Welcome to tonight's webinar, Can You See Me Now? Optimizing Telehealth in Sports Medicine. This is a three-part webinar series from AOSSM. Tonight you can enter questions throughout the webinar by using the questions tab. Questions will be seen by faculty and answered at the end during the panel discussion. And with that, we'll go ahead and get started. Good evening, everybody. It's a great honor to help chair this webinar, three-part series, as we said, with my partner in crime, Dr. Lau, out of Duke Sports Medicine, vast experience in telehealth and telemedicine even before the pandemic made us all active players in the game of telehealth. So it's definitely, as my first slide says, a brave new world of telemedicine. Before March of 2020, very few physicians actually used telemedicine for visits. Most weren't interested, complicated regulatory landscape really ruled the roost. There's added costs, poor reimbursement, difficult for patients to negotiate it as well. Now, most are using some form of telemedicine and it runs the whole spectrum as we'll go through tonight. It's an interest of necessity for many of us. There's minimal regulatory hurdles right now. There's free to competitive pricing kind of models, and that's based on supply and demand in your certain market. And there's improving reimbursement or at least equivalent reimbursement. And the question there is, is that temporary? Is that just going to be of interest during the uptick in activity or downtick in normal activity during the pandemic, or will the insurers sort of be forced by peer pressure, by public pressure or political pressure to keep the game going? So in the next slide, we've got the COVID-19 pandemic declaration, obviously was in March, March 17th. I've written down as the one specific date. And CMS said they will pay providers to care for Medicare beneficiaries for hospital office or other visits via telehealth anywhere in the country, including patient's place of residence. So that really opened it up. No longer did patients have to go to a place where they provided telehealth on both ends. They could literally be at their desk at work. They could be at a break at their place of employment. They could be between classes at the university setting, as we know now. Nursing homes we could interface with to keep them safe in a safer bubble type environment. Hospital outpatient departments could open up to telehealth visits. We could, dieticians could get in on the game and nutritionists as well. And there's been waivers or copay reductions with no reduction in physician rates up to this point. So in our next slide, we've got the requirements. They're pretty open-ended. I mean, they're super high tech, all inclusive models. There's ones that plug into EMRs that we'll go over. There's real time video and audio interaction in almost all of them that's feasible. And it's one of the things we dictate in as a boilerplate into our notes that there was a synchronous audio and video link up. The video solution has exception for HIPAA security rules requiring a business associate agreement for technology. And that waiver is nice. It means you can actually use FaceTime on your iPhone or similar device. And HSS stated they will not audit claims to ensure a prior relationship existed, which is key. That's a key regulatory hurdle that's now overcome. And it's good for new or follow-up visits. And they've waived the penalties for HIPAA violations with providers good faith of service. And some of the big names we all know, it's no surprise, Zoom, FaceTime, as I mentioned, Doxy.me and Skype and so many others. The market is booming right now. So it behooves you to shop around and get something that either works with your EMR flawlessly or you just feel comfortable with. So the basics. Doctors, what do you need? We need a computer or a phone or similar connected device. It's great to have a camera. As orthopedic surgeons, we're very visual and we know that. We like to capture screenshots. It actually speaks a thousand words and it's better often than my clinic notes, I find. A headset, as I'm wearing now with a microphone, kind of clears the dust in the array of audio interference in the background of a busy clinic. And you can stay right where you are oftentimes and the patient still feels like they're having a private conversation appropriately. Secure platform that can manage telemedicine information is nice too. And patient access to their patient portal is in the background or real time in most situations. In fact, as mentioned, during this public health emergency now, doctors can perform telemedicine simply by using a smartphone and making a call and maybe converting it to Skype or FaceTime at their beck and call if needed. Even when talking to loved ones postoperatively in a crowded surgery center, we use a modicum of telehealth just to talk with the loved ones now because we don't want to have as many feet or footprints in the building. And we talk to them as they circle the building ready to pick their loved ones up at the pavilion entrance. So our next slide talks about whether you want to use a smartphone or computer. It's less critical. It's more of a personal preference. If you're on the move and you can see and you've got great vision, a smartphone is a great platform. For me, I need a little bigger screen nowadays. You need to access your EHR and have access to video. That's nice. And so many of the platforms now have it built in or are working on it as we speak. You can use a single desktop, a laptop with multiple screens as I have set up here in my home office. You can use two devices, one device for the EHR, so you can see to your right or left like what you need to talk about and see the lay of the land for your clinical layout. And then one to actually interface with video. And that can be a laptop, a tablet, or a mobile phone. In many EHRs, including Allscripts, Cerner for sure, and certainly Epic, and Athena, which we use here in South Texas, provide basic telemedicine functions. And they seem to be adding on apps or add-ons every week we get an update. So, in our next slide, we're going to talk about... Dr. DeBardino, that's the last slide I've got for you. Sorry about that. That is, okay. We're gonna move on. I'm gonna actually introduce my co-chairman for this great webinar, Dr. Brian Lau from the great state of North Carolina in the Duke Sports Medicine Orthopedic Program. Take it away, Brian. Well, thanks Tom for that introduction and welcome everybody and hope that everyone's safe in this difficult time. Also wanna thank our panelists for taking time to join us. So this is the first part of a three-part series on telemedicine and sports medicine. Today's focus would be kind of on the what, why, and how on what is telehealth and then how to perform a good physical exam with that and then a panel discussion. As mentioned before by Alexandra, throughout any questions that come up, feel free to put in the chat box and we'll make sure those get addressed during the panel section. So without further ado, I wanna get started and introduce Dr. Eric Strauss from NYU, an associate professor there. He's also the fellowship director there who's probably the largest, if not one of the largest programs in the country. Really well-known researcher in cartilage research. And obviously in being in New York, one of the epicenters in the US and throughout the world when this is all first started. But before that, even in the last two years, Eric has really been leading the efforts at NYU in using telemedicine. And even in the most recent AOS conference was the lead author in the highest rated paper in the practice management section on NYU's use of telemedicine in the post-operative period, which he'll talk a little about today. So Eric, take it away and teach a little bit about what is telehealth and the NYU experience. Hello, my name is Eric Strauss from NYU Langone Orthopedics. To kick off tonight's session, I'm gonna give a brief introduction to telemedicine. I wanted to thank everyone at AOSSM for including me and to all of you for tuning into tonight's event. Here are my disclosures. So the goals of this introductory talk are to define telemedicine and the varied telemedicine services that are available. Go over a brief history of telemedicine, review the benefits and challenges associated with using this technology clinically, and finally, discuss the level of acceptance and utility of telemedicine in orthopedic surgery. There are currently over 100 peer reviewed definitions of telemedicine in the literature. The most commonly utilized are the use of technology to remotely deliver clinical care, the delivery of healthcare from a remote location using integrated computer and telecommunication technology to replace in-person contact, and finally, the provision of a healthcare service to a patient from a provider who is at another location, typically involving a video connection. The specific definition of telemedicine used by the United States Centers for Medicare and Medicaid Services is the exchange of medical information from one site to another through electronic communication to improve a patient's health. Telemedicine can be classified into one of two categories depending on the nature of the encounter and the information transmitted. Synchronous telemedicine, otherwise known as real-time telemedicine, is the utilization of videoconferencing technologies to allow patient-provider interaction. Asynchronous telemedicine, or store-and-forward telemedicine, involves creating images and data which is then transmitted electronically for later review and discussion. CMS recognizes a variety of telemedicine services, including telehealth visits, which requires the use of an interactive audio and video telecommunication system to permit a real-time encounter. Virtual check-ins, which are intended for patients who already have an established relationship with a healthcare provider. Non-face-to-face electronic visits, including emails and electronic medical record communications, and finally, telephone services. The use of telemedicine in orthopedic surgery was first reported in 1996 by a group in Finland. During the last two decades, improvement in audio-visual communication technologies has led to a dramatic expansion of telemedicine utilization and acceptance. This includes more widespread availability and use of personal computing and smartphone devices, coupled with advancements in high-speed internet and teleconferencing platforms. At NYU, we started looking into how telemedicine technology could be worked into our practice a handful of years ago. We conducted a study where 250 patients undergoing outpatient sports medicine surgery were randomized to one of three communication modalities postoperatively. Patients either had no contact on the night of surgery, a telephone call, or contact through a telemedicine video call. We looked at patient HCAHPS survey responses and found that those randomized to the postoperative video call had significantly higher overall satisfaction with the care that they had received and were significantly more likely to refer their surgeon to family and friends. We concluded that day of surgery video calls were a novel and effective way of increasing patient satisfaction with their overall clinical care experience. The COVID-19 pandemic's effect on healthcare delivery had a dramatic impact on the utilization of telemedicine services in orthopedic surgery. Our group at NYU surveyed 268 orthopedic surgeons and found that while 20% had been using telemedicine in their practices prior to COVID, this increased to 85% as institutions imposed restrictions on inpatient office visits and patients were less inclined to come into the healthcare setting. There are a number of potential benefits associated with the incorporation of telemedicine into an orthopedic surgery practice. In the last few years, published studies have demonstrated that telemedicine can be cost-effective depending on the number of patient visits where it is utilized and the average travel distance to specialist care. Multiple studies have also found that telemedicine increases access to care for patients in remote locations and can lead to improved efficiency and accuracy of care. One study found that remote orthopedic surgery consultation diminished the need for in-hospital evaluation and reduced the average time for decision-making by more than 50%. With better access to care and reduced costs, progress is being made with respect to patient and clinician satisfaction with telemedicine services in orthopedic surgery. In our survey of orthopedic surgeons, more than 75% were satisfied with using telemedicine services for routine follow-up and post-operative visits. Surgeon satisfaction with new patient visits, however, was lower. While the benefits of telemedicine have been demonstrated, widespread implementation faces multiple barriers. These challenges include difficulty establishing the patient-physician relationship remotely, the startup and maintenance costs of telemedicine technology, lack of awareness, access, and technology literacy, especially among our older patients, decreased ability to perform a thorough physical examination and inability to obtain X-rays or other imaging studies at that visit, reimbursement implications, and finally, the potential for increased medical legal exposure. Through my recent experiences at NYU through the COVID-19 pandemic, I believe that telemedicine in orthopedic surgery is here to stay. Our electronic medical record system has allowed for easy incorporation of telemedicine visits during my office days, as you can see from my schedule in March, which is the height of COVID in New York City. While it required a bit of an adjustment period, telemedicine has become a regular component of my practice and will continue to do so moving forward. So to pull it all together, telemedicine has varying definitions depending on the source. Universally, telemedicine involves the use of electronic communication technology to connect the patient and their physician. Telemedicine continues to increase in utilization and acceptance as advancements and improvements in communication technologies occur. The acknowledgement of the benefits and how we overcome the challenges of telemedicine will undoubtedly influence the role that it plays in our field moving forward. So once again, thank you for tuning in to tonight's event and I look forward to interacting with you during our panel discussion. Thanks. Thanks, Eric, for that talk. I'd like to now introduce Dr. Michael Banfi who will speak on who we should be selecting for these telehealth visits. He comes to us from Cedars-Sinai Colonel Jobe Institute in California. He serves as a team physician for essentially all the LA teams, including the Dodgers, the Lakers, the Kings, and the Rams. And he also serves as the clinical director of the Sports Medicine Fellowship at Colonel Jobe. And he will be speaking on and helping us determine which patients we should select for telehealth visits. Hi, I'm Dr. Michael Banfi from the Cedars-Sinai Colonel Jobe Institute. I'd like to thank the AOSSM for allowing me to participate in the telehealth webinar. I've been tasked with discussing who are the ideal patients for telehealth. First, I'm gonna begin with some definitions. Definition of telehealth is it's patient's care that is provided at a distance utilizing information technology such as cell phones, computers, or other electronic devices. Telemedicine is a subset of telehealth, and this is the delivery of clinical care to a patient without an in-person visit, but it needs to be performed via a HIPAA-compliant platform. And this is really where our EMR systems have come to play in that they've allowed us to communicate with our patients utilizing their smartphone devices via our EMR to do this in a HIPAA-compliant way. We know that 95% of American adults own a cell phone and 77% own a cell phone. So this interconnection between the EMR and their smartphones really allows us to provide good quality telemedicine. We know that over the last several decades, there's been this rapid emergence in technological advances such as these smartphones. So this has led to improved access to care, improved cost-effectiveness, as well as improved efficacy. Now, in response to the novel coronavirus, this allows us to have a patient visit in the EMR system, to have a patient visit in the non-in-person setting when the risks of being in-person outweigh the benefits. But we know that beyond COVID-19, when all this is really behind us, because of its true efficiency, this is truly gonna have an increasing role as the new normal in orthopedic surgery. So who are the ideal telehealth patients? Are all practices the same? Well, no. So it really is going to depend upon your particular practice on which proportion of your patients are gonna be best served for telehealth visits. For example, this is my practice. I'm out in Los Angeles at the Curling Joke Orthopedic Clinic. I am a team physician for both the Los Angeles Dodgers as well as the Los Angeles Rams. And so my clinical surgical practice has a wide variety of patients. I have the high school and collegiate athletes. I have the professional athletes, but I also have the weekend warriors. I have elderly patients, and I also have the middle-aged patients. And so each of these patients are gonna have their different risks and benefits with regard to telehealth and telemedicine. And I'll go through that in some of these groups that I'll be discussing. So the elderly patient, or the patient with multiple medical comorbidities is probably the best. It's the no-brainer telehealth, telemedicine patient. We're still in the pandemic currently. And these elderly and other high-risk patients are going to be at severe risk for having a severe illness if they contract COVID-19. So being able to keep them out of the office, keeping them away from patients, even in the compliant mask environment is ideal because we know that many of their musculoskeletal issues may be going left unaddressed, simply for the fact that they're afraid to come to the office. So it provides a very safe option for them. But there are also some issues. With regard to the elderly, we have issues with regard to them being able to utilize the technology. They may not be able to turn on the volume. You have to go through that with them. They may not be able to give you a good physical exam. They may not be able to look at some of the imaging studies you're trying to show them. So having a family member there that is able to utilize these technologies is usually very important. But I think that the benefit of having the telehealth visit with them to keep them out of the office clinic is definitely worth any of those other issues that I was discussing. Another group is the follow-up patient, going over images. Frequently, we see the patient as a new patient in the office. They have some advanced imaging that is ordered for them to get that completed, but it's done elsewhere outside of your office, or it is done late in the evening so they can't follow up. It's pretty inconvenient for them sometimes to be able to do that. And frequently, you're asked to have telephone calls after hours to go over the studies with them. Now that we have telehealth, this is a very efficient way to review these studies with them. We can show these studies to them on their smartphones, go over the MRIs, go through each sequence with them, and they are very appreciative of it. Furthermore, it is going to minimize these phone calls that you're gonna have after a long surgery day or after a long clinic day. These are scheduled visits that are billable. And so it really is a win-win for both patients and your clinical practice. This is a little bit more controversial, the post-operative patient. There are some patients that really require a visit in that first and second post-op visit. Certainly if they have stitches that need to be removed, or if they have wounds that you're concerned of, or they're a patient that you have a range of motion issue. If they had a he's a capsulitis, you performed a manipulation under anesthesia, you wanna really make sure that they're progressing with physical therapy after that first post-op visit. But there also is a large cohort of patients that would certainly benefit or do not need to come in for that first post-operative visit. If you had a simple meniscectomy and you put dissolvable stitches in, you can see them via the computer, via your EMR, assess that they don't have a very large effusion. You can give them a physical therapy prescription at that point, and that will certainly minimize the contact that they need to have with you. And we know that after that first and second visits, there are plenty of patients, even in complex surgeries that are doing quite well. You can follow up with them via the EMR system in their smartphone. You can give them a new prescription for physical therapy. And it has been shown that patients actually prefer this method many a time. Now, the one thing is patient compliance. If you have a patient that you're worried about, you gotta bring them in. So I would suggest you're only doing this with your most compliant patients. But there was a randomized controlled study. This is published in JSES this year. They looked at patients that underwent rotator cuff repair, 66 patients, and randomized controlled trial separated them into two groups, telehealth group versus the inpatient office group. And they found that in the telehealth group, in the office group, there's similar pain and overall satisfaction scores. But within the telehealth group, there is less time consumed with regard to missing work, driving to the office. And of those patients that were in the telehealth group, they actually wished to continue telehealth medicine after the study was over. Another great group is someone that is seeking you as a second opinion that's already had a workup. They've already had x-rays done. They've already had a physical exam done. They've already had advanced imaging done. Now, the physical exam is a bit of an issue here. A lot of times if you are seeing someone as a second opinion, it may be something complex. You may want to lay your own hands on them. But if it's someone that you trust, such as your primary care sports medicine doctor that you work with intimately, and they've already tried all the conservative care, and this is really a surgical consult, this is actually someone that is a great telehealth or telemedicine visit, and that you can discuss with them the surgical options. You can discuss with them what other conservative things may be attempted if they've been missed. So I think that this is also another great group for potential telehealth medicine. And then finally, the traveling patient, or actually the traveling doctor in some cases is another way to utilize telemedicine. Frequently, patient care is initiated in person. It's a college student that is home for the summer or for Christmas. They went skiing, they tore their ACL, or the summer was a great time to have surgery. Then they go back to school, and frequently they're lost to follow-up, or you have to transfer care to another doctor to where they're living. And with telemedicine, particularly if in the state that they're in, if it is out of state, the physical therapy laws allow you to still send physical therapy prescriptions. You literally could take care of their entire post-operative care via telemedicine. Now, another issue is the traveling doctor. For example, currently I'm in the MLB bubble, and just this morning I had telemedicine visits where I was able to review MRIs of patients that were planning to come see me. Even had a patient that had had previous meniscal cyst strain that is now thinking of turning over to surgery. And so I was able to have a very good conversation with her, be able to communicate with my office staff, and they're able to get things rolling so that my clinic doesn't remain dormant, even though I have a PA that's back at home keeping things going. We need to still, as physicians, be on top of our clinic practice for scheduling surgeries, reviewing some of these studies of patients that personally I'm just not comfortable with my physician assistant to be doing. So in summary, telehealth has paved way into the way we practice orthopedic medicine in 2020 and beyond. Several groups of patients, as I've discussed, are ideal for telehealth visits. But remember, compliance is key. You really gotta keep in mind individual patients' candidacy for telehealth and really rely upon their individual needs. But telehealth has afforded us opportunities of improved access, continuity of care, improved cost effectiveness, improved efficiency, as well as improved safety in these high-risk patients. And as studies have shown, likely improved patient satisfaction. I'd like to just leave you with some additional information that I utilized to put together this talk. And thank you very much. I really appreciate you guys listening, and I look forward to seeing you guys all in person sometime soon. Thanks, Mike, for that talk. We will now be moving on to the next section of the webinar, in which we focus on how to navigate a virtual visit and with a focus on the physical exam. And so now I would like to introduce Dr. Matthew Preventer, who comes from the Stedman Clinic and Stedman-Philippon Research Institute, where he serves as the research director there. He continues to be a captain in the U.S. Navy, where he serves his fellow soldiers, as well as the special forces. He has been the team physician and consultant for various professional and collegiate teams throughout our country, and is one of the leading experts in shoulder and knee pathology, as well as complex surgeries and operations. And he will be speaking today about how to perform a virtual physical exam on the knee. This presentation is telehealth for the sports medicine practitioner with focus on knee exam. My name is Matthew Preventer, out of Vail, Colorado, the Stedman Clinic. My disclosures are available online and listed here and on the AAOS website. So I think we've all entered into the brave new world of telemedicine. I'm gonna talk about how we've used the ability to put it into practice, and some of our lessons learned, and then focus on some of the knee physical exam and imaging. We know that telemedicine is on the rise. It offers new technology, and it really lends itself well to orthopedics or people wanting to get back to activities, because we can use video to see what they do. Consumers increasingly say that the availability of telemedicine is a factor in choosing their providers. And in fact, my use of telemedicine, well prior to COVID-19, started really in the mid to late 90s. This was a necessity in my practice in the Navy. We had a lot of overseas, undisclosed, secret locations, or just sheer distance. And we did a lot of telemedicine to interview our patients, and we did a lot of telemedicine And we did a lot of telemedicine to interview our patients, to interact with other musculoskeletal providers, athletic trainers, physical therapists, and to provide what we thought was our best opinion and best recommendations for the patients. So we've been doing this a long time in the military, but now we have to adapt it to usual sports medicine practice. These are great for screening visits, preoperative teaching, postoperative assessment, post-op check-ins, being proactive with a patient. And I've found that patients really like it. They get the questions answered. They really feel one-on-one with the provider. It's efficient for them. It's respectful, and can really maintain the connection with the provider despite their very busy lives. Telemedicine has been around for a very long time, back to the 1940s, where radiology, a documented image, is sent 24 miles between two Pennsylvania towns. And now it's routinely done throughout the world and even out to space and the International Space Station, and certainly through the military and Department of Public Health. We have 240 military treatment hospitals and clinics within the Navy. It really provides a global direct care for network and worldwide access. And this really decreased the reliance on brick-and-mortar facilities and really brought medicine to what we call as the deck plates, or bringing it to the fleet, bringing medicine and the highest specialists to where it's needed most, our sailors that are in the fleet. New technologies such as artificial intelligence and other smart applications are really trying to help us make it easier to stay connected with our patients and to truly try to decrease the burden of paperwork. Within orthopedics, we've really tried to dovetail this into post-operative visits, surgical discussions, non-surgical discussions, image reviews, post-operative checks. And you can really keep a very reasonable patient load without sacrificing your time or patients' time. And you can continue to keep this going, even despite COVID-19, depending on where this unfolds in the next three to five years. So how do we put it into practice and then extrapolate it to, say, doing a knee exam? You really need to have a high-level bit of encryption. I would encourage you to work with your IT department to make sure that you have HIPAA-compliant software for transmitting protected personal health information. Many portals have telemedicine functions to allow secure HIPAA-compliant access. And your company can use these systems if you have a signed business associate agreement, BAA, that is HIPAA-compliant. Just an FYI, Apple Company will not sign a BAA, so FaceTime is truly not HIPAA-compliant. They just don't want the liability. However, many EMR systems, including Allscripts, Cerner, Epic, and many other EMRs provide basic telemedicine functions that are encrypted within their EMR system. Performing the history, I like to print out the previous note or operative report for reference, or have a second screen up in my office that I can reference their screen, reference their images, and be able to get all their information on the go while I'm talking to them. I usually have my advanced practitioners or medical assistants initially take the history, see how they're doing, perform exams, and certainly answer initial questions. And then you have a lot of time to be able to spend with a patient on their most meaningful questions, repeating the exam findings, joining the conversation, making sure all of their questions are answered. Lastly, it's really important to formulate a clear plan and follow-up. So what about the knee? Can we do some of these clinical exams virtually? Potentially, but it is a little bit hard to really get a true high-end ligament exam, stress exam, meniscal exam, MCL, LCL, drawer test through a video portal, but there are some tricks. In general, we perform the exam as best we can through the video. A lot of the principles of the exam are already covered, including inspection, range of motion, what the incision looks like, prior incisions, muscle, gait analysis, strength test, and you can even do more with body weight, objects, or help of a second individual to do the test actually for you. It's useful to have the patient with someone else also for better visual, although you can use forward and backward cameras on most commercially available smartphones. It's important to provide a patient-guided exam, and I sort of have a checklist that I go through and walk them through each movement, just like we would in the office, but it's a little bit different when using video. I like using different angles, and sometimes we have to coach the patient on phone and video usage, but I have to take advantage of others in their residence or possibly their place of work where they're doing the video, as long as they're comfortable with that person being there. So you can have the patient walk first. Here you can assess gait, full extension, coronal alignment. You can look at their quads, look at their calves, look at their heel strike, toe off, calf size, strength, squats. You can have them do toe raises. And looking from front and back without having anyone helping you can see a lot of information here that you can write down in the note. Here you can assess just lying on the couch or you can do it on the ground, and then you can just have a person either filming it or you can set the phone against a block or a few books. You can look at hip range of motion, knee range of motion, quads, calf size, dorsiflexion, plantar flexion of the ankle, inversion, eversion, straight leg testing. A lot of things you can document here just by good exam and inspection through the video portal. Here's another look at this, and it's really easy for the patient to actually point the phone straight down at their knee. And here you can assess the VMO really nicely, the lateralis. You can assess for effusion. You can see if the patellar tendon has good definition or if there's swelling or effusion. And here you can even stress with the heel against an object. You can push the heel, you can push the heel medial lateral, you can push the heel up, you can push the heel down. And here you can even assess for pain. And here you can also test for varus, valgus, and even anterior and posterior drawer, which you might even be able to see a shift. It's also important to review imaging with the patient. You can, ahead of time, if you do not have imaging, send a script for the patient to complete at a nearby imaging center or a nearby hospital where they can directly go to the hospital and get an imaging done. Or a nearby hospital where they can directly go to the radiology department. And then you can mail the disc or electronically upload it through secure servers. You can do new patient post-operative image review via these patient videos. And it allows for only necessary travel to clinic if needed for injection, bracing, pre-surgical visits, true final knee exam, and a true final plan, which I always certainly give caveats because there's only so much you can do on the video. But as you can see, it's quite a bit. I do like sharing my screen for real-time view of MRIs and x-rays. It's actually even better than an office review because I think they can see it better. They're on their own screen. Pre-selected images and series makes it easier and more efficient. And it's just easier with a multi-screen setup. So I have my multiple screens open if you have that ability, both on right and left screen, either with one computer or two computers, to be able to go back and forth and drag in your images and show the patient efficiently where the most important injury findings are on the x-ray and or MRI. So in conclusion, telemedicine is becoming increasingly popular. With the correct equipment, this can be a viable option for most patients. You can maintain patient load without sacrificing patient's time. And by providing a patient-guided exam where you walk through movements, walk through certain poses, positions from a gait analysis back and forth, from a squat forward-backwards, from sitting supine on a couch or on the floor, and then also looking straight down or straight up and potentially having someone there that they trust to help them video or to even test the knee in certain positions, you can walk through the patient quite a bit. Real-time image review is fantastic and can be super interactive and informative. And I really like this as another part of it. Of course, I always give a caveat that this is telehealth and we certainly need to make final decisions, especially when you're thinking about guiding treatment options based on an in-person final exam, like we all know so well. But we can certainly give the patient a lot of information from a good telehealth visit and a solid knee exam by video. Thank you very much. Thanks, Matt. I'd now like to introduce Dr. Jocelyn Wittstein, who comes from Duke University as an associate professor, and she is one of the leading experts in women's sports medicine, as well has been studying and presenting and researching the shoulder physical exam with the use of telehealth for several years now, even before COVID-19. So she is gonna be giving us some tips and insight on how to perform the shoulder physical exam using telehealth. Hi, I'm Dr. Jocelyn Wittstein, and today I'm discussing telehealth evaluation of the painful shoulder. These are my relevant disclosures. Today, we'll be discussing types of shoulder telehealth encounters that you might utilize, examination techniques, as well as accuracy of the telehealth platform for evaluating the painful shoulder. I started using shoulder telehealth in my practice about a year prior to the COVID-19 pandemic, mostly because it was apparent that there was lacking subspecialized care in rural areas, that patients preferred to travel less than 30 kilometers, and that examination for evaluation of the painful shoulder is particularly amenable to telemedicine, given the convenient location of the shoulder and the pain. So I started using telehealth in my practice about a year prior to the pandemic, and it was apparent that there was lacking subspecialized care for telemedicine, given the convenient location of the shoulder that's typically visible on the screen while you're talking to a patient. I read this article in the Wall Street Journal, and it really started my interest in telehealth. And looking back at this now, a year prior to the pandemic, some of these statements seem quite funny, so in regard to types of shoulder visits that are quite amenable to use of telehealth, the most obvious one to me early in practice was the use of MRI review and follow-up with telehealth due to the limited examination that's often needed, as you've previously seen the patient typically in clinic, and many technologies do allow for a screen share so that you can review the MRI with the patient. Other than that, postoperative care seemed like an obvious transition, particularly in follow-up of arthroscopic procedures, and this has been well-demonstrated by Cain et al in JSES recently with a study of comparison of telehealth to in-person post-op visits following rotator cuff repair, which demonstrated telehealth as a safe option that saved time for patients, as well as time off of work, and provided similar satisfaction. The trickier part, of course, is new patient shoulder evaluations that require a more thorough examination, and that's what we're gonna focus on next. Prior to administering a shoulder examination via telehealth or having an encounter via telehealth for a new shoulder patient, we recommend communicating to the patient the following needs, including a wireless connection, a mobile device or laptop, use of some sort of item like a cane, yardstick, broom handle, or other lightweight wand for some of the assisted examinations, access to a doorframe or wall, as well as a tabletop or a chair back. In my practice, the patient receives written instructions as well as a tutorial video to watch prior to the visit to help familiarize them with the examination, although the patient is coached during the examination as well as needed. Here's an example of parts of the video that patients are able to view. This is where the pain starts. Next, lower your arm down to a raised position. Place the good hand on the bad elbow and pull it towards the good shoulder. Let me know if you have any pain with the top shoulder. Many of the examinations are observational and assisted here with a wand, as you can see, for some of the equivalency of passive range of motion. Many examination findings can be observed in a single motion, such as a drop arm or painful arc. And you can see there are many modifications we make to sort of simulate a typical in-person examination that require a hands-on portion of the exam. For strength, we use resisted isometric strength testing and ask the patient to report pain as well as subjective weakness. So as you can see, there are portions of this exam that are essentially what I call no touch or observational. Some are truly observational, such as skin condition, shoulder atrophy, or presence of a Popeye deformity, whereas other portions of the exam do require some instruction but can be observed without any hands-on portion, including the painful arc, shoulder shrug with abduction, lag signs like a hornblower sign or external rotation lag sign, liftoff or belly press. And then in terms of visualizing and recording active range of motion, this can be done in a variety of mechanisms. There's of course the typical eyeball method that many of us use. Some apps allow use of a digital goniometer for more accurate measurement. And some services provide digital motion capture that can be captured with images that can be saved for a partly asynchronous exam to be followed by a more focused physical exam by a provider. So the trickier part, of course, is the hands-on portion for which we need to create modifications to make this a self-examination or what I call sort of sister examination to the typical in-person hands-on portion. As we discussed and showed images of, the passive range of motion can be captured with wand assistance for external rotation and forward flexion. The contralateral arm can be used to assess Nears, Hawkins, speeds, cross-body adduction, AC palpation, and crepitus. And strength can be assessed with subjective rating of weakness and pain with isometric resistance. This creates a set of bullet points for documentation and decision making that looks not dissimilar to a typical in-person examination. After we developed this exam technique, we studied this at Duke with the assistance of the Duke Institute for Health Innovation and wanted to look at the accuracy of telehealth examination versus in-person examination for detection of rotator cuff tears. Patients randomly underwent telehealth versus in-person examination and MRI was used as a gold standard to detect full thickness rotator cuff tears. We then assessed agreement between telehealth and clinical exam findings and looked at accuracy for diagnosis of cuff tear for the two platforms. What we found that is most accurate variables for both the in-person and telehealth examination platforms showed fair, moderate, and high agreement. More importantly, the pooled accuracy for the clinical exam versus the telehealth exam was very similar, nearly identical, and was quite similar to reported accuracy rates in the orthopedic literature for physical examination for detection of cuff tears. So the takeaway is that the accuracy for both telehealth and traditional exam is similar to reports in the orthopedic literature for detection of rotator cuff tears in this feasibility trial and that telehealth clinical-guided patient-performed self-examination appears feasible and non-inferior. Physician-guided patient self-examination can provide similar breadth of data points for documentation and will likely be useful for COVID-19 and beyond. Here are a couple of useful references. Thanks very much. Thanks, Jocelyn. Thanks, Jocelyn. Now I'd like to introduce Dr. Chad Mather, who is an associate professor at Duke University and is a leading expert on hip pathology and surgery and speaks frequently around the country and doing courses on those. In addition, he is one of the pioneers in telehealth and hip physical exam on telehealth. And so he's going to talk today about some tips and tricks that he has learned over the years in performing the hip physical exam on telehealth. I appreciate the opportunity to participate in this webinar series. And today we'll be presenting our work to develop a hip self-exam to be used in telehealth applications. I have no relevant disclosures. I do want to acknowledge my team that worked on this project, two of our trainees, one of my longtime academic partners, and two physical therapists who are experts in the hip physical exam, both developed the self-exam as well as the framework for testing it. Video visits have the potential to improve access to care, enhance triage, they reduce the cost of care, and our experience have had high patient satisfaction with greater than 50% of patients stating that a video visit was as good as their in-person visit. But in order to replicate that in-person exam, a virtual physical exam is needed. With hip conditions and FAI syndrome, we know that the recognition of this disease is increasing and as is the treatment. There's an increased focus on the role of clinical exam in the diagnosis, and there's particular interest in this given the variability in cost associated with radiographic testing. We've shown that the value in the diagnosis of FAI syndrome is driven more by the history and exam than by advanced imaging, thus making physical exam the key to diagnosis of the hip and the most difficult data to attain in the telehealth setting. So that's why we embarked on this key question of can a patient's self-exam perform as well as a physician-administered exam, or could it actually perform better? We utilized a phased approach, and we'll be reporting on phase one today. Phase one focused on the efficacy question and on the non-inferiority of the self-exam. We used a prospective case-based, case-controlled non-inferiority study. We used the STARD guidelines. We studied this in 80 patients that were seeking care for hip pain in my practice. They were randomized to perform either the standardized clinical exam, or the traditional exam, or the self-exam first. We utilized two different providers for this, and they were blinded to the results of the final diagnosis. I performed the standard clinical exam, and then my fellow administered the self-exam. Well, this is what there is, that there was no difference in accuracy. Here are the maneuvers used for the self-administered exam. We started with palpation, and here's an example of trochanteric palpation, a restricted range of motion in the supine position in both the flexion and favor position, and then in bent knee fallout. All of these being considered positive, they reproduced pain, as well as restricted visual mobility. We also looked at mobility in the seated position, range of motion there at the bottom, and then tested strength in this position, as well. We tested functional strength and balance with a single leg stance, as well as a single leg squat. And then, really, my workhorse for the virtual physical exam is a series of squat maneuvers, starting with a traditional squat, then a sumo squat, as well, and then a knock-knee squat. The knock-knee squat is essentially what replicates the FADER test. The standardized clinical exam consisted of palpation, restricted range of motion, favor, resisted hip adduction, abduction, resisted external derotation test, FADER, Thomas test, and a log roll. Reference standard, the diagnostic standard, was independent evaluation for pain with the impingement and maneuver in the presence of radiographic evidence of pincer or cam morphology. And this is taken from the description of FAI syndrome and the work agreement. We looked at sensitivity, specificity, positive and negative likelihood ratios, and then the post-test probabilities were calculated for each component, then pooled that for mean diagnostic accuracy. So, results showed that the self-exam demonstrated greater statistically significant mean diagnostic accuracy. The individual test maneuvers demonstrated wide variability, but neither the standard exam or the clinical exam, traditional exam, demonstrated significant change in post-test probability for the diagnosis of FAI syndrome. So the takeaway here is that the self-exam was non-inferior, in fact, it was slightly better, but neither of them moved the needle a whole lot. So in discussion, a patient's self-administered exam was statistically more accurate than traditional clinician-performed exam, and this is not completely surprising given that as a clinician I bring bias to my exam and that the patient does not have, and that's the origin of potential improvement in accuracy with a self-exam. As this pertains to telehealth, we now know that evaluation of the patient via telehealth is likely non-inferior to an in-person, now that we can replicate the physical exam, although this does require the phase two effectiveness to confirm. Although neither exam affected post-test probability or diagnosis significantly, this is not particularly new as found in previous systematic reviews, likely due to a large degree of heterogeneity within the FAI diagnosis, multiple subtypes, and I can't explain that low post-test probability with the pooling of the results. But I would also argue, is diagnosis even a relevant outcome, or should it be something like decision-making? For example, if the decision is the same in the treatment, that makes it less valuable to be accurate in the diagnosis. Also as we're moving stepwise through treatments, we may not need to be 100% accurate in our diagnosis at that, say, first visit or any individual visit along the way, but we do need to be accurate in what the appropriate decision is if we're moving to that telehealth setting. And lastly, how do we use this today? Well, these are basically the big five types of visits that I do video visits for, which are post-ops, the non-operative imaging follow-up, busy patients, and new patients seen both in and outside of Duke. Again, we want this to mimic an in-person appointment, so we administer it by a non-attending team member at the beginning of the visit to increase efficiency and focus primarily on palpation and range of motion in a three-way squat. We utilize it primarily for our post-ops where the exam could be changing, and then new patients referred outside of Duke where we do not have an established exam. The three types of patients generally in the middle will have a stable or established exam. In an ideal steady state, we see the patient performing a self-exam and entering those results very much via their typical MyChart intake process. So this could sit alongside their more standard patient-reported outcome questionnaires. Thanks for the opportunity to speak to you tonight. I look forward to the discussion. With that we'll begin our panel discussion if our panelists can go ahead and join Trying to work camps, thanks All right, well that that was excellent Tom de Berardino here from San Antonio I learned so much in that brief hour I got to say what's very interesting I thought I mean we talked about value and it talks about outcomes and cost This is great research going on now around the country that you heard from all four corners a lot of it out of Duke And I applaud you all and out of New York with Eric and on the west coast as well I think it's amazing that our intuition is now bearing fruit We always say in med school that 95% of our diagnoses are gleaned from the patient in a great history Now we have high-tech audio-visual Synchronous asynchronous data to add to that just to bump it up a bit and a lot of the work you just heard about really Validates the fact that you know there is value in telehealth visits where the whether it's an initial visit where the bar is lower and and that was just mentioned in Our last talk the bar for an exact diagnosis is lower. It's an entry-level exam We often you know, allow our fellows to do it or allow our Associate practitioners to do it and it's really a lot of times as we know it's to get advanced imaging You know What's the bar to get an MRI to see if you have a cuff there? the patients almost could call in and tell you my arm hurts when I abducted it's nice to get pictures and Everyone showed these great ways that they can capture the data real-time visually and document it but also do screen capture and that really adds benefit to a note when an insurer reviews a note and sees a little picture of a Resisted abduction and then that netogram with a patient struggling on their face I think there's so much value in that and I've had it Insurers and work comp people that are in the room and they say, you know, we actually see that data. So I wanted to ask Eric, what do you see? I mean, I think we see the boom in this uptick What do you think to lead off the discussion you talked a lot about? regulatory issues In this in South Texas, we keep hearing different things for insurers that the parties over on December 31st What what are you hearing? What's the lay of the land on the regulatory? Scene right now. Is this going to Travel into 2021 when hopefully the pandemics even more under control and not not in our rearview mirror But maybe in the double screen where we're actually functioning fully and we're still worrying about it doing the right things all the safety measures But now we're gonna be up against the the insurance companies So I think that's a great question that unfortunately, I don't think has a perfect answer at least right now Just because there's so many unknowns we're all you know in New York, we're bracing for potentially a second surge of kovat But to try and give you what I'm feeling is I think there's another aspect that we kind of touched on is I think people are starting to acknowledge to a greater extent the improved satisfaction that Patients have with this mode of health care delivery and I think the insurance company is gonna pick up on that They're gonna see there is a benefit to allowing this this technology-based provision of care and I'm hoping that they're gonna utilize what they're gonna get from their surveys of their patients and to see that there's there is efficacy and Extend the the basic the reimbursement for telehealth telehealth Moving forward even subsequent to our control of kovat. So I do I really do think you said it was the brave new world I think telemedicine is here to stay and I'm hopeful that the insurance companies allow us to keep it going in this direction Brian you didn't get to chime in much but you listen to these great talks, too When you think about you know, what are the driving forces? We've got the customers which are the patients. We've got the insurers We've got us. We love it. It's great for orthopedics. What about the big employers? What about the Walmart's out there? What about you know Amazon? UPS big players even little players when they have a say and how their patients or their employees are taking care of What do you think their take is on all this? Well, I think they probably like it because they can get people to see experts or from far away You know, someone's really busy close by they can get you know, the next available quicker They get their patients seen quicker. If somebody has a complex problem, they get consultations about having to you know worry about wait times and all that stuff and our experience here, I feel that a lot of times our Virtual viz can be used as a screening method to determine way whether they're not they need to make the trip over to Durham From wherever they're coming from and I think you know, probably the big players probably like that You know some of the challenges of course the regulatory parts of people crossing state lines, but you know Well these within the states or people you've had some established care with that does seem to be I think a huge benefit for it for patients and employers Right this idea limiting travel Matt I'm gonna go to you on travel a lot of people travel to Vail for fun But also to see you my man So imaging, you know, we live and die by imaging if a patient thinks I got to go see. Dr. Preventer What's the first thing we want there or you want to see it's probably imaging So, how do you see the future of maybe even preemptively having the patients upload images to a secure server? Your team gets to review them so you haven't even wasted any of your precious time as a provider But then you get to then make your team maybe Preemptively strike up the telehealth conversation with a patient, but you've kind of pre-filtered and pre-screened and you're not in clinic You're still doing things that are more useful to you. What do you think? Yeah, tell me all the above we we've had really good success with getting images ahead of time Pre screening providing patients information and frankly patients are just getting more savvy you know, they want to they want to have their images reviewed before making a commitment to You know walk two blocks to go see Eric Strauss or travel a couple hours to see me. So it's a People are just getting more people get more savvy and there's unfortunately technology is keeping up a lot of the Radiology Servers and systems. I think we have passwords to probably 10 or 15 that we have access to the patient grants access to so That's very helpful to be able to get those You know, then obviously have the old snail mail way all the way with the disk, which obviously is not ideal It's not immediate But these are these are becoming more prevalent in all of our EMRs the ability to drag and drop Dicom files to be able to decode those through an add-on viewer That's all here now and very easy to do the one issue we've run into is Ordering exams if you really haven't established a full Patient doctor relationship yet if you don't have that note and You order a test the burden guess what? It's sort of on you who ordered the test to figure it out and go through insurance Approvals and that that can be a bit of a challenge. So whether it's CT MRI Hip to ankle x-rays weight-bearing special x-rays anything you want that can be a bit of a challenge So you got to make sure you have some documentation and reason to get it so that the insurance approvals are easy but just as was pointed out here by You know all of my highly highly esteemed colleagues if you do it Well, the insurance company and the hell is going to accept it. It's not going to be a problem just document That's like a build-it-and-you-will-come scenario I think with you guys all collecting all this great data and many other places around the country and hopefully elsewhere I don't I don't know how they ignore this. I think this is like the elephant in the room and it's a good-looking elephant Mike you're in a bubble What do you see you mad? Maybe a little you probably haven't at any time because you're at you're kind of running and making stuff up as you go Literally procedure wise and protocols, but when you've got a free moment, what do you see? Right around the corner. What are we missing? What's the next hurdle in this whole enterprise of telemedicine? Oh, you know a lot of the things that we've been talking about with regard to is it going to end, you know What's not going to end is a lot of the the 90-day stuff, you know, even if all of a sudden the billers go away That that is something that I think we can take with us no matter where we are for traveling with the team We can still be doing a visit easily within that 90-day period So I think that that's one thing that we will be able to take with us You know the next hurdle I actually don't have a great answer for that you know It's probably gonna be the billing You know What I've been doing is frequently putting the the minutes for all of my communications with the patients on there and supposedly, you know That's going to equate to the level that I typically build So if I have an established patient or visit that's going to equate to 25 minutes So probably just equating that better being being better with our notes knowing specifically what we need to put on these Telemedicine visits are going to be critical going forward Yeah, I think our administrators they're getting clued in in a whole different wheelhouse about the the boilerplate so we all need to have tagged into these visits like patient agreed with verbal and written consent for a Synchronous audio and video link up and they understand the limitation, you know Those kind of things that just go at the bottom of our email signatures but they need to go in the darn note in a bigger bolder way probably because as Matt alluded to and in Jocelyn to and everyone including Brian at the beginning that there are you know, we have to admit to the patients. This isn't a perfect world This is a this is a work through. It's not a workaround. We're working through a problem We're attacking it on face and we're making the best of it. And I think we're coming up with a pretty good apple pie here Richard what do you have to say with the hip is the hip the hardest of the three big joints? What do you think you made it look easy? Yeah I think Matt's got it harder there with the knee really You know shoulders pretty straightforward and Jocelyn did a great job of creating a really detailed exam there But you know for us I get up to go back to the decision-making You know, it's really about it really about the decision-making and for for us, you know If the impingement test is negative, it's probably an extra articular problem And it's positive, you know, that's it's a that's a fairly sensitive test and move down that route. So You know the later later things and what we evaluate are their proximal muscle control, which is very well Evaluated with single leg activity. So now I think it's actually pretty straightforward for us. You made it look easy I mean that was every one of you really went through a great detail to be a great Educational archive for everyone to plug into later and we're going to be able to teach fellows and residents and even our partners They just watch the video Brian I'm not sure how much time we have to run with here Any other closing thoughts from you as our leader? Yeah, I mean there was a few questions one I think for Matt in terms of what Shao just talking about in terms of the physical exam for the knee Is there like a certain one of those exams that you feel like is that screening method for decision-making to? Come to see you or get an MRI imaging and then have you ever had that? Second person in the visit try to do the ligaments exam for you Have you tried to talk doing a ligaments exam for you? I don't know Yeah Yeah, Brian, you know great great questions the the the ligament exam can be a challenge But you know, it's what's pretty good is a good gait analysis. You look at your varus valgus thrust. First of all The second thing is you can actually have the patient do one almost dynamically so you have to get them out of full extension to get the MCL and LCL really tested the amount of times the MCL is Off in full extension the LCL often in full extension is very minimal So you try to get them to flex a little bit and then you know If you can look straight on you can have them see how much they can put valgus or various stress Then you compare it to the other side Yes, sometimes you get on plant then plant the tibia and see how the femur shifts forward and forward and backward But again, a lot of this comes down to you know, just a really great history as well, too So there are a lot of tricks and things you can find or you can have them put their finger on the Centermedial joint line move it back a little bit. Nope higher a little bit lower right there Okay, bend your knee do a squat with that. Does that hurt? Oh, yeah, I just felt a little pop. Okay well, that's possibly a pretty good McMurray sign there, so You know, you could put it down again. You have a caveat. This is telehealth and You have to be a little bit careful But it's a really it's a nice way to get the ball rolling and if you have enough with a great history of Concordance of exam with the history and their complaints then you have the ability to put down some diagnostic codes What they've tried what they've done and to beat up insurance to try to get an MRI It's not it's really helpful. I mean, I think you know, you know documenting for the insurance companies is important, too Kind of leads into Mike for you and your deal for a lot of professional athletes. What about documenting for the agents? How are they taking on to? You know telehealth and seeing you and doing kind of that screening. How's that been? Well, I mean they obviously love it traditionally what we've been doing, you know As you know is is conference calls, you know with the the player and the agent and they love that You know I think that the issue though with telehealth right now with the players is they need to be in our EMR system So currently for me with epic I need to have them have a chart and then they can log in through their portal And so that that's that's how I've been able to do it here in LA for some reason We don't have the zoom technology that you guys have or even the FaceTime ability to do it. So You were currently with regard to the athletes that are in different states or or even you know If they're on our team, but they want to have a communication with the agent. It's so usually via telephone Okay, gotcha And Eric you had mentioned when your slides that at the time there was like 75% of your visits or new patients Is that still you guys still using for 75% new patients or you know, has that changed since we've gotten more experience? so yeah, I chose a representative shortened schedule like literally right at the peak of the pandemic when when Patients were just not interested in coming into the hospital setting and we were actually really restrictive So that what you saw that was like 75 80 percent of the schedule was telehealth Now I would say it's more like 10 to 15 percent of a busy office day And I thought you know my rationale for who to see is right along the lines what Mike? Outlined in his talk, which I thought was great a lot of you know, range of motion checks the routine follow-ups It's simple post-op checks The screening new patient visits, so I would say it's about 10 to 15 percent After speaking with the Berardino, I'm going to try and utilize I'm gonna try to fill my gaps like in between cases what I'm waiting I'm gonna be trying to use telemedicine visits whenever to optimize my time But it's definitely it's definitely an active part of my practice and will continue to be so And I want to make sure we get Johnson's thoughts here, I know you had a little bit in it troubles but That physical exam is really was really thorough and you've done a really good study showing how to use it I guess one of the questions of that thoroughness is and having the coach people through it How much time does that take does that feel like that is a challenge in getting? Maybe an order population as Mike had mentioned may be an ideal for if it could also be a challenge Yeah You know, I don't make everyone do every maneuver and in many people you can sidestep a ton of them Obviously, you're not gonna need to do like lag signs if someone can do active motion so Certainly, you can focus the exam. You don't have to do every range of motion if you feel that you can rule out stiffness It's just a couple. So Having them watch the video definitely shortens it. It does take a little bit longer than a typical in-person exam because you have to educate the patient about the process and I think that That will be the benefit to partly asynchronous exams if you can get some range of motion recorded some pictures captured and then you go in and do your focused exam such that you're still doing a You're doing the synchronous exam. It's not asynchronous, but you shorten the time of the entire exam by capturing more data points. Also asynchronously That's good And then I know probably run a little bit over time, but you know, we're obviously all early adopters You know, we're all people who believe in the technology and maybe for those who are still skeptical Maybe each of the panelists can mention, you know, what keeps them doing it? Is it because the patients are happy is it because you're expanding your practice is it because you know What are the reasons why you're doing it and why others should do it? And maybe we start with Eric. I Really think the patients enjoy it. They they appreciate the benefits of a telehealth visit. It's making my life easier And basically I'm able to you know, I'm basically able to accomplish a lot of goals. So I like I'm all in And then Mike maybe follow you wait, what are you still doing in why should others do it I Agree it's patients do really appreciate it and more than a phone call I think in the ability to really review the images with them, you know real-time is nice and it is quite efficient I still have not found a way to do it during clinic though and try to try and fill in those nooks and crannies Everything just gets way too hectic for me. So I've been more reserved to doing it You know first thing in the morning I bang a few out maybe a couple at lunchtime or if I'm doing some kind of traveling or something like that So I'm just trying to use it to be as efficient as possible Yes And what about what about you Matt with your experience over there in Vail? Yeah, you know Brian's been interesting it's honestly it's it's I Didn't even know it but it was part of the fabric of you know, my Navy life and then we had this covert thing I was like, yeah sure telehealth. No problem you know, we we actually had a whole secure telehealth center in our Navy Hospital in San Diego where we Go and you get called over there and be on call and have to Two three times a day if you're on call go over there and do telehealth visits It was it was really cool and this goes back to the 90s so this has been part of the fabric of my life for a long time and then just trying to extrapolate it to insurance to Imaging to get any MRIs we've talked about making sure the document documentation is as good as we can be This is this is gonna be a long time part of my practice. I try to weave To Michael's point. I try to weave Appointments in during my day and actually put them on the schedule and they're actually coded as telehealth You can certainly do that, but it can you know, you can't get a little bit behind You have to watch happy mindful of it I usually have my MA or my PA check in with him first I get going and then I can get right into it, you know, five ten minutes later So there's a lot of ways to do it and be effective. What I'm finding is the patients really like it Do I have to come back? No, I just do a telehealth. You're like two weeks from a knee scopes I don't want to I don't want to come back. Yes. I'll just I'll just check in video like that's that's fine. So There's a way to weave it in and make it efficient. I think it's it's here to stay So I think it's coming upon us to help help lead the way Yeah. Yeah, I find that especially those knee scopes they come back and they have to travel a long way you feel obligated to talk to them for longer, but if it's a telehealth visit, you're like, well, you know, you got on real quick, I can sort of make this a little bit quicker. But how about Jocelyn, what's your, you know, why are you doing it and why should others continue doing it or pick it up? Yeah, I think for the patients that like this, it's, there are ones who like this, there are ones who don't. So we're gonna maximize all of our patient satisfactions by not forcing people to do telehealth, but if they want that option, they have it. And those who want it really want it. And to Chad's point, I do feel like I'm making similar decisions based on initial telehealth examinations as I am in person. So I don't think that they're having an inferior experience or outcome. And if it makes them happy, that's good. And then we'll finish off of Chad here, because I know we're running out of time, but you've been doing this the longest and you've been advocating this since I can remember. So what's the parting words here and why we should all have listened to you years ago? Well, I do feel like it's part of my role to experiment with these things. And I think that's one of the reasons we all need to do this is for discovery, because we'll find things that we didn't know before, like how strong a preference patients have for video, like Eric should, or another study that we didn't get to see the Academy this year, which in the shoulder out of Rothman, but that showed the preference that patients have after they experienced a telehealth visit for telehealth is hugely higher. And those are all things we wouldn't have otherwise known. And I think we wanna use COVID as our springboard to discovery of telehealth. And it's gonna be up to people like us and really the people listening to this webinar to do that. The other reason though is that I can't underscore enough how valuable it is for the patient. I mean, that's who telehealth creates value for. And that's ultimately what we all wanna be doing is creating value for the patient. 57% of patients in our initial series said that it was as good or better than an in-person visit. And given the amount of time savings and loss from work from a video visit, I would argue that it is our responsibility to do telehealth and deliver that to the right patients as Justin said. Well, thanks everyone for joining and thanks to the panelists for taking their time out, putting the presentation together and joining us today. Next week, we go to part two where we talk about kind of the medical legal aspects of things and how to stay out of trouble for those. So again, appreciate everyone's time and everyone have a good night and stay safe. All right, have a nice night. Thanks guys. Thank you.

telehealth

painful shoulder

initial evaluation

follow-up visits

physical exam techniques

range of motion

rotator cuff tears

hip examinations

improved access to care

patient self-exams

screening method