December 2015

Telemedicine: Going virtual improves communication and outcomes

By Shalmali Pal

In addition to his usual daily appointments, meetings, lectures, and surgical procedures, David Armstrong, DPM, MD, PhD, a professor of surgery at the University of Arizona College of Medicine, and director of the Southern Arizona Limb Salvage Alliance (SALSA) in Tucson, AZ, often has more than a dozen encounters with patients that last mere seconds. These “meetings” are brief, but they can make a big difference to someone with a diabetes-related lower extremity issue.

“I probably get fifteen to twenty texts a day from my patients,” Armstrong said. “Now that may seem like a drain on my schedule but it really isn’t. I can ask questions like ‘Are you wearing your removable boot [for offloading diabetic foot wounds] or do I need to put you in an irremovable total-contact cast?’”

Telemedicine has been around for some time–phone-based consults and video conferencing were early examples–but with the widespread distribution of mobile computing platforms, such as smartphones and tablets, telemedicine is becoming a robust, full-fledged tool for patient care.

And, while much of lower extremity care requires hands-on interaction with a patient, users say telemedicine does have place in the field, whether it’s in the form of remote monitoring of a patient’s condition or the ability to interact virtually, but in real time.

For example, physiotherapists in Brisbane, Australia, compared face-to-face and telerehabilitation assessment of 15 patients presenting with ankle pain. They found a similar agreement of 93.3% in their pathoanatomical diagnoses and an 80% exact agreement between on-site and video remote encounters with this small group of patients. Telerehabilitation also compared favorably with in-person physical therapy visits in a study of total knee arthroplasty patients conducted in Quebec, Canada (see “Telerehabilitation after TKA: Remote PT matches in-person outcomes,” LER, July 2015). Other successful applications of telerehabilitation have included automated resistance training and gait training after stroke.

Another use of interactive telemedicine is pre-admission consultations. Occupational therapists at the University of Queensland in Brisbane found close to 100% agreement between face-to-face and online assessments of transfer ability and home environments for 40 patients scheduled for either a total hip or knee replacement.

And researchers from New Orleans conducted a study of 140 neuropathic forefoot ulceration patients that measured the effect on healing time of real-time interactive video consultation compared with face-to-face follow-up. The unadjusted forefoot healing time was 43.2 days for the telemedicine group versus 45.5 days for the control group, a difference that was not statistically significant.

“On the whole, I think telemedicine is worthwhile,” Armstrong said. “As we move from volume-based care to value-based care, telemedicine is going to become more valuable.”

John T. Brinkmann, CPO/L, scientific liaison for the Gait Society of the American Academy of Orthothists & Prosthethists and an assistant professor with the Northwestern University Prosthetics-Orthotics Center in Chicago, described his vision for telemedicine in O&P.

“The areas of assessment and follow-up seem like the most obvious domains in our practice framework that provide immediate opportunities,” he said.

For instance, Brinkmann said, gait assessment can easily be done remotely by having a practitioner view a live feed of a patient ambulating. After all, gait is already commonly recorded by practitioners for later analysis and documentation, he noted.

When it comes to checking on the fit of a device, a phone- or video-based follow-up can save time for both the patient and practitioner. “With a few pointed questions, [the practitioner] can often determine that [the patient isn’t] wearing the right ply of socks,” he said. On the other hand, if the practitioner sees evidence of a more serious problem with the device–skin breakdown or a specific functional problem–then an in-person appointment can be arranged.

Telemedicine may be viewed as less personal or thorough than conventional care, but Brinkmann noted that the ease of interaction could actually lead to a better experience for everyone.

“It can provide access to care for patients who would otherwise have to travel an extended distance or patients with limited mobility or transportation options, or simply improve convenience for highly active and mobile patients,” he said. “Each of these scenarios involves a situation where an in-person visit is either not possible or would delay care, so the telemedicine encounter may actually improve the level of care.”

For Armstrong, telemedicine has been very useful for serving remote patients as part of SALSA, which provides health services to 22 Native American nations in the southwestern US. Many of these patients live on reservations that are hundreds of miles away from Tucson.

The SALSA team uses telemedicine in two ways when working with these patients. Indian Health Services clinicians will send text messages with photographs attached (with the patient’s permission) to SALSA for follow-up assessment. At least one dermatology study supports the effectiveness of this type of “store-and-forward” technology.

For what Armstrong called “more complex, live assessment,” his group relies on readily available programs such as Apple’s Facetime or Microsoft’s Skype to help ensure that not every situation becomes an emergent one.

For example, during a follow-up virtual consult with a patient who has returned to the reservation after receiving treatment at SALSA for a diabetic ulcer, Armstrong said he may notice some redness near the ulcerated site.

“Rather than saying [to an IHS colleague], ‘Let’s get that patient into an ambulance and have him brought here right away,’ we may be able to assess the problem and say, ‘Why don’t you have him continue on the antimicrobial and come back to your outpatient center in a couple of days?’ If the situation still hasn’t improved, then we can arrange to have the patient brought here,” he said.

Brinkmann urged practitioners who adopt existing video technologies, such as Skype or Google Hangouts, to ensure that they and the patient are meeting privacy standards set by Health Insurance Portability and Accountability Act (HIPAA) regulations.

SALSA is currently testing a new text-based system to boost patient compliance. A “tickler” text is sent from SALSA, asking the patient if he is wearing his prescribed shoes, or if she has any questions about an orthosis or other device. The patient then responds “yes” or “no.”

Depending on the response, or the time it takes for a patient to respond, the SALSA team may follow up by phone or request that the patient make an in-person appointment.

Armstrong said he believes the best place for a patient to rehab and heal is in an environment where they are most comfortable.

“The place for patients to heal is at home and with family,” he said. “I think telehealth makes that more feasible.”

Shalmali Pal is a freelance writer based in Tucson, AZ.

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