The Potential of Telehealth in Surgical Services
During the height of the pandemic last year, Amy Wylder, Director of Surgical Services at Jersey Community Hospital in Illinois, got some bad news while her staff was preparing for a case. The surgical sales representative due in the operating room to oversee the use of their medical device was running late. Soon it became clear that they would not make it on time.
“I was like, great. Normally, we would need to cancel the case. Then I thought, well, can we just FaceTime him?” said Wylder. “The only challenge we had was holding the iPhone in a way so that they could see into the wound without contaminating the sterile field. But we did it.”
And they did it again when another sales rep had COVID-19 but was well enough to engage via video. This moved Wylder to consider if this could be something that stuck after the pandemic receded. A sales representative unable to physically be in the operating room would no longer be a stumbling block. This practice could also unfold access to more senior salespeople in other locations. What began as a hack might become a permanent solution to what would previously create an inefficiency.
“Now, we’re considering using video towers in the OR to create a more integrated system versus just using a cell phone,” Wylder said.
Telehealth Takes off During Pandemic
Because there is so much in-person contact between patient and healthcare provider throughout the perioperative process, it may seem impossible to incorporate telehealth into the process. But the pandemic forced surgical services to widen their options, as Wylder had to do last year, to varying degrees.
A March 2021 study, “Use of Telehealth by Surgical Specialties During the COVID-19 Pandemic,” published in JAMA Surgery, found that telehealth use rose significantly in all surgery specialties during the pandemic, peaking in April 2020, then beginning a slow decline in June 2020. Use also varied across surgical specialties.
Researchers used claims from a large commercial insurance payer in Michigan to gather data on new patient surgical visits during three periods in 2020. Period 1 (pre-COVID), January 5-March 7; period 2 (early pandemic), March 8-June 6; and period 3 (late pandemic), June 7-September 5. Surgical specialties included urology, neurosurgery, thoracic, colorectal, orthopedics, obstetrics/gynecology, plastic surgery, ophthalmology/ENT, and general surgery.
Out of a cohort of 4405 surgeons, almost a third (26.8%) used telehealth for new patients. Of the 109,610 surgical new outpatient visits between March 8 and September 5, 2020, 6,634 were telehealth visits. During the same time frame in 2019, 8 patient visits out of 173,939 were telehealth. Before March 2020, less than 1% of new patient surgical visits were done through telehealth, but that number peaked to 34.6% in April 2020.
The telehealth conversion rate (rate of new patient telehealth visits per week divided by the mean weekly total new patient visit volume in 2019) for most specialties was less than 10%, peaking at 8.2% in April 2020. But neurosurgery and urology stand out with the highest rates of telehealth conversion. Urology leads the pack at 14.3% in period 2, while neurosurgery takes the top spot in period 3 at 13.8%. Orthopedics (2.3% in period 2) and ophthalmology/ENT (0.3% in period 3) tag along at the ends.
Telehealth Still has Space to Grow in Surgery
Researchers propose three contributing factors for telehealth decline:
- After healthcare facilities reopened, the number of in-person visits increased, but the number of telehealth visits remained the same.
- Patients who postponed care at the beginning of the pandemic returned en masse for in-person care.
- Healthcare providers and patients may have viewed telehealth as a temporary replacement for in-person care.
There were a few limitations in the study. The authors were unable to account for the population of patients whose medical issues required an in-person visit and telehealth would not have been an option. Data on race and ethnicity was not available, so subsequent studies in telehealth should evaluate racial and ethnic disparities in access to telehealth.
Telehealth in surgery is not new or experimental; urologists were already using it and the authors theorize that helped them have an easier time converting their new patients to telehealth. In addition, neurosurgery already had established telehealth networks, described as “teleneurology”, years before the pandemic. An example is Oregon Health & Science University’s Telemedicine Network.
Even with some success in urology and neurosurgery, telehealth in other specialties still has barriers as evidenced by the lower conversation rates. In a summer 2020 survey, “The COVID-19 Healthcare Coalition Telehealth Impact Study”, 76% of surgeons were concerned that newly allowed reimbursements from insurers for telehealth would stop when the pandemic eased. In that case, it would not make financial sense to modify workflows to accommodate telehealth. There is also a knowledge gap when it comes to diagnosing patients by video as many surgeons are not trained to evaluate patients in this manner. Some surgeons may also feel it is unsafe and unproductive to use telehealth if that patient will still end up coming in for an in-patient visit.
The increase and decline of telehealth in surgery shows what can be done in a pinch. But much more research needs to be done on clinical implications and disparities in access before it becomes a regular feature of perioperative care.