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Telemedicine in the COVID Era and Beyond: Overcoming Barriers to Improve Access to Care

Russell Woo, MD, FACS, Annabel Barber, MD, FACS, David Tom Cooke, MD, FACS, Heather Evans, MD, FACS, Sundeep Keswani, MD, FACS, John Kirby, MD, FACS, Angelica Martin, MPH, Mark Sawyer, MD, FACS, and Jyotirmay Sharma, MD, FACS

July 1, 2022

Telemedicine in the COVID Era and Beyond: Overcoming Barriers to Improve Access to Care
Highlights
  • Describes how the COVID-19 pandemic led to wider adoption of virtual care for surgical patients
  • Provides case studies that highlight different advantages of telehealth, including improved access to care
  • Issues a call for further study regarding the patient experience and medical education

The public health crisis that the COVID-19 pandemic ignited has led to the rapid implementation of telemedicine as a means of delivering surgical care. This abrupt and global change required flexibility and intense collaboration between surgeons, patients, healthcare systems, and technology partners.

Following the stay-at-home orders in the early phase of this public health emergency, the demand to maintain safe access to surgical care drove the increased adoption of remote video and telephone visits. Factors that have always affected the care of surgical patients, particularly our most vulnerable populations—geography, socioeconomic disparity, patient disability, and time constraints—became even more problematic during the pandemic, and the lessons learned have the potential to improve the practice of surgery as a whole.

Although surgery is a hands-on specialty, telemedicine defined as “remote provision of clinical healthcare services through telecommunications technology” has emerged as a surprisingly useful tool in the delivery of surgical care. Areas such as preoperative workup, advanced consultation, informed consent, and other preparations for a procedure can be facilitated or enhanced by virtual care. In addition, patients can receive a substantial amount of their preoperative care via telemedicine, enabling them to minimize travel time to the advanced centers of care where the actual procedure will be performed.

This article describes the application of telemedicine as a means of improving access to quality surgical care through clinical vignettes and case studies.

Case 1:
A Telemedicine-Based ICU Program to Manage a Patient in Septic Shock

A 45-year-old male with insulin-dependent diabetes mellitus and a body mass index of 60 kg/m2 arrived at an outlying hospital emergency department (ED) in diabetic ketoacidosis and septic shock from Fournier’s gangrene. This facility has a virtual/electronic intensive care unit (eICU) program. Because of a lack of beds and his instability, the patient could not be transferred to a larger hospital. He was resuscitated and then brought to the operating room (OR) for surgical debridement. The eICU assisted in managing the patient from the ED through postoperative care via 24/7 live, secure audio/video and data stream linkage.

The eICU helped expand the local ED’s capabilities to complete the patient’s resuscitation, surveil his wound for serial debridements, and wean his drips as he responded to treatment. Although the patient initially improved in the first 6 hours after the operation, his overall trajectory declined overnight, and an urgent dressing change showed tissue necrosis.

In concert with the surgeon, the patient went back to the OR for further debridement for source control as well as imaging to ensure that further tissue spaces were not becoming involved in the tissue necrosis/infection. This imaging allowed his return to the OR to occur under more planned circumstances. The patient came back to the ICU and underwent dressing changes such that his diabetic ketoacidosis and sepsis resolved. During postoperative days 2–3, the eICU supervised his sedation holidays and early spontaneous breathing trial so that he could be extubated. The eICU team met with the family members at the bedside so that all stayed informed, even during off hours.

Summary

The eICU transformed a difficult situation into a success story. Even without logistical issues limiting transfer, telemedicine contributed to an earlier initial debridement and timelier serial debridement. Goal-directed resuscitation, protective lung strategies, serial operations, sedation holidays, and spontaneous breathing trials could be coordinated. The clinical change detected by the eICU prompted an earlier dressing change that allowed a planned return to the OR.            

Conclusion

This application of telemedicine in the form of an eICU program allowed a multihospital system to work more effectively. This technology empowered the care team to achieve quality of care goals for a patient with a challenging metabolic syndrome and multiple comorbidities. In this era of pandemic shortages, it allowed us to avoid a transfer and maintain infectious disease isolation of patients.

Future pandemics may involve infectious agents that increase the value of the eICU for remote, touchless care to benefit patients, staff, and systems. It could open the door for how telemedicine might be applied intraoperatively when an operating surgeon could have someone with more familiarity with a specific issue consult remotely. If such an option seems overly optimistic or medicolegally risky, it is already happening in real time for complex, critically ill ICU patients via eICU processes. These eICU programs can allow higher levels of oversight for not only direct care of both individual patients and groups of patients, but also managing transfers. Attention and continued study of telemedicine, as well as the eICU’s value versus its costs, are warranted for its full development.

 

Although surgery is a hands-on specialty, telemedicine defined as “remote provision of clinical healthcare services through telecommunications technology” has emerged as a surprisingly useful tool in the delivery of surgical care.

Case 2:
Telemedicine for Treatment of Esophageal Cancer

A middle-aged Latino male who is a commercial transportation driver living in a rural California town was diagnosed with adenocarcinoma of the mid-esophagus during the COVID-19 pandemic. His job status was such that prolonged absences related to healthcare appointments were difficult to arrange.

Telemedicine provided an opportunity for socially distanced access to healthcare services in California through deregulation of outpatient evaluation and management rules during the pandemic.* Hence, telemedicine was an opportunity for this patient to be treated in a timely manner at a high-volume surgery center, despite socioeconomic and geographic challenges.

Summary

The patient presented with an esophageal mass. He had a long history of reflux disease and recent dysphagia to solids as well as unintentional weight loss. Once diagnosed with stage 3 adenocarcinoma of the mid-esophagus, a treatment plan was recommended consisting of trimodality therapy with concurrent chemoradiation followed by surgery. His neoadjuvant chemoradiation was performed within his local community, and surgery was scheduled at our center, which is more than 300 miles from his residence and the only high-volume center for esophagectomy in the region.

Because of limited financial resources, he could not travel to our center for frequent in-person clinic visits and preoperative assessments. The pandemic-related deregulation around telemedicine, such as audio-only visits reimbursable by health insurance, facilitated his treatment at our institution.* We performed two telemedicine visits (audio-only), a new patient visit, and a post-neoadjuvant therapy restaging visit. We then performed an in-person final preoperative visit the day before surgery, after making local lodging arrangements for him and his spouse.

After a negative COVID-19 nasal swab test, the next day we performed an uncomplicated successful minimally invasive robot-assisted three-hole esophagectomy. He stayed near our institution for his first postoperative visit. Subsequent visits have been via telemedicine.

Telemedicine and its expansion through new policies were essential in the surgical treatment of this patient. As illustrated by his experience, telemedicine has proven beneficial for preoperative assessment and diagnosis, evaluation after surgery, and follow-up visits.†‡ The rapid adoption of telemedicine during the COVID-19 pandemic demonstrates its status as a now-essential ambulatory care tool.

Conclusion

This patient’s story highlights the intersection of socioeconomic status, health, and innovation. Notably, the telemedicine appointments allowed our patient to schedule his visits during his breaks at work. This flexibility led to an equitable approach to providing care; he did not have to choose between tending to his health and earning a living wage on days when he had appointments. This case underscores telemedicine’s effectiveness in facilitating the surgical needs of patients who often are underserved in medicine.

Case 3:
Telemedicine Facilitates Timely, Convenient Surgery

A 49-year-old male professional in South Carolina with a past medical history significant for solid pseudopapillary tumor of the pancreas underwent a Whipple operation at a tertiary referral center prior to the start of the COVID-19 pandemic. Postoperatively, he traveled more than 500 miles to follow up with his surgical oncologist every 3 months, but the pandemic’s travel restrictions made this practice impossible.

The patient used telemedicine not only to engage with his surgeon, who detected a postoperative complication, but also to initiate a new surgical consultation closer to his home. Additional video visits and patient portal messaging facilitated a complete preoperative workup and treatment within 1 month of diagnosis.

Summary

In March 2020, many states initiated lockdown measures, limiting travel and closing businesses to the public. Many medical centers shuttered in-person clinics to curtail the transmission of COVID-19, and for several months telehealth visits were the only outpatient access for nonemergency clinical care. During this time, our patient discovered that he had pain in his upper abdomen. As the pandemic triggered more travel restrictions, he obtained follow-up computed tomography (CT) imaging in his local community and engaged with his surgeon via remote video visits.

He was found to have a complex incisional hernia and initiated self-referral to a hernia specialist in his region whom he found via a web search, at an institution where elective surgery was continuing. The patient digitally transmitted his CT scan images and operative reports to the herniologist, facilitating a comprehensive review of past medical and surgical history before an initial video visit consultation. During this visit, the hernia surgeon used a commercially available telemedicine platform to review the images from the abdominal CT scan with the patient and to discuss options for surgical treatment of the incisional hernia. The patient was able to correlate his symptoms and a physical demonstration of an upper abdominal wall bulge with the findings on the CT scan. The surgeon recommended a complex abdominal wall reconstruction because of the width of the hernia, including the need for possible bilateral component separation.

The patient’s wife accompanied him during the visit, which they completed at home, and both of them had the opportunity to ask questions about the surgical plan, potential complications, estimated hospital length of stay, and expectations for postoperative recovery.

After the visit, the patient engaged further with the hernia surgeon via the patient portal to clarify pre- and postoperative logistics. Within a month, the hernia surgeon met the patient in the preoperative holding area and completed a written informed consent process before undertaking a successful abdominal wall reconstruction.

The patient was discharged to home on postoperative day 3 with two drains in place, necessitating a single in-person clinic visit within a week of discharge to remove the drains. A subsequent 2-week follow-up visit was completed at the patient’s home via video conference. The patient indicated that he was highly satisfied with the care he received, especially because he was able to avoid traveling and missing work for the initial consultation and postoperative follow-up.

Conclusion

Telemedicine was used to facilitate timely care of a complication during travel restrictions brought about by the COVID-19 pandemic. Not only was a full preoperative workup possible, but the therapeutic relationship was established before the initial in-person encounter between surgeon and patient on the day of surgery. Use of telemedicine for new consultation not only is possible, but some patients prefer it for the convenient and timely coordination of care. Although not all preoperative consultations may be possible via telemedicine, telehealth is an essential component of state-of-the-art patient-centered surgical care.

Case 4:
Telemedicine Allows Efficient Workup and Surgical Planning for a Patient with Geographic Challenges

A 38-year-old woman who lives 435 miles away from the treating facility was diagnosed with idiopathic gastroparesis and pancreatic divisum and referred for consideration for placement of a gastric neurostimulator device. The surgeon is the sole provider in the state who has institutional review board approval to place gastric stimulators, as this surgeon has been granted a humanitarian exemption from the US Food and Drug Administration. 

Summary

Initially, this patient and her husband drove 7 hours for evaluation. Subsequent telemedicine visits with the patient were carried out to further evaluate her response to nonoperative therapy. As her referring physician suspected, she did not adequately respond to medical therapy. The patient kept records in a symptom diary daily for 6 weeks in an effort to optimize her medical treatment regimen (prokinetics, antiemetics). This patient had one in-person and three virtual visits over 5 months preoperatively. She and her husband flew to the city where the medical center is located for an outpatient robot-assisted laparoscopic insertion of gastric simulator and pyloroplasty. The couple spent that night in a hotel and flew home without incident after a telemedicine postoperative visit the following day. Her follow-up visits have been conducted via telemedicine and she has done very well. She has been weaned from prokinetics and rarely needs antiemetics.

Conclusion

Telemedicine offered this patient, as well as others in similar circumstances, the opportunity to consult, review tests, and evaluate nonoperative therapy over time. Surgical scheduling and informed consent discussions easily can be done virtually. A brief preoperative in-person visit on the day of surgery offers another opportunity to review the procedure, answer patient and family questions, and plan for follow-up. This visit provides an opportunity to improve surgeon and patient confidence. Virtual follow-up is arranged at the time of surgery. Telemedicine is highly suited for the care of gastroparesis in patients with geographic barriers to obtaining specialty care.

The Upside of the Pandemic

By necessity, the COVID-19 pandemic resulted in the broad and rapid implementation of telehealth processes to facilitate the care of surgical patients. With this collective experience, it has become apparent that telehealth can play a role in individual practices that benefits providers, administrators, and patients. Individual practice circumstances, as outlined in these vignettes, will dictate the details of how telehealth can be safely and effectively used as well as the ongoing value that this technology may provide. Issues in topics for future investigation include the nuances of how telehealth encounters are arranged, organized, and integrated into existing surgical clinics; how billing and regulatory factors practically influence the continued use of telehealth; and how telehealth affects quality of care, patient experience, and medical education.

Note

For up-to-date information regarding billing and coding aspects of telehealth, visit the US Department of Health and Human Services resource site at telehealth.hhs.gov/providers/billing-and-reimbursement.


*Volk J, Palanker D, O’Brien, Goe CL. States’ actions to expand telemedicine access during COVID-19 and future policy considerations. Commonwealth Fund. June 23, 2021. Available at: https://www.commonwealthfund.org/publications/issue-briefs/2021/jun/states-actions-expand-telemedicine-access-covid-19. Accessed May 10, 2022.

Asiri A, AlBishi S, AlMadani W, ElMetwally A, Househ M. The use of telemedicine in surgical care: A systematic review. Acta Inform Med. 2018;26(3):201-206.

Hands LJ, Jones RW, Clarke M, Mahaffey W, Bangs I. The use of telemedicine in the management of vascular surgical referrals. J Telemed Telecare. 2004;10(1_suppl):38-40.


Dr. Russell Woo is professor of surgery and associate chair, research, department of surgery, University of Hawaii, John A. Burns School of Medicine, Honolulu.