. When comparing random samples of patient diagnoses made via the digital images with the corresponding pathology reports, the authors found that 83% of all lesions were diagnosed correctly. More importantly, reviewing this random patient sample indicated that no malignant lesions were missed.[20]

Figure 2.

Traditional model of plastic surgery consultation at West Haven, Va.

Figure 3.

Model of health care using telemedicine for plastic surgery at the West Haven, Va. *CBOC, Community-based outpatient clinics.

Similar applications of store-and-forward telemedicine, which involves the transfer of static images of accompanied by relevant clinical information, have been utilized in the management of hand trauma. Hsieh et al.[21] reported the use of store-and-forward telemedicine for patients presenting with digital amputation injuries. The authors reported an overall sensitivity and specificity of recognizing digital replantation potential via telemedicine as 90% and 83%, respectively.[21]

Although store-and-forward systems are beneficial, greater diagnostic accuracy can be achieved with the use of live-interactive systems.[8] The remote use of preoperative evaluation for ambulatory surgical cases was also validated by Rollert et al.[22] in a maxillofacial study, which demonstrated that of 35 patients who underwent preoperative evaluation using telemedicine services, 95% of patients required no further evaluation before surgery.[22]

Just as the use of telemedicine in diagnosis, perioperative and postoperative care has been documented, so has patient satisfaction. Marcin et al.[23] demonstrated that overall satisfaction with live-interactive telemedicine consultation in a cohort of pediatric patients was rated as "excellent." These studies corroborate our findings. By adhering to a strict protocol, which included attendance at every telehealth appointment by the physician and an information technology personnel, we were able to eliminate travel time and visits to the main hospital. Presence of the physician at each visit helped create patient rapport. Thus, 3 visits (preoperative visit, operative, and postoperative) were consolidated into one for the procedure (Figs. 2, 3).

Our survey results demonstrated that over 80% of patients who used telehealth services were satisfied and would use it again for future appointments. Ninety-seven percentage of patients did not require any further testing or intervention before their procedure. The single exception was a patient with a history of a heart transplant who developed an upper extremity squamous cell carcinoma. This patient was felt to benefit from an in-person consultation from the referring primary care physician due to the possibility of his long-term immunosuppression leading to a more aggressive cancer.

The emerging use of telemedicine in many aspects of health care and across medical specialties demonstrates the utilization of technology in patient care will continue to evolve. Across the country, 48 states reimburse some form of telehealth. Of these, all reimburse live video, 13 reimburse store-and-forward, 22 reimburse patient monitoring, and 9 reimburse all 3. The Center for Medicare and Medicaid services has recently allowed for expanded use of telehealth services by removing restrictions on patient and hospital locations.[24] The telehealth program at the VA Connecticut Healthcare System demonstrates not only patient satisfaction, but feasibility of the system. The Veteran Health Administration (VHA) has provided care via telehealth to over 150,000 beneficiaries in 2012. In that year, the VHA estimated an average savings of $6,500/patient. Outside the VA system, Johns Hopkins Medicine has pioneered the Hospital at Home program for elderly patients who refuse to go to the hospital or are immunocompromised. This program showed a total cost savings of 32% compared with traditional hospital care.[25] Factors that have limited the wider adoption of telemedicine systems include initial cost, provider licensing issues, nonstandardized electronic medical records (EMR) systems, questionable insurance coverage, and lack of standardized legislative regulation.[26] However, the VA system is an environment where telemedicine can be used without these problems. Factors that contribute to the ease of using the telemedicine system in a VA setting include that it can be implemented across state borders, that all hospitals have a consistent EMR system, a "captive patient population", and there are limited problems with insurance coverage. It should be noted at this time our patient population with whom telemedicine has been used has grown to over 100 participants. However, problems can arise with operation of the system as wait times to see the provider can increase due to prior inspection of the equipment before use.

There are limitations to our study. As this was a cross-sectional study, the patient cohort may have self-selected in a way that overrepresents the percentage of people likely to be satisfied with telemedicine. Moreover, satisfaction data from this pool of VA patients may not be more broadly generalizable. Finally, because our study was limited to English-speaking participants, biases may have been introduced such that the satisfaction rates associated with telemedicine may not extend to non-English speakers. Tackling the challenge of developing telehealth technologies that address the needs of various ethnic groups will be important if this technology is to fulfill its purpose of enhancing health care access to all underserved populations.[27] As this study did not specifically address the cost-effectiveness of telemedicine in this setting or a non-VA hospital, this is a proposed subject of further investigation.

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