Welcome to the American Journal of Sports Medicine's webinar in conjunction with the American Orthopedic Society for Sports Medicine. Thank you for joining us. I'm Donna Tilton, Editorial and Production Manager for the American Journal of Sports Medicine, and I'll be the operator for the webinar today. Before we get started, I would like to take a moment to acquaint you with a few features. There are options for how you can listen to this webinar. If you have any technical difficulties hearing the audio properly, please try clicking the phone call option and calling in for the audio or switching speakers that are being utilized. At any time, you may adjust your audio using your computer volume settings. To send a question, click the text box and type your question. When finished, click the Send button. Questions you submit are seen by today's presenters and will be addressed throughout the presentation, so please send those questions as you watch rather than at the end. There is CME available for this online activity tonight. Here are the learning objectives and the disclosures for the faculty. At the conclusion of today's program, we ask that you complete a brief evaluation by going to education.sportsmed.org and logging in. Please take a moment to complete this if you wish to collect CME for this activity. At this time, I would like to introduce our moderator, Dr. Miho Tanaka. Dr. Tanaka is the Director of the Women's Sports Medicine Program at Massachusetts General Hospital and Associate Professor of Orthopedic Surgery at Harvard Medical School. She is a member of the AJSM Electronic Media Editorial Board and will be moderating our webinar. With that, I'll turn the microphone over to you, Dr. Tanaka. Donna, thanks so much. Thank you to AJSM for hosting this webinar on this topic, and thank you to our panelists for joining us tonight. I think this will be a great session. Tonight we have Dr. Robert Gallo, who is a Professor of Orthopedic Sports Medicine at Penn State Health. He's also the leader of the Penn State Hershey Medical Center Orthopedic Telemedicine Service and has spoken extensively on this topic. Dr. Chad Mather, unfortunately, could not make it tonight due to a medical emergency, and so Dr. Gallo will be covering part of his talk on the regulatory considerations during his talk. And then we have Dr. Alfred Atanda, who is the Chief of the Center of Sports Medicine and Chief of Clinician Experience at Nemours Children's Hospital in Delaware. He's an Assistant Professor of Orthopedic Surgery at Sidney Kimball Medical College at Thomas Jefferson University, and he's also the Chief Editor on the world's first textbook solely dedicated to telemedicine in orthopedic surgery. So thank you to you both for being here. So I think we can get started with Dr. Gallo's talk. He's going to be covering the implementation of telemedicine in a sports medicine practice, and then be covering a little bit about legal and regulatory considerations as well, Dr. Gallo. All right. Thank you so much, Dr. Chanaka, for the introduction, and thanks for the opportunity to AJSM. I'm going to be doing a little bit of pinch hitting for Dr. Mather. Unfortunately, he couldn't be with us today, and hopefully I'll be providing some content later. He gives a great talk on regulations, and I hope I can do him justice. So I'm going to talk a little bit about just implementing, you know, who to start thinking about using telemedicine on, because it really is not for every patient, and it's not for every provider. I'm trying to give you some points on how to recognize who to select, both as a provider and as a patient, to offer some suggestions on ways to implement telemedicine. And then finally, I'll talk about some of the regulatory and potential legal issues that may arise. So should we commit to telemedicine? I think that's a question that you have to be honest about with your practice. I think more and more, it's a service that you probably should think about offering to your patients. It does take time to set it up. It does take money to set it up, you know, and not every provider is going to be very happy about it. So you have to navigate. Those are some challenges that you have to navigate, but I think it's definitely worth it when you think about the potential benefits of telemedicine. You know, today I had 10 or 12 telemedicine visits this afternoon. I can tell you, if I had to map out where these patients came from, it's probably about a total of four hours, north, south, east, and west. So it's a huge savings and I don't think any of those appointments were more than 10 minutes. So it's timeless. It allows patients, you know, I was on vacation last week, so I'm kind of backed up, so it allowed me to do these MRI follow-ups pretty quickly without patients having to wait a long time. And obviously, it increases their access because they can get in to see me sooner. It decreased both their costs and our costs. So I'm just doing telemedicine, I don't really need an MA, I don't need a front desk staff checking in and out. And obviously, with this price of gas, at least in Pennsylvania, it's a huge savings for someone who has to drive an hour, an hour and a half. And I'll show you some studies that show that patients do like telemedicine and it's been borne out in several studies now. So just an example in our practice, we have a problem with x-ray that's using the bottleneck for our practice. So the average time for a patient who needs an x-ray is approximately an hour and a half. Even those who don't need an x-ray, our patients spend about 45 minutes in clinic. It's a huge amount of time people are spending. And this is, you know, this is maybe 15 minutes average time with the provider. So vast majority of the time is spent waiting either for x-rays or for the provider. When you look at telemedicine, you can see the wait time has dramatically decreased. The total time, including the length of the visit and the wait time, is 30 minutes. That's far less than just the wait time just for the appointment visit. And I would say that that wait time is a little bit misleading because if my appointment's scheduled for two o'clock telemedicine, usually they're logging in a quarter of, and that counts. That counts when they log in, not when the actual appointment time is. So really, the wait time is very minimal with telemedicine. And you can see when you look at the ratings, only one completed, only one patient was really unsatisfied with the visit. This is a study, just looking at the effects of access and cost. This was one of the early studies, and this was out of Australia. And they looked at a trial of rural telemedicine for fracture clinics, so, you know, people several hours away from a tertiary care center. And they looked at the cost and the savings. So they looked at it, you know, just to have a video conference, it was almost $1,200 per clinic. And again, remember, this is 2012 where the systems aren't readily available. You know, so even then, they saved a tremendous amount of money by not having to transfer patients, again, for an opinion that could have been done online. This is a more recent meta-analysis, looking at another, the cost savings for telemedicine. The RFC would be the in-person visit, you can see the costs in the left-hand column there. And then to the right, you see the cost of VFC, that's the virtual clinic. And when you look at those numbers, you can see in the column to the right, just huge savings with telemedicine. And this is just for the clinic. We're not even taking into account patients' time lost from work and time for the car visits and wear and tear on the car. So you can see it's a huge savings for your practice. This was another earlier study when they looked at the economic evaluation when they're first starting, when the systems weren't as readily available. And according to that, it took about somewhere between 150 and 180 visits for you to make your money back with telemedicine. And then with satisfaction, this is one of the first studies after the pandemic that looked at patient satisfaction. So these were all patients who were kind of emergently scheduled for telemedicine. And in that group, this is a group that was originally scheduled for in-person, 92% were satisfied with the telemedicine visit, and it really eliminated two-thirds of the in-person visits. And really, again, the only time you really need the in-person visit, if you need a physical exam or if the communication isn't great. So how do you implement this? So there's a bunch of telemedicine systems. There's different considerations with room setup, workflow, and patient selection. So here, if you're mostly, you probably already have a telemedicine system in place, either you've already purchased it for your group, or your hospital has one, but there's just a couple of things to think about. This is on the Academy website, look under telemedicine AOS. And it talks about, there's a little bit more detail about things to look for, look at if your platform is connected to your EHR, and how much tech support they have. Because I can tell you, when you first start telemedicine, those first couple of visits, there's going to be problems. So I think that's very important. Obviously, the upfront maintenance costs for private practice groups, and the other big thing is the HIPAA and medical boards. How much is it protected? I'll talk about later, that's probably one of three areas where you can get sued. Some systems integrate better than others. We have Cerner for EHR and Amwell for our telemedicine. I think some people who have Epic or other units integrate a little bit easier. For me, I need two screens, because they're not on the same system, I can't just readily pull up the EHR on one screen. So I typically have two screens. You can see that I have a camera at the top, so the patient can't see my screen unless I move the camera. So, and that's just the way I do it. I don't use a laptop for that reason, because the patients I'm going over an MRI, they wouldn't be able to see the imaging. I think, you know, everyone just has to determine what works well for them. Each system's a little bit different. Our system's a little bit clunky. And I think in those situations where the EHR doesn't directly streamline to the telemedicine site, I think a camera is probably not a bad option. I use headphones often just because for patient appliance, I'm in an office with thin walls and a bunch of other people around. Workflow is a really complicated view of the workflow system we have. Really it's a lot simpler than that. So a real workflow is I identify the patient, and usually it's a follow-up patient. I create the appointment, and I create it, and that's when the medical assistant actually goes in the system, puts the appointment in our system, both in the EHR and the telemedicine portals. But again, it's a lot easier on some of these other systems where they directly integrate. And they contact the patient, give them the appointment time, and if the patient doesn't have an account with the telemedicine provider, for NRK Sanwell, then they'll help them create an account. And this happens at a variable time prior to the visit. And then 24 hours before the visit, usually the morning of, our medical assistant will call and have some intake questions answered, make sure everything's ready to go. And then right after the appointment, we have the appointment, then right after the appointment, same medical assistant will download the orders and then check for future appointments and then set those up and repeat the process. So it's not as complicated as that first workflow would lead you to believe. Creating orders, there's various ways to do it. Most systems will have that. We have a dropdown now that you can either select what type of visit, personal, I'm sorry, in-person telemedicine or telephone. In terms of scheduling patients, we've had some issues with some of my partners. I don't think it really works well when you schedule patients, especially the videoconferencing in the middle of a busy clinic. It just seems to me like whenever I've done that and my partner's done it, everyone's very dissatisfied because it's really hard either dropping out, if you're running a little bit late, either making the patient online late and they're not sure what's happening or you're going to have to skip a patient in the clinic. So typically what I do is I either put it, if I'm going to do during clinic time, I'll do it at the very beginning of clinic because usually these telemedicine visits are a lot more predictable in length than my in-person visits. Typically when I first started, I was given 30 minutes per visit and now I'm down to, I can easily go down to 10 or 15 minutes and I just slot it one afternoon. I'll spend a couple hours and it's just amazing how quickly, how efficient it is in those two or three hours. Most systems have intake questions. We keep it simple. You could easily do patient functional outcome scores and depending on how easy it is to integrate in your system, we've tried to keep it broad just that it could integrate across the different subspecialties, but certainly if you're a single specialty practice, it would work well to just have a IKD score, ASES score. In terms of billing, most of you probably already know this, but any telephone visit, it's a five minute minimum is required and you can't have a visit within, a visitor procedure within seven days. The advantage of telemedicine there is these minimums aren't there and I would say that 33% of my visits are within five to seven minutes on telemedicine. So if you can get them to do the video conference, they're definitely billing advantages in addition to the inherent physical exam benefits of telemedicine and video conferencing. So when you're doing the, in addition to the time limit for both virtual video conferencing and the telephone visits, you need to document that you consented the patient for that, that you identified them, that using a synchronous platform and both the provider and the patient location currently. Most, and we'll talk about this later, most states require to be in the same state as your patient is physically located in. And that's, so those are the only five, only four things you need to document for a video conferencing. In addition for the telephone conference, you have to document the duration and then who initiated the visit. This is just an example of what I do on my video conferencing. We have a little bit more intricate one for the telephone conference. So now that you have it set up, who to schedule? Because not every patient really wants to be a part of telemedicine. Some people are just, you know, are just diabolically opposed to it. And I think, you know, obviously it's, you don't want to force anyone to do anything. I think those would be the people who are unhappy. My practice is really sort of unpredictable as to who wants to do telemedicine, who doesn't. It's pretty even male to female. The age is right, right in the middle. I've had people as young as 14 or 15 with their parents and people as old as 80. It just depends on their comfort level. What types of visits do I typically use? For me, MRI follow-ups are kind of the gold standard for me. I think those are the easiest ones. Those are the ones that just, they just seem to work really well with telemedicine. The other ones that work really well are the follow-ups with a predetermined plan. I think shoulder pain without trauma and the patient who comes in with a couple of weeks, you send them therapy for six weeks or three months, if it doesn't get better. And then you think about doing an MRI, I think those work well. And then select post-op follow-ups, especially in the ACL population where they're transient and they're, I've had people doing summer internships, I had a patient today who's four hours away in Pittsburgh doing a summer internship. This makes life a whole lot easier for them to be able to do that. There's a lot of data on fracture follow-ups. And then any call that's expected to last more than five minutes, that's typically something that's not reimbursed. So if you know that the call is going to be more than five minutes, don't think about doing a telemedicine visit or even a telephone visit. We talked about, here's some studies on fracture follow-up, because there's a lot more literature than you would think on fracture follow-up in telemedicine. This is a meta-analysis. Recent meta-analysis looks at 18 articles, and really they were looking at number of adverse outcomes. And there really weren't as many as you would think. I think there was one in that whole, you can see the list of the number of patients. There was only one patient who had to have an operation because something was, a fracture was missed. It was developed by a symptomatic malunion. But of all those numbers, typically the outcomes are very good for fracture follow-up. This is a study done at NYU, where they looked at using telemedicine for all post-op follow-up visits. Obviously, I can say just in a place like NYU, we probably have a lot of people coming in and out of the city just for the appointments. So it was a prospective randomized control study, where they looked at people whose two and six-week visits were done either telemedicine or in person. And you can see here that the numbers were pretty split. Slight advantage for people who would prefer an office visit, but the people who had the video visits were very satisfied. So of all those that had an office visit, 85% would prefer an office visit again. And telemedicine, surprisingly, was pretty close. Of all those that had a telemedicine visit, almost 80% of those would prefer a video visit. So patients don't mind, and then for those who worry about complications, really, especially DBT in that population, it worked just the same. For those that were telemedicine, and we do it all the time at our facility, if someone's suspected of having a DBT in the call, we just have them set up same day at a location near them. So there was no, according to them, no missed DBTs or any higher DBT rate in either group. So they thought their conclusions were that patient satisfaction with post-operative care is equivalent. And based on their primitive study, they thought the level of care was equivalent. This study out of Rothman, this one's a little bit different because they're taking all comers in this study. This is an early COVID study where they assess patient and provider perspective telemedicine implementation. Again, you had all kinds of visits, you had post-op follow visits, established patients, and new patient visits. In this group, although not statistically significant, the satisfaction rate was a little bit higher in the post-op follow-ups and the established visits, as opposed to the new patient visits. And I would tend to agree, I rarely use telemedicine for new patient visits because I think a physical exam in those patients is really important. So overall, 90% satisfied, and again, almost 95% if you're just looking at the post-op follow-up visits and the established patients. So the difference became is that those that had technical difficulties did not like it. And I think anyone that's done telemedicine would probably agree with that, especially if you're having a lot of technical difficulties. Another interesting finding out of the studies were patients tended to like telemedicine better than the providers did. Patients that didn't like it, I think it tended to, probably if you looked at it, were probably more of those new patients who thought the level of care they received wasn't as good as it would be in in-person. So their conclusion that patient satisfaction overall was high, provider satisfaction was low, and that just because someone's satisfied doesn't necessarily mean that they prefer it, that even though the lies patients said they were satisfied with telemedicine, that many preferred in-person visits. And obviously technical difficulties are burdensome for both patient and provider. So speaking of challenges, technical difficulties obviously at the top of that list, reimbursements, another potential challenge, especially moving forward. Again, moving forward, leading considerations right now don't appear to be a problem, but I think it's only a matter of time before those become a major issue. And the last one is just buy-in in your practice. I think in my practice, even though at some point everyone in our practice probably has done a telemedicine visit, I'm probably the only one that still consistently does telemedicine. And I think people who don't use it and don't see the merits of it, it's really hard for them to buy into it. We talked about this one. And again, this study, if you're having technical problems, that could be a major barrier to implementation. I think unfortunately COVID forces use telemedicine positively, but the problems were, I don't think we're always ready to do it. And in our practice, people are overwhelming the system and the people who are already skeptical had technical problems and never really adopted it because they were so frustrated. I think this Jefferson study really bears that out. This is our data. So if you look at our data, the orthopedics department, so we have orthopedics and primary care sportsmen and kind of get grouped together. You can see that when you lump them all together, the highest percentage were the people who didn't use it as much. I'm gonna be that high user as me and maybe one or two other providers. And you can see our rate almost gets in half. And really the more experience you have, the less technical difficulties you have, in part because I know which problems I can fix and which ones I can't. As soon as I see the clock spinning around, I don't give it very long before I just call the patient. And a lot of times if I see the connection's not great, I'll really try and do the physical exam first and then give them a telephone call. I did that once today. I think I have a low threshold for turning the video conference into a telephone conference. And most patients are okay with that. You can see there are, at least with our system, there are certain devices that work a little bit better. For us, the Macintosh systems tend to do a little bit better than the Android systems. So if you're thinking about using your mobile device versus a computer, typically the Macintosh products do a little bit better. So reimbursement, this is another common problem. I think probably when you think about it more for in private practice, but reimbursement currently, at least in our state, pays telemedicine with video, pays the exact same as outpatient visits in person. I think that the other thing to note is the square on the right. So if you're looking at telephone visits, currently still in our state, the five to 10 minute telephone visits compared to the level two established, the 11 to 20 minutes visits compared to the level three visits, and then the 21 to 30 minute telephone calls compared to the level four visits. So the telephone visits, surprisingly, still in Pennsylvania get reimbursed fairly well. When you talk to VPs of health insurance companies, I think there is a part of them that really wants to cut back on telemedicine reimbursement, reimbursement with telephone and those things. But I think that comes at the cost of consumer demand. I think they're always, even though they're looking for ways to cut costs, I do believe telemedicine is a big enough attraction for patients, especially in rural areas, that I don't know that they're gonna cut back too much on the reimbursement for those. So legal considerations really can get broken down into three different domains. So there's negligence, licensure issues, and then compliance issues. So probably the one that most people are concerned about are just direct lawsuits from negligence or malpractice. This is a study out of JAMA, they looked at a number of cases with a medical malpractice with direct to consumer telemedicine. And according to this study, there were 551 medical malpractice cases, none involved telemedicine. I think some of the concerns, there's a little bit of a selection bias that we'll talk about. And really, because there's no telemedicine visits, I'm sorry, because there is no current telemedicine precedent, lawyers don't really know how to fight it. So there's a lack of evaluation of the cases as well. So you don't know how much the lawsuits are gonna be worth. So it's really hard to tell. And I think once you start seeing one or two telemedicine lawsuits, you might start seeing a lot more of them. Areas of concern, at least from this article, were failure to diagnose. And I don't know how not being able to see somebody on a visit is gonna impact that. HIPAA compliance, I think that's a big one and that's an easy one to go after. And then obviously state licensures, that's pretty objective. So again, you need to know if the patient is not in your state, you need to know the rules on whether you can conduct a telemedicine visit. In most states, it goes by where the patient is at, not where the provider is at. So if the patient is in New Jersey and you're in Pennsylvania, you can't do the visit unless you have a New Jersey license. So again, generally you're required to be licensed in the state at which the patient's receiving services. So we have some patients around that. I'm at the start there in Hershey. We have some patients that live in Maryland right about that 83. So if worse comes to worse, sometimes I'll have them drive over the state line just to do the telemedicine visit. Other options, there are systems in place in which you can get licensures pretty quickly from other states. This is the Interstate Medical Licensure Compact. So what you can do is you can submit one general application and then apply to a bunch of different states here. The states in the dark teal are the ones that already have it in place. You can see most of the other states are starting to fall in line and become part of this. The problem with this is you still have to pay the licensure fee for each state application. So for some states it's pretty minimal. For some states, I know that Pennsylvania is pretty substantial. To really find out what each state, what the requirements are in each state, if you're looking to individually to practice telemedicine, this is a great website. I don't have any relationship to Beasley.com. It's a great website that can tell you a host of details about every state and what they exclude, what they don't exclude and what you have to do to legally do telemedicine in that state. And then just a brief note on buy-in. I talked about this a little earlier. I think there's some people who no matter what you do, you're not gonna get them to buy in. I think it's okay. I think everyone in your practice has to do telemedicine. I think it's a great tool. And I think especially as you move forward and people get used to doing it, I think it's a way to attract patients to your practice and make their lives a lot easier and everyone happier. This is just for those who want a little bit more information, here's some resources. This is a JBGS review article that just gives you some resources to look for. So in conclusion, the lessons I've learned is certain patients and visit types work well for telemedicine. I think the MRI follow-ups are awesome and the established patient visits are great. They're just tailor-made for telemedicine. I think you need to allow enough time and schedule it so that you're not doing it in the middle of a clinic. I think you need to be patient with the system. There are gonna be issues and you just have to have ways to go around. It's just like surgery. If there's problems arising in surgery, you find another way to get it done. Same thing with telemedicine. I think the other thing is that not everyone wants telemedicine, so I ask patients before I schedule for telemedicine, obviously. I think that way everyone's happy. So I'd like to thank you all and I look forward to the next presentation. Great. Thank you so much, Dr. Gallo. That was fantastic. Next up, we have Dr. Alfredo Tanda. He's gonna be speaking about advances in telemedicine. While he's getting his talk pulled up, thanks to those who have put your questions into the chat. And for anyone else who has some questions, please enter them and we'll get to them during the Q&A. All right. Dr. Tanaka, can you see everything? Yes, looks good. Great. Let me, sorry. Give me one second here. Just having trouble getting this. I'm getting the screen out of my... Give me a second. There we go. Well, thanks everybody. Sorry for the little glitch there. Alfredo Tanda, one of the Pete Sports folks in Wilmington, Delaware. And these are my disclosures, mostly relating to some of the telemedicine work that I do. So, Dr. Gallo really set the stage for kind of the landscape of where telemedicine has come from and where we are now and how we've gone through the pandemic, mostly from kind of a practical operational standpoint. And that really sets a great foundation for kind of thinking outside of the box and different ways that we can utilize telemedicine and telehealth in sports medicine and orthopedic surgery. My talk, I kind of break it down into three main themes of ways that I like to think of how to use telemedicine for my practice and for some of the folks in my department. So, I think of direct-to-consumer premium, which is a little bit further, step further besides direct-to-consumer, which we heard a lot about with Dr. Gallo's talk, which a lot of us have been doing with our own regular patients, but I will chime in on the premium aspect. The new wave of provider-to-provider technology, which I think is really going to be that second big paradigm shift that we've seen with virtual health. And then last but not least, different ways to utilize video technology in a passive manner. So, what I really think of direct-to-consumer premium, like I said, it just takes things a step forward of engaging the patients that we see. And I always talk about this analogy. So, for any of you who've ever been to DuPont in Wilmington, this is our hospital cafeteria. And I always talk about, well, when you look at somebody who is in a cafeteria, you're automatically just going to assume that they're there because they're hungry, right? But when we rely on the jobs to be done theory that's been popularized a lot by Hayden Christensen from Harvard Business School, when you look at somebody who's in a cafeteria, there's actually a lot of reasons why someone would find themselves there. Obviously, if they need food, but they can need a drink. Sometimes people have meetings in the cafeteria, they need to use the microwave, they need utensils, they need to find somebody who's in the cafeteria. The list goes on and on. So, the same thing happens for our sports medicine and our orthopedic patients, right? You can't just assume because somebody comes to your office for knee pain that they're all there for the same thing. We all, as consumers and customers and clients and what have you, have a job that needs to be done. Sometimes another provider told the patient to follow up with orthopedics or with sports medicine. Sometimes for me in a children's hospital, the kids just need sports clearance. Sometimes the parents, they're not all that worried, but they just want a little bit of reassurance as to why their kid is complaining about pain. Sometimes they need a second opinion. Sometimes a physical therapist or an athletic trainer is worried about the progress of the patient. Some people come and they literally just want an MRI. And as Dr. Gallo alluded to, sometimes there's lawsuits involved. So, the main thing to take away from this is we have to really figure out a way how we can figure out what our patients need. And hopefully we can do that prior to them showing up. So, what we've done with telemedicine is create like a virtual triage navigation system or really a pre-screening model. So, we started off with patients with a problem and we utilized our athletic trainer and connected the patient to them with a secure telemedicine app. And our athletic trainers work very closely with us in the clinic. And just like they do in person, they go through the history and the demographics and where the patient is and their insurance. But they do this virtually prior to the visit. Because one of the things that really is irritating for a lot of us providers is sometimes the patient shows up to see you and they don't actually need to see you. They just need to see your partner. And that can be very frustrating for the physician, but it can also be very frustrating for the patient. As you can imagine, somebody takes their time off of work and their kid out of school and they spent half their day getting to your clinic all to find out that they need to see somebody else. So, we've really leveraged telehealth and telemedicine to try to gather as much information from our new patients in a virtual way. And by using somebody who is clinically oriented like an athletic trainer, they can see the patient, they can have the patient point to where their pain is, they can kind of go through a quick history so that when the patient shows up, we know exactly what images to order so we can send them directly to x-ray before they're even put in a room. We know specifically why they're there. And as I alluded to before, it's not just, oh, I have knee pain or I have shoulder pain. Everybody has a reason why they're there. And our clinical staff are very adept at figuring all that out before they even show up to the clinic. And we did a little pilot a few years ago where we compared screened patients to traditional patients and even presented it at the AOSSM a few years back, basically looking at the overall exam time and the room visit time and the percentage of time spent with the provider and found that basically all of those times were decreased when we pre-screened patients and were able to figure out what they needed prior to them showing up. Family conference is another big thing that we do in terms of direct to consumer on a premium level. So this is just a story about a patient of mine who it was a Friday and the following Monday I was slated to do an ACL reconstruction for her, but she had more questions. But that particular Friday, her and her family were doing various things. Dad was actually playing golf, mom was at work, the girl was at school and this strapping young gentleman who was supposed to be me, I was at home. I just happened to be off that day. So my secretary set up a quick telemedicine visit where everybody can be involved. You know, and I had my laptop, I had four boxes there, one with my face and the other three with the rest of the family members. Everybody was able to chime in and ask their questions and be reassured and were able to bill for it. So you can imagine in a traditional sense in this particular scenario, there is no way that we could have come together unless we leveraged digital health and telemedicine technologies, which is very interesting and exciting. Another thing that we're doing directly to patients on a higher level is second opinions. This is something that a lot of private corporations have been doing for many, many years, but academic institutions are starting to do it as well. You can imagine you get, you know, a 15 year old lacrosse player who saw somebody in a different state or somebody downtown with an ACL tear. They've been counseled, they've had everything explained to them and they literally just want another opinion. So, you know, sometimes we bring those patients in and we examine them because they're in front of us, but ultimately they literally just want to talk to us about what we think about their problem. So now you can just get the MRI and the imaging studies pushed over to our system and you can do a quick telemedicine visit with them and answer their questions, reassure them, talk to them. I mean, they may not even actually want to come to you for surgery, but they may just want your opinion. So utilizing digital health and telemedicine is a very easy way to kind of evaluate these pre-packaged people who literally just want an opinion. When we think about direct-to-consumer premium, you can see that there's a lot of companies putting these kind of high-tech kind of digital phone booths in places and it's providing MSK and other types of specialty care wherever you are, Careport, MD and OnMed are just two examples. You can see they have little screens and filters in them with specialists and primary care physicians that can pop up. They have a lot of attachments and peripherals. Some of these have medical assistants and nurses that man them. Some of them are freestanding. And in our state, in Delaware, there's a huge contract with Careport, MD and Acmes as well as in schools in the area. But you can imagine bringing that same ideas to places where people congregate, whether it be restaurants, whether it be gyms, whether it be even churches. The old paradigm of putting up a site in a specialty clinic and physicians in a brick and mortar center and having everybody flop there is slowly changing. You can get all sorts of other aspects of your life at the tip of your fingertips, wherever you happen to be, whether it be video streaming, ride sharing, e-commerce, healthcare is soon gonna follow suit. We're obviously lagging behind a lot of those other industries, but eventually the idea would be that you can get care wherever you need it. And we're not doing any of this kind of stuff just yet, but we're hoping to bring that soon on the horizon. And you can see there's a lot of these kind of digital mirrors and screens that people have in their homes. So you can imagine that, just like having this exercise mirror there, you can have a PCP or a specialist there or even emergency room doctor. And all of those things are kind of there in theory and the capability and the technology is there. It's really just adjusting the culture and kind of moving the needle towards that. So the next big thing I wanna talk about is provider to provider technology. And this is something that, it's not really talked about a whole lot and not a lot of institutions are doing it, but I really do think it's gonna be the next wave of the future. When we start off as sports medicine folks, as you know, there's a lot of sideline coverage we do. And a lot of us as physicians and advanced providers cover games. And you know, that kind of creates a little bit of an access to care issue, right? Because there's only a certain amount of sports surgeons and physicians and clinicians out there, but there's a lot of different schools at different levels. There's a lot of sports out there. So invariably it becomes like the more well-resourced and usually the private schools and the schools with the funding and the big ticket sports like football and basketball that get a lot of our attention. But guess what? A lot of smaller schools that have sports like, you know, field hockey and baseball and track, you know, they all need technical coverage and advice as well. So by utilizing telemedicine, we've actually piloted with a bunch of schools in South Jersey near us, where we can provide provider to provider care with athletic trainers and other assistants on the sidelines. And then the physicians can actually move our knowledge and our information and our expertise to where it needs to go to. Because for those of you that have covered games, obviously there's certain situations where really kind of dire, serious things happen. But a lot of times the athletic trainers are well-versed and very well capable at covering most of the things that happen. So by moving our knowledge and information and utilizing telemedicine, we can actually be in more places at once and provide that higher level of care to a lot of other places where physicians may not even be accessible to. Physical therapy is very interesting. And I'm not talking about doing physical therapy from home. I'm actually talking about connecting myself with our post-operative patients while they're at physical therapy. So the physical therapy patients, you know, immediately post-op patients, they go, they do what they need to do. But oftentimes there's a disconnect between the therapist and myself, right? They send over forms and they fax things to our office that may get lost that I may not ever see. They rely on the patient to tell me things and ask me questions. So now my secretary sets it up in a lot of ways where my post-op patients go to physical therapy and they do the telemedicine visit right then and there. So a physical therapist is my eyes and ears. They can ask me questions. I can ask them questions. The parents can ask both sets of providers questions. So it really just closes the loop and connects everybody. And it kills two birds with one stone. So now that patient has less to do because they don't necessarily have to come see me for that post-op visit, because they've already gone to their physical therapy visit. And as you know, a lot of those visits are in the global period and we don't necessarily get reimbursed for them anyway. So it's nice to keep them in other facilities, but still be able to kind of manage their care and provide that insight. Frontline consultations is huge, right? We have a lot of frontline physicians, PCPs, ER docs, urgent cares, where I'm at a children's place, so where our injured kids go, but even the adult places. This is the first line of contact into the healthcare ecosystem. And most patients go to these places, not necessarily because they're gonna get higher level orthopedic care, but they go because they're open, they're accessible, they're in their communities, they're well-known to them. But by connecting myself to these places, I can then interact with the PCP and the ER doc and the urgent care doc and help manage expectations, help look at images, counsel the families, tell them, oh, you know, you have this distal radius buccal fracture. It's nothing really crazy. It's nothing you have to worry about. The doctor is gonna splint you and then you come to my office next week and then we'll kind of sort through things. And when they come to my office the following week, I've already seen them. I've already met them. I've already managed their expectations. So they know exactly what I'm gonna do. If it's a sports patient with like a knee injury, something, I tell them if I'm likely to get an MRI or not get an MRI. So when they come to my clinic, they're not asking me for one because I've already kind of counseled them. And some of those visits I don't necessarily do. We have our athletic trainer, reach out to some of those places, gather that information and put it in the chart. So when that patient does show up, I know what I'm expecting. Some of the visits we do at satellite offices where a PA or an APN is, or even just the medical assistant, and they can do simple things like put on DME, put on splints, take out sutures, pull pins, take off casts, put kids in boots. Because a lot of the, especially the follow-up patients, they don't necessarily have to come up all the way to my subspecialty clinic just to have their cast removed or just to have their stitches taken out. They can do that in some of the low-lying satellite offices that can be 50 to 100 miles away from our main hospital, still get what they need. I can beam in, I can talk to them, I can answer any questions. And it's just like they came up to the main hospital. Streamlining ED transfers is a huge thing. This is a real example of a kid, he's a 15-year-old football player who had a medial epicondyle fracture. He went to an urgent care. They saw that he was a child, his elbow was swollen. They had issues with their X-ray machine. So they sent him to another urgent care, and that place actually got X-rays. And they saw that he had a medial epicondyle fracture. They told him he had a very unstable elbow and he had to go to the emergency room. Well, that emergency room saw him and said, well, he's a kid, so we don't treat kids. He needs to go to DuPont. And of course, you see where their story is going. He gets to DuPont, the second year resident sees him in the middle of the night. We see this fracture and it is operative depending on who the attending is on call. But regardless, he's sent home and we just follow him up as an outpatient and have a surgical discussion with him there. And that's our viewpoint. But imagine being that patient. Imagine all the pain he's in and the fear and the anxiety that he's in. The expectations, every single step along the way, somebody is telling him something about his elbow and something about what's gonna happen if he needs surgery, if he doesn't need surgery. And they even told him at that emergency room that his elbow was so unstable that he had to be transported in an ambulance to our hospital. And you can imagine how expensive that was. It took about nine to 10 hours of time for all of this to happen. The amount of resources is unbelievable. Every single one of those places, somebody had to check this patient in, check his insurance, weigh him, take his vitals, evaluate him, put him in a room, a physician had a document on this patient, when all the while, nobody was even providing any value to his overall care for the most part. And imagine the money. It's astronomically expensive to go to all of these places, specifically that ER transfer to our hospital. So imagine a world where my knowledge and my information that I can provide could have been transported to any one of those early on facilities, that first urgent care. If I said, it's really swollen, but he's neurovascularly intact, I understand you can't get an X-ray, just put him in a splint and then send them to our hospital in his own car the following morning. And we'll be able to sort him out, get X-rays, or even that second urgent care. After we saw the X-rays, we could have been like, oh, okay, well that's something that probably needs surgery, but just have them come to my office as an outpatient. Here's the number. But we could have really obviated all of those unnecessary steps. And it sounds crazy to put it this way, but this kind of thing happens all of the time. And we actually looked at all of our transfers, about 350 kids in a year's worth of time. And we realized that about 30% of them did not need to come to our emergency room. Now they may needed to follow up with us in general, but they did not have to come through the emergency room. They could have definitely just followed up as an outpatient or come straight to surgery if they needed something that was surgical. And we're basically trying to get this written up and submitted for publication now. E-consultations is another provider to provider thing we're thinking about. This is more asynchronous. So this is something that's usually along the lines of like an email. So a primary care doctor usually sees a patient, evaluates them and has some questions about whether or not they need therapy, whether they need an in-person visit, whether they need an injection of some sort. And they send that consult to like a nurse triage person who routes it to the appropriate specialist. A lot of private companies do this, to be honest with you. And then as a specialist, you respond in a day or two. A lot of times, most of the things that the patients, the PCPs need is just a little guidance, a little reassurance. They kind of know what to do already, but they just need somebody backing them up a little bit just to make the patient feel a little bit better. So by inputting my knowledge and my expertise, it helps that PCP take care of that patient, but it most importantly helps that patient feel comfortable getting that subspecialty care in their PCPs office. Because a lot of times the knee jerk is like, oh, you have, no pun intended, but you have knee pain or shoulder pain or elbow pain. You just need to go see an orthopedist. I don't want to deal with that. Now, this way we can help PCPs keep that revenue in their offices, manage them. We can provide and we can get some revenue out of it. And the patients can stay in their medical homes where they belong. So last but not least, I want to just share a few words about video technology. It's more passive video technology, not so much telemedicine in the way that we're used to it, but there's lots of things that we can provide our patients prior to these visits. So for my ACL patients, I made a little video that everybody asks the same questions when they tear their ACL and they come to my office and there's usually a lot of angst and a lot of tension and nerves and anxiety. So I made this 15 minute video that now people can watch in their homes that goes over every single thing that I would tell them when they come to my office and they watch it before. And then when they show up, now they've kind of heard everything. They've thought about their problems and questions in a very kind of thoughtful way. And they just kind of confirm some other things with me and ask me any last minute questions. But basically those visits are so much more informative for them because they come informed as to what I'm going to say. And it's quicker because they just have less questions because typically everything has been answered. And I do this for a various, you know, a bunch of different topics. But the idea is again, moving knowledge and information to people in a way that's convenient, comfortable, and kind of coaches them and preps them for visits. So we're not spending so much time just answering the same questions over and over and over. Informed consent is another big thing. So when I do ACL cases and MPFL cases, again, it's the same things that I go over in the informed consent process. And in a busy, loud, chaotic, preoperative holding area, you know, people will sign anything that you put in front of them. But a lot of times for liability issues and other issues, we stand there and we talk to them for 25 minutes, going over everything. And then when we're doing that, anesthesia can't see the patient. The nurses can't see the patient. They can't get their clutch training. Everything kind of stops when the surgeon shows up. So now I just have them watch everything ahead of time. And then when they show up, if they have any last minute questions, because it's literally everything that's on the consent form, they can ask me, but now they can just sign the consent form. I can mark their limb and I can go about my business just helping to move them through pre-op to get them actually what they need, which is the surgery. Same thing with discharge instructions. You know, after a surgery, the parents and the patients are nervous. The kids are groggy and nauseous and in pain. And we're shoving all of this stuff in their brains and in their faces, sending them all these papers and checking all these boxes. Okay, well, I gave them discharge instructions. God only knows if they actually ever read and comprehend things. So we made a bunch of videos of a lot of different things. I usually send it to them the night before, but I also send it to them and have them watch it while they're waiting for the surgery, right? So if you're waiting for your kid to have an ACL reconstruction, you could be sitting there for three, four hours, literally doing nothing. So I have them watch this little brace video about how to adjust the brace. I have them watch a little video about how to teach their kid how to change their dressings and what have you. And whether they watch it or not is up to them, but at least they've seen it, they've been primed for it. So when the nurse in the recovery room is spewing all this information to them, they've at least seen it, they've heard it once before. It's kind of somewhere in their brain and it just preps them a little bit because to shove all that stuff on them right when they're with their family member, it's usually going in one ear and out the other. And last but not least, we just do a few things with student education. Obviously we have our typical didactic lectures that we give and videos that we make on lecture topics, but also different things that we talk about, especially kids this day and age are glued to YouTube and they absorb a lot of information via video. So we've made a few videos about different things for mentoring purposes and the like. So just some take home points. I know that's a lot of information we threw at you today. And just like Dr. Gallo said, I mean, telemedicine is a tool just like anything else is a tool, whether it be a reflex hammer or an EKG or stethoscope, all of these things have to be used in the right way for the right patient, for the right problem. And it's not for everybody, just like he said, haters are gonna hate, not everybody is gonna buy into telemedicine, specifically a lot of these kind of outside of the box things I'm talking about. But for those of you that are interested, it's there, it's possible. And there are other people trying to move the needle and raise the bar a little bit. And I always tell people, at least for me, a lot of these things are not meant to replace clinical care, it's really just to augment it, make it more streamlined, make it more efficient. And I like to harp on the fact that, the pandemic really exploded telemedicine and what we've been doing and a lot of us are doing is basic, direct to consumer, you're my patient, I'm gonna go over the MRI, I'm gonna do a post-op visit, I'm gonna counsel you about surgery. But there are lots of other ways to think about digital health and moving knowledge and information just in the simple way that we're used to. And you have to be flexible, you have to be patient. I presented all these kind of crazy things I've been doing for the past seven years with telemedicine, but it didn't start out easy. I started out exactly like Dr. Gallo was talking about, picking one or two patients at a time with simple problems who I knew, who I had a good rapport with. And over time, after being flexible and being patient and troubleshooting all the audio visual issues, you kind of get better at it, but you definitely have to start off being patient. Lots of other docs, whether they've been neurologists and emergency room docs and family practice docs, have been doing these sorts of things for a long, long time. And I think orthopedic surgeons in our specialty have a lot to learn from them. And one thing that I've always tell people is that being an innovator is very lonely, right? Just like Dr. Gallo said, sometimes you find yourself as the only person in your department who is drinking the Kool-Aid, who's really there to fight the good fight and keep forging along. And that's okay. Most truly innovative, disruptive things get ignored at first. And you find yourself on this island talking about all these random, crazy things like you're a mad scientist or something. But I think persevering and believing in these sorts of things can be very worthwhile. And last but not least, have fun. Obviously, it's a great privilege and honor to be an orthopedic surgeon and to be able to treat sports medicine patients and athletes. And this is just another thing that we can do to increase the fun for ourselves, but definitely for our patients and those around us. Fantastic. Thank you so much. That was a great talk. We have about five minutes left for questions. So anyone with questions, be sure to put them into the chat, please. We do have a few. And I think Dr. Gallo, we'll have you turn on your video and we'll have each of you guys answer these questions. So we have a question from Ian asking what are the characteristics that sports orthopedic practices should be looking for when investing in a telehealth platform? I'm gonna pull up. Was that directed to Dr. Gallo? Yeah, I think either one. Rob, you wanna start with that? Yeah, I think that there's no right or wrong answer to that. I think one, I think if it's a private practice and you have, I think you need to have, at least in my opinion, they need to have good customer service and support. We have, you know, I'm at Penn State. So we have someone who's devoted to us. We have people that that's their whole job. I can tell you the first couple of times you do it and you struggle and you feel like you're on your own and you just wanna throw up a machine. You know, so I think that like you really need to have customer support. I think it's really helpful is if it integrates into your medical record. I don't, we don't have that luxury but I think it would be a whole lot easier because it would save your staff. We have to duplicate efforts because it's not in the same system. Those are the two things that I would say are most important. Yeah, I mean, I agree. And, you know, I'm fortunate at DuPont where we use Epic and we use America Well and it's embedded directly into our Epic system. So, you know, we can go straight to our patient list and just click on a video icon and boom, the visit pops up. But that's only recent. I mean, that started maybe about a year or two ago but like the first four or five years I was doing it it was kind of like Dr. Gallo was saying it was a separate entity. So if you are looking to invest I would wholeheartedly say that. I do like the fact of being able to screen share. So I'd make sure whatever platform you have gives you that ability so that you can, I use one screen and I pull up my images that way. So when I'm with the patient in the telemedicine visits I can go to the screen share and then the x-rays pop up and we can both see it. So that does make things a lot easier and obviates the need of having two screens. And then last but not least I definitely echo the customer support service. You know, when we started I was doing a lot of my telemedicine visits after hours because I didn't want it to interfere with my regular clinic. So once everybody left then I would start my telemedicine visits. And then of course nobody was there to help me but now we have kind of real time live customer support where there's almost always like a telemedicine person available to kind of beam right into the visit, you know and talk to the families if, you know they can't hear me or see me. And they also prep the families and Dr. Gallo alluded to that as well prep the families prior to the visit to make sure they're on the right wifi and that sort of thing. So those are definitely some key, key things that you want to make sure every platform has. They're going to try to sell you things with all these crazy bells and whistles. All you really need is appropriate support and the functionality to embed it in a streamlined way into your workflow. Great. Next question. So Dr. Otonda, I think you covered a little bit of this in your talk. Any experience implementing telehealth for evaluating acute injured athletes during competition? Can it provide ATCs a potential lifeline if physician can't, if physicians can't attend an event? So if you want to expand on what you talked about. Yeah, that was, you know, that was probably of all those kind of outside the box things. That was the first place that I started because to be honest with you, we get a lot of pressure from our organizations as sports surgeons to increase outreach and go out to the community. But as you all know, you work a long day and, you know in the middle of November, when it's freezing cold you don't want to be standing on the sidelines of a high school football game. So I kind of thought of these things and I started doing that. And I targeted schools that actually didn't have any physicians mostly because it's that whole access to care. So they just literally had athletic trainers kind of on their own Island. And we did it in two different ways. I did it in an on-demand fashion. So on a Friday night, I'd have two or three athletic trainers be able to pull me up on an iPad and I had a few screens at home and I can do it like literally on demand. But I also have like a virtual training room where, you know, for those folks that I couldn't, you know I had my own things to do and I could not be available on Friday night, Monday afternoons at 12 during my lunch hour I would have them round up all the kids that had gotten injured over the weekend and bring them into the training room. And then we would just do the telemedicine visit there. And then I can watch the evaluation. I can talk to the kids. I can give them my number for their parents to call me. So there's a lot of ways to do it. And I think there's so many kids in so many schools even in a lot of athletic clubs that literally just don't have a physician. And it's very highly integrated into the care that the kids are receiving that there's a lot of opportunity. And if even if it's very rudimentary anything that you can try to set up I think would be wholeheartedly welcomed by a lot of folks. Okay, great. Another question, maybe this one is for Rob. Do you have to discuss telemedicine with your malpractice provider? And I guess I'll add to that as a follow-up, you know do either of you say anything specifically during your visits to limit liability? I don't, I mean, we're self-insured. So that's not really relevant to us. I'm not aware, I don't know that that's a standard price cause there really is no precedent on it, you know in terms of having to tell your insurance carrier. And then the second part of that is I don't I just treat it like a regular visit. Yeah, same here. And, you know, especially when you're starting out I always cherry picked the types of visits that I did for telemedicine anyway. So there are people that I usually had a good rapport with or they had very simple problems. I definitely don't do like really highly complex things solely virtually. And I think that's the beauty of it. I mean, you can kind of pick and choose what you do and just, you know, use your own common sense and your own judgment and your own risk tolerance. And just like Dr. Gallo, I don't say anything specifically about, you know, malpractice to them and we're self-insured as well. So it's not typically an issue. Yeah, I think, you know, it's a different world from when we had no options except to use this. And now we can kind of, you know pick the optimal cases for this. So I think we're coming up on time. I know that Donna has a few closing words here but before we get to that I just wanted to thank both of you for your insights. I learned a lot and I think this was a fantastic session. So Donna, do you want to close out here? Yeah, I'd like to give a big thanks to all of our panelists and to all the people who attended tonight. We appreciate you being here. If you're interested in CME or you would like to view the recording of this webinar please go to education.sportsmed.org, log in and click on my resources and then click the course title. You can then complete the evaluation for CME or view the recording which will be available later this week. This information will be emailed to you in 24 hours. So please don't worry about remembering it all. We thank you again for your participation and have a great rest of your night.

American Journal of Sports Medicine

webinar

telemedicine benefits

patient satisfaction

implementation tips

telemedicine utilization

patient needs

practical implementation

sports medicine

orthopedic surgery