If you think of the Covid-19 pandemic presently hovering over the world as a cloud, then a silver lining will likely be the rapid advance of telehealth, both its methods and its acceptance, by patients, health care providers, and insurance companies. In the March 2020 issue of the Journal of Hand Surgery (American), orthopedic surgeons from Pennsylvania review the current and potential applications of telemedicine in hand surgery. How timely! Many of their points are relevant to hand therapy, so here is an overview of the article.
Access and barriers: as of 2010, 78% of hand surgery patients owned a personal computer. For technology-challenged patients, family members can often provide assistance, especially if they are responsible for patient transportation. Because of licensure requirements, the healthcare provider and the patient must be in the same state.
Confidentiality: Breeches in confidentiality can occur with both audio and visual elements of telemedicine. The authors recommend use of a written informed consent form that can be completed within the application before the telehealth visit. The provider should conduct the visit in private and let the patient know if any additional people are present in the room, for instance students or other health care providers.
Physical examination: In a randomized controlled study of video-assisted orthopedic telehealth visits, the doctors rated their ability to perform a good to very good examination at 98%. Several previous studies, referenced below, have noted excellent agreement between smartphone assessment and conventional measurements for all upper extremity joints. Assessment of sensation and production of provocative nerve irritability tests would be difficult (as would joint end-point stiffness). Another study indicated that 94% of patients took adequate smartphone photos of their incisions for tele-assessment. The authors of the current review found that they could easily recognize wound complications from photographs.
Cost: One study notes that in-person orthopedic clinic visits cost 45% more than a teleconsultation when equipment costs, maintenance, and staffing were taken into consideration. More difficult to measure but equally important would be economic and time savings related to travel and loss of time from work or school.
Patient satisfaction: In a randomized controlled trial, investigators found that 64% of patients randomized to an in-office consultation and 86% of patients in the telehealth group preferred the latter for subsequent encounters.
COMMENT: Yes, the requirements for an effective hand therapy visit are different than those encountered in a hand surgery office, but OTs and PTs are creative problem solvers, and I have faith that workable solutions will evolve quickly. Here are three PowerPoint slides summarizing references regarding tele hand therapy taken from Doctors Demystify The Aging Boomers, Implications for Hand Therapists.
I suspect that years from now, practitioners will look back on the pandemic of 2020 and note that it was a turning point for the way we deal with many things, including hand therapy. A face-to-face visit might seem as archaic then as a doctor making house calls seems today. Stay safe.
More references regarding telehealth, mostly orthopedically inclinded:
Wagner, E.R., Conti Mica, M., and Shin, A.Y. Smartphone photography utilized to measure wrist range of motion. J Hand Surg Eur Vol. 2018; 43: 187–192
Zhao JZ, Blazar PE, Mora AN, Earp BE. Range of motion measurements of the fingers via smartphone photography [published online ahead of print January 28, 2019]. Hand (N Y).
Meislin, M.A., Wagner, E.R., and Shin, A.Y. A comparison of elbow range of motion measurements: smartphone-based digital photography versus goniometric measurements. J Hand Surg Am. 2016; 41: 510–555
Tofte JN, Anthony CA, Polgreen PM, et al. Postoperative care via smartphone following carpal tunnel release [published online ahead of print November 14, 2018]. J Telemed Telecare.
Harno, K., Arajärvi, E., Paavola, T., Carlson, C., and Viikinkoski, P. Clinical effectiveness and cost analysis of patient referral by videoconferencing in orthopaedics. J Telemed Telecare. 2001; 7: 219–225
Ohinmaa, A., Vuolio, S., Haukipuro, K., and Winblad, I. A cost-minimization analysis of orthopaedic consultations using videoconferencing in comparison with conventional consulting. J Telemed Telecare. 2002; 8: 283–289
Buvik, A., Bergmo, T.S., Bugge, E., Smaabrekke, A., Wilsgaard, T., and Olsen, J.A. Cost-effectiveness of telemedicine in remote orthopedic consultations: randomized controlled trial. J Med Internet Res. 2019; 21: e11330
Sathiyakumar, V., Apfeld, J.C., Obremskey, W.T., Thakore, R.V., and Sethi, M.K. Prospective randomized controlled trial using telemedicine for follow-ups in an orthopedic trauma population: a pilot study. J Orthop Trauma. 2015; 29: e139–e145