Telemedicine Orthopedic Consultations Duration and Timing in Outpatient Clinical Practice During the COVID-19 Pandemic

Introduction

The role of telemedicine is rapidly evolving in several medical specialties, including orthopedics.^1–5 American Academy of Orthopedic Surgeons,⁶ British Orthopaedic Association,⁷ and Australian Orthopaedic Association⁸ have urgently advocated telemedicine during the COVID-19 pandemic to prevent disease transmission without hindering providing services to orthopedic patients. Evidence suggests that telemedicine in orthopedics can be safe, cost-effective, valid in clinical assessment, and high patient/clinician satisfaction.^1,9–18 Telemedicine allows providing medical care to people exposed to infection with a virus of extremely high virulence.^1,5,14,19,20 Scheduling consultations in general medicine, including telemedicine, is standard.^21–24 Remote outpatient care and continuous management of orthopedic patients during the pandemic require systematic workflow, proper coordination, and careful selection of patients for teleconsultation. As a result of the pandemic, telehealth became more widespread.²⁵

The COVID-19 pandemic has significant and lasting effects on orthopedic surgeons and their practices, with a substantial decrease in the number of patients treated, surgical volume, and revenue.^26,27 Many orthopedic surgeons have incorporated telemedicine into their daily practice with a high probability that it will be a permanent change in their future practice after COVID-19.^28,29 The pandemic has transformed the traditional model into a virtual model of care in orthopedic surgery.^30–32 The duration, length, and organizational issues of outpatient teleconsultations in the conditions of the COVID-19 pandemic are not often described in the literature, and knowledge on this subject is usually based on publications in other specialties, trying to approximate the circumstances described there to the specificity of orthopedic telemedical consultation (OTC). Organization of telemedicine visits for patients and admission schedules are essential elements influencing optimizing patient flow and schedules,^33,34 accommodating more patients, and reducing patient wait time.³⁵ The factors affecting the organization and duration of visits should be analyzed to optimize them.

Significant changes include changes to workflow organization (patient triage and timely care based on symptom severity up to a continuum of follow-up), resource/personnel requirements (hardware, software, network connectivity, and patient/provider characteristics), and professional expectations. Provision of OTC has already become an essential element of care for musculoskeletal (MSK) patients, which will remain a permanent change in the health care system.³¹ Some conditions necessary for using the OTC include relatively communicative patient, sufficiently skilled in telecommunication, and enough awareness and ability to perform orthopedic surgeon orders required to conduct a specialized orthopedic examination.³⁶

The study aimed to evaluate outpatient orthopedic teleconsultations’ timing, length, and organizational issues in the circumstances of the COVID-19 pandemic based on consecutive orthopedic teleconsultations during the period of the first lockdown.

Methods

The retrospective study included 1,071 OTCs from March 23, 2020 to June 1, 2020. Mobile smartphone billing and the provider’s electronic health record (EHR) served as data sources. Teleconsultations were provided for new patients and regular follow-up visits, including preoperative and postoperative virtual visits. All OTCs were planned and scheduled over the call center or mobile app. The consent signed by patients, along with the signing of the contract for subscription health services, significantly improved the identification of patients at the beginning of each OTC. The nurse or the physician’s assistant did not perform the preliminary interviews or triage. The OTC always started as a voice call through a smartphone with the simultaneous use of EHR. The first step has always been to identify the patient. The connection could then be transformed into a hybrid form involving the transmission of medical images, electronic medical records, and videoconferencing.

Videoconferencing was used when it was necessary to observe specific signs and symptoms required for the examination by remote orthopedic examination methods. In this series, telemedicine services were provided by patients from over 30 cities across the country.

During OTC, patients could send their medical documents, mainly PDFs, JPEGs, and DICOM files, using a method known to them (SMS, MMS, sharing in the Internet EHR system or mobile application, or with the support of a call center). In addition to DICOM file transfer, a dedicated cybersecurity PACS server has been launched for patients. All medical history-related electronic documents were attached to the patient’s EHR. The length of the OTC ranged from 5 to 60 min despite the prescheduled duration of each specialist teleconsultation being set at 10 min. On weekdays, teleconsultations were scheduled from 8:00 am to no later than 8:00 pm because of on-site registration work hours. The OTCs were served on a “first-come, first-served” basis. All OTCs performed were based on the legal regulations of the telemedicine services in Poland.^37,38

Patients were remotely interviewed, and telemedicine-specific physical examinations were performed in each case. The diagnoses were based on the International Statistical Classification of Diseases and Related Health Problems (ICD)-10. Patients could receive e-prescriptions, e-Referrals, e-Orders for orthotics, and e-Sick-leaves during the OTC. Age, gender, diagnosis of the disease, number of diagnoses made based on a complete medical examination, and evaluation of the results of additional tests were treated as factors potentially causing differences in OTC length. The influence of issuing the e-Prescription, e-Referrals, and e-Sick-leaves on the OTC duration was evaluated.

STATISTICAL METHODS

Statistical analysis of the collected material was performed using Statistica 13.3 (data analysis software), version 13.3 http://statistica.io (TIBCO Software, Inc., 2017, Tulsa, OK). Nonparametric tests were used to analyze the variables because the Shapiro–Wilk test revealed a lack of conformity of the distributions of the studied variables to the normal distribution. The Mann–Whitney U test evaluated the differences in the average level of a numerical characteristic in selected groups. Spearman’s rank correlation was used to measure the correlation between rank variables and determine the association’s strength and direction between datasets. Pearson’s chi-square test was used to determine a relationship between categorical variables. Kruskal–Wallis’s one-way analysis of variance was used to explain which specific groups of the independent variable were statistically, significantly different from each other. The level of statistical significance was p < 0.05. This study does not include any human studies and represents the retrospective nature of the study.

Results

Patients were from 8 to 81 years of age (mean = 41.7 ± 11.49; median 41). The study included a group consisting of 514 (47.99%) women at the mean age of 43.37 years (standard deviation [SD] 11.1) and 557 (52.01%) men at the mean age of 40.16 years (SD 11.6). The age difference between sex groups was significant (p < 0.05) (F-ratio 21.36; p < 0.001). Orthopedic disorders (ICD-10 Chapter “M”) were the most frequent (65.3%). Diagnoses of MSK injuries (ICD-10 chapter “S”) occurred in 26.3% of patients, and other diagnoses indirectly related to the MSK in 8.4% of patients.

There were single or few cases, which were diagnosed, after a thorough medical examination, as diseases classified in the following chapters according to ICD-10: B—Chapter I, Certain infectious and parasitic diseases; C—Chapter II, Neoplasms; D—Chapter III, Diseases of the blood and blood-forming organs; G—Chapter VI, Diseases of the nervous system; H—Chapter VIII, Diseases of the ear and mastoid process; I—Chapter IX, Diseases of the circulatory system; K—Chapter XI, Diseases of the digestive system; L—Chapter XII, Diseases of the skin and subcutaneous tissue; R—Chapter XVIII, Symptoms, signs, and abnormal clinical and laboratory findings, not elsewhere classified; and Z—Chapter XXI, Factors influencing health status and contact with health services. Sometimes the diagnoses were unrelated to the MSK system because the patients themselves chose a specialist for teleconsultation in the health subscription system without triage of a family physician. The most common diagnosis in the analyzed material was back pain (M54) (25.5%). Eight hundred ninety-three patients had a single diagnosis. Two coexisting diseases were diagnosed in 152 cases. Eighteen patients had three, and seven patients had four different diagnoses.

The analyzed OTCs averagely lasted 13.36 min (SD 8.63; median 11). Only 78 (7.3%) OTCs were held precisely on time within 1 min of the OTC time allocated to the patient (arithmetic mean 13.46 min SD 6.59). The difference was not statistically significant (F-ratio 2,538; p = 0.08). Most OTCs were delayed (795–74.22%) concerning the planned counseling schedule. The average delay time of the orthopedic OTC initiation was 16.10 (from 2 to 133; SD 17.71) median (12 min). Attempts to administer OTC ahead of schedule were successful for 198 patients (18.5%). The average connection ahead of schedule occurred at 8.66 min (SD 19.1). Their average mean duration ahead of schedule OTC was 14.58 min (SD 11.94).

The delay was assumed to derive from the previous OTCs elongation. Sometimes physicians’ call was not picked up by patients according to the schedule. Holds require systematic informing patients about the change of the OTC time, usually over SMS.

The duration of OTCs was not different regardless of the gender of the patient (F-ratio 0.414, p = 0.520). The number of OTCs per single patient in the presented study group was 1.96 (SD 1.62). Re-OTC was usually needed to evaluate the results of the tests a patient had referred to during the previous OTC. The average OTC duration was significantly longer in the groups of patients in the age range from 20 to 25 years (14.88 min); 26–30 (14.58 min); and in the group 61–65 years of age (15.19 min) (Table 1).

When patients needed a sickness certificate for the employer, the consultant issued a certificate stating the time needed to recover. The number of days issued on sick leaves was 1.36 (SD 3.36). OTC duration was significantly longer (14.82 min, SD 10.54) if the patient (228 cases–21.29%) required issuing the sickness certificate (F-ratio 8.393; p = 0.004). It was expected that OTC duration could be significantly different if the patient required e-Prescription, e-Referral, and e-Sick-leave, or one or two of those. Recognizing more ICD-10 diagnoses also influenced the duration of the OTC (Z = 2.76; p = 0.005). The Mann–Whitney U test confirmed that OTC duration did not differ significantly (Z = 0.16; p = 0.869) to issue an e-referral during the visit. The OTC duration did not differ significantly, regardless of the necessity to issue an e-prescription during the visit (Mann–Whitney U test value: Z = −0.50; p = 0.619). A statistically significant difference (p = 0.039) using the Wilcoxon pair test and a longer first OTC time was observed when needed e-referral.

The OTC length was significantly different (Mann–Whitney U test value: Z = 1.99; p = 0.047), and the visit was longer if the e-Sick-leave was given during the visit. The differences in the duration of teleconsultation depending on the diagnosis are presented in Table 2. The tables were arranged according to the OTC duration—from the longest to the shortest. The teleconsultation length differed significantly (p < 0.001) depending on the ICD-10 principal diagnosis.

Table 3 presents OTC lengths in relation to the specific principal diagnosis group classified in the ICD-10. The longest OTCs were significantly longer than the average. The longest OTC in this series were from Chapter XIX: Injury, poisoning, and some other consequences of external causes (S10—Neck injury, S50—Superficial forearm damage, S82—Tibial fracture, and S22—Thoracic spine fracture), from Chapter XII: Diseases of the skin and subcutaneous tissue (L84 Corns and callosities); and single case from Chapter II Tumors (C43—Malignant melanoma of skin affecting musculoskeletal system). The most common cases in this series were from Chapter XIII Diseases of the musculoskeletal system and connective tissue (M54—Dorsalgia/Back pain; M70—Soft tissue disorders related to use, overuse, and pressure and M75—Shoulder lesions); and from the Chapter XIX Injury, poisoning, and certain other consequences of external causes (S93—Dislocation, sprain, and strain of joints and ligaments at ankle and foot level and S83—Dislocation, sprain, and strain of joints and ligaments of knee).

The duration of most frequent OTCs did not differ significantly from the average for all.

Discussion

The period of the pandemic undoubtedly increased and accelerated the interest and use of telemedicine in healthcare^39,40 in various medical specialties, including orthopedics.^1,20,41 OTCs have proven their real value since the beginning of the COVID-19 pandemic as a way to limit the potential transmission of infection between medical staff and patients or between patients.⁷ The launch of OTC teleconsultation led to a significant reduction in the exposure of patients and medical personnel to the direct transmission of a viral vector of extremely high virulence and the spread of infectious diseases.^42–46 Successful implementation of telehealth among patients with various orthopedic disorders and injuries in a clinic not previously teleconsulted was comparable to in-person visits carried out the year before the pandemic.⁴⁷

Outpatient clinical care and constant care of orthopedic patients with the use of OTC requires a systematic workflow, proper coordination and careful preparation of patients for teleconsultation, and appropriate clinical evaluation. The clinical assessment of the patient plays a crucial role in virtual orthopedic consultations.^36,48–51 The remote physical examination allows skilled orthopedic surgeons and patients to participate more efficiently. Movement assessment while performing certain activities and gait analysis can also be performed remotely.⁵²

Clear instructions on the performance of specific actions are required during the examination given by the consulting physician during the teleconsultation.³⁶ However, instructions to prepare the patient for OTC may be sent in advance to allow the patient to prepare for such an examination.^7,48,53,54 It would be optimal for each patient to have ready answers to questions about signs, symptoms, and anatomical locations. Several articles consider the virtual orthopedic tests of various anatomical sites, including the spine.^{3,48,52,55,56} Patients who require appropriate imaging tests could obtain an e-referral to the Diagnostic Imaging Department before the visit.⁴⁷

In the present study, all e-referrals were given during the OTC. Medical images are crucial to diagnose, plan, treat, and evaluate outcomes in orthopedic surgery. Some may need analysis or measurements (i.e., size or angle).⁵⁷ Patients’ medical images can facilitate the process and help keep costs down, particularly in developing countries.⁵⁸ However, there is no regulation or standard instruction about using smartphones to take photographs of medical images effectively.

Audio OTC remains feasible because telephone calls are best understood and easiest for most patients.⁵² Switching from audio to videoconferencing using smartphones is possible without any technical hurdles but may require additional training.^3,4,15,19,59

Measurement of a clinical visit length is considered critical to the operational efficiency of medical service delivery.^34,60,61 Despite the unprecedented increase in the use of telemedicine from 2020, there are only single study in the literature on the length of virtual visits and schedule adherence. Only a few studies on orthopedic telemedicine in the literature relate to clinical practice and the provision of medical services to patients on remote.^30,62–67 This study revealed some organizational aspects of consecutive outpatient orthopedic teleconsultations during the first lockdown due to the COVID-19 pandemic.

The discrepancy between the planned OTC schedule and their practical implementation is complex. Only 7.3% OTCs were held perfectly on time. In cases of 18.5% OTCs, an effective attempt was made to connect to the patient and meet the OTC ahead of schedule to save time or make up for delays and improve services. Unfortunately, more than 5 times as many OTCs were served later than the scheduled time (74.2%). The “snowball effect” describes well the consequences of a single OTC delay and the mechanism of subsequent delays.

SMS notification about the delay was implemented to counteract patients’ dissatisfaction with starting OTC. SMS text messages to patients’ mobile telephones were already described as an effective appointment reminding method.⁶⁸ An attempt to call a busy “call center” turned out to be an additional trap creating a further delay and often only intensifying the snowball effect. Physicians’ work ergonomics would significantly improve using an automatic system or an application. If the first OTC, delay appears early after the start of the day of admission, the following OTC will be delayed. The reasons for the prolongation of OTC include the lack of patient familiarity with the protocol and procedure, especially in patients naive to OTC. The problem of physician/patient communication during remote anamnesis occurs primarily in the case of only voice OTC.

Patients are often unable to name the medical issue, signs, and symptoms and name the location of the anatomical area affected by the disorder. The OTC length was longer in the age groups from 19 to 30 and 61 to 65. Explanations for these results in the literature were not found. Younger patients could have little experience and have difficulties communicating with the doctor. Older patients may have experience but also more symptoms and comorbidities. Coherent communication with adolescents can be explained by their participation in OTC with their parents or legal guardians.

The study has shown that the cases with most frequent diagnoses do not extend the OTC time compared with the average. On the other hand, the OTC time of patients with the most extended OTC duration was less common and less typical, which could affect their duration.

During teleconsultation, the physician can issue orders for orthotics, e-referrals, and e-prescriptions and give a sick-leave certificate containing the expected duration of sickness absence necessary for recovery and return to work. As shown, these obligations influence OTC length.

Most of the recent studies related to the issue of patient satisfaction with the use of OTC.^{1–3,14,69–79} The duration of teleconsultations in this study did not differ from those described in the literature and was comparable to the time of face-to-face visits. Some articles distinguish between the time spent directly contacting the patient and working with the EHR. The time spent contacting other health care professionals and visiting a physician at the outpatient clinic is also distinguished. In this study, the total time of OTC compared with the observations of other researchers was similar. The mean duration for teleconsultations reported by Lambrecht et al⁸⁰ was 12.8 min. In the Aarnio et al⁸¹ study, most consultations lasted from 11 to 15 min. Visit duration increased over time from 17.9 to 20.3 min for primary care visits (p < 0.001) and from 19.0 to 21.0 min for specialized visits (p < 0.001) across all age ranges and for different numbers of diagnoses²³ with the increasing trend of elongation of the average duration of office visits with primary care physicians and specialists across all age ranges and different diagnoses.

Compared with in-person visits, the time of scheduled OTC seems to be similar. It should be noted that the literature describes the phenomenon of extending the time of visits due to the description of visits in the EHR.⁸² Primary care physicians spend their patients each visit from 16 to 18 min,^24,61,83 and the exams may run later than their scheduled duration. The 10- or 15-min visits were more likely to exceed their allotted time. That was also observed in the present study. It was also observed^24,61,83 that almost 50% of the visit time was spent on activities related to electronic medical records.

Physical therapy/occupational therapy and primary care telehealth visits described by Zhang et al³⁴ were much longer than in this study. They also confirmed that examination lengths of most visits tended to run over time than the scheduled lengths when the appointments were scheduled for 15 min. This study confirmed observation by Hirsch et al, who also found that⁸² level of service and numbers of medications, procedures, and laboratory orders elongated time with clinicians. Similar trends were not found in this report. The longer wait times and more extended time with clinicians were not associated with older age, female sex, and chronic disease in this report. However, Hirsch et al observed such a trend during face-to-face visits analyzed with EHR.⁸²

Extending the time of one patient’s OTC, resulting in a delay in all subsequent visits, was observed. OTCs of shorter duration or even ahead of planned OTCs could occur in this study, but their frequency was so disproportionate that they could not compensate for the delays. The follow-up televisits did not turn out to be faster than anticipated.

Regardless of the specialty, the wait time remains a driver of overall patient satisfaction.⁸⁴ McMullen and Netland⁸⁴ found a significant correlation between patient waiting time and overall patient satisfaction scores (p < 0.001). Patients who were not fully satisfied waited twice as long as those completely satisfied (p < 0.001). Although the present study did not carry out a simultaneous assessment of patient satisfaction, it should be considered that⁸⁴ the shorter the waiting time to enter the doctor’s office, the higher the patient’s satisfaction. In the present study, patient dissatisfaction with the scheduled OTC delay was usually not directly expressed, probably due to the pandemic circumstances. The appointment reminders effectively improve messaging for the patient’s on-time performance,^68,85 and ad hoc massaging may tone the waiting patients. However, the behavior of the patient while the SMS notification is being sent is only anticipated because the available literature are the only activities on the subject that sending appointment reminders to patients is an effective strategy to improve patient attendance rates.

Theoretically, teleconsultations may take longer than stationary ones. Any extension of the patient’s OTC in a busy schedule could create a “snowball effect” or even an “avalanche” of delay for each subsequent televisit. Despite our facility’s simplified workflow of orthopedic telemedicine visits, attempts to shorten the waiting time were unsuccessful.

The study has some limitations. First, the study is limited to one outpatient clinical specialization within one health care organization and only represents the course of orthopedic teleconsultation within that health care organization. Only orthopedic teleconsultations provided by one supplier were included in the analysis. The results of this study may be somewhat more difficult to generalize and transfer to other health care systems.

The hybrid provision of medical services has its limitations. Each component works as a separate application in a web browser or as an application on a mobile device, for example, a smartphone. When videoconferencing software opens a new platform, simultaneous EHR work requires working in a separate window or place. The lack of a timestamp visible on the screen does not allow for easy and constant control of the duration of the provision of services. Real-time medical service delivery times can easily be extended when services are provided with due empathy.

Conclusions

Telemedicine orthopedic consultations have been carried out effectively and can be used appropriately in clinical practice by the recommendations of scientific societies and legal regulations. Teleconsultation time may not be dependent on gender, older age, or more diagnoses. The services like e-prescriptions, e-Referrals, e-Orders for orthotics, and e-Sick-leaves influence Orthopedic Telemedicine Consultation time. In a busy schedule, any extension of the patient’s OTC could create a “snowball effect” of further delay for each subsequent televisit. Patients’ dissatisfaction with the delay in the planned teleconsultation is challenging to assess due to the circumstances of the COVID-19 pandemic. Orthopedic teleconsultation requires new understanding and skills by both the patient and specialist physicians. The OTC performance data, approach, and results described in this study can be widely used to assess telemedicine visits and help operational teams customize planning templates to reflect better the time needed for future teleconsultation. Future research directions should also concern the practical aspects of orthopedic teleconsultation, shedding light on the legal, organizational, and technological issues related to their implementation.

Institutional Review Board Statement

The studies come from daily clinical practice and meet the general guidelines of the Declaration of Helsinki, and do not contain sensitive data.

Informed Consent Statement

The presented study does not contain any investigations performed by the author with human or animal subjects. Patient consent was waived due to the retrospective character of the study.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this study.