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Innovations and Implementation of Telemedicine in Surgical Clinics Beyond COVID-19: A Narrative Review

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Introduction

The COVID-19 pandemic required many surgical clinics around the world to transition into a predominately telemedicine mode of health care delivery. Telemedicine was appropriate for this transition, as it is the “use of electronic communications and information technologies to provide clinical services when participants are at different locations.”1 Enforced distancing requirements enabled telemedicine technologies to be at the forefront of communications for clinical medicine.

Where technology was available during the pandemic outbreak, the rapid transit to virtual means was coupled with a desire and need for safe and accurate communication methods. Many initial challenges arose, such as lack of technological infrastructure, remuneration concerns, cybersecurity vulnerabilities, and technology illiteracy.2 In surgical clinics, virtual interactions that may be particularly challenging include consent, breaking bad news, and clinical examinations for surgical planning, which need to be met with adaptations to how telemedicine is delivered. Before COVID-19, there were already a number of developing innovations that have since expanded and optimized.

With many countries around the world still experiencing social distancing restrictions, telemedicine should be readily available, adaptable, and robust. Of note, there is a need for a current integrated summary of telemedicine advancements for surgical clinics to guide future planning. This article aims at collating and commenting on published evidence for how current challenges in telemedicine for surgical clinics are met by innovations currently in development. We also comment on implementation and monitoring strategies for telemedicine.

Methods

We conducted a narrative review with a systematic approach and sought to answer the question, “What innovations in telemedicine for surgical clinics have been developed to allow its implementation during and beyond the COVID-19 pandemic?” The search strategy was in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA)3 (Fig. 1). Computerized literature searches of databases were performed on August 20, 2020 and updated June 8, 2021 by using PubMed, OVID Medline, Embase, Scopus, Web of Science, and review of reference lists. Key words used included: “telemedicine”; “telehealth”; “videoconference”; “outpatient”; and “surgical clinic.”

Fig. 1.

Fig. 1. PRISMA flow diagram of included articles (3). PRISMA, preferred reporting items for systematic reviews and meta-analyses.

A combination of terms formed the search strategy (Supplementary Appendix SA1), and articles were recorded. We screened each title and abstract of the articles according to inclusion criteria (Supplementary Appendix SA2): articles in English, published between 2000 and 2021, when telemedicine research was developing, and in an outpatient surgical setting. A subgroup of articles published after 2019 were collated for COVID-19 related telemedicine.

Results

Figure 1 illustrates the PRISMA3 flow chart of the process and results. A total of 345 initial studies were identified. After removing duplicates and screening, the abstracts of 143 studies were reviewed and the full text of 73 articles was included (Supplementary Appendix SA3). The included articles summarized in Table 1 were mostly published between 2016 and 2021 (n = 57), and the authors were mainly from the United States (U.S.) (n = 33) and other Western countries (Australia [n = 8], the United Kingdom [UK] [n = 7], Norway [n = 4]). They detailed a range of surgical sub-specialties, predominately orthopedics (n = 12), general surgery (n = 9), pediatrics (n = 7), and neurosurgery (n = 7).

Table 1. General Characteristics of Identified Articles on the Use of Telemedicine in Surgical Outpatient Clinics (N = 73)
YEAR OF PUBLICATION 2000–2005 (n = 5) 2006–2010 (n = 6) 2011–2015 (n = 5) 2016–2021 (n = 57)
Country of origin Australia (n = 8)
The United Kingdom (n = 7)
Norway (n = 4)
Spain (n = 3)
Finland (n = 3)
Italy (n = 3)
Germany (n = 2)
The Netherlands (n = 2)
India (n = 2)
Canada (n = 1)
Egypt (n = 1)
France (n = 1)
Ireland (n = 1)
Saudi Arabia (n = 1)
Czech Republic (n = 1)		 Remainder from the United States
(n = 33)		    
Surgical sub-specialty Orthopedics (n = 12)
General surgery (n = 9)
Pediatrics (n = 7)
Neurosurgery (n = 7)
Urology (n = 4)		 Cardiothoracic surgery (n = 4)
Vascular surgery (n = 3)
Gynecology (n = 3)
Otolaryngology (n = 3)
Colorectal surgery (n = 2)		 Hand and upper extremity surgery (n = 1)
Maxillofacial (n = 1)
Anesthesiology (n = 1)		 A review study with no specialty focus (n = 16)
Type of journal Surgical (n = 39) Health service research (n = 19) Educational (n = 15)  
Type of article Review (n = 16) Perspective piece (n = 8) RCT (n = 12)
Observational, retro-/prospective (n = 24)
Cohort, prospective (n = 8)
Pilot (n = 4)
Case report (n = 1)		  

Forty-seven were original comparative studies, 16 were review articles, and 8 were perspective pieces that included 2 position statement articles. Thirty-one studies directly compared telemedicine with face-to-face outpatient appointments, whereas 22 articles focused on the implementation of telemedicine during the COVID-19 pandemic.

Discussion

Our results show an increased interest and the development of processes to counter new challenges. Studies were published mostly in first-world countries where technology and funding were available. Established systems are likely to continue beyond the pandemic due to the reported benefits and conveniences provided. We have grouped the reported innovations into key categories involved in consumer–provider interaction (access, provider interface, provider monitoring, consumer interface) and highlighted where new innovations are able to meet the challenges in these areas (Table 2).

Table 2. Need and Innovations in Telemedicine for Surgical Clinics
  NEED INNOVATION
Access Stable audio–visual communication technology and infrastructure 4G, 5G and Wi-Fi capabilities
High definition, narrow bandwidth devices
Smartphone and portable devices
User-friendly and secure software applications Videoconferencing regulation/approval
Integrated electronic medical records Platform integration that enables: documentation, consent, access to investigations, education, and billing
Streamlined workflow processes Telemedicine hubs and co-ordinators
Users Consumer and provider digital literacy Familiarization and education programs
Physical examination during clinical encounter Assisted examinations, virtual examination equipment, and augmented reality devices
Efficient triaging e-Consultation
Improved accessibility to providers Monitoring and self-evaluation platforms
Delivery to consumers Hub/Spoke models including international consults

Access

Access involves communication platform/s, scheduling, and administrative support required to enable the clinical interaction.

Telemedicine has evolved from singular voice communication to sophisticated mechanisms with multimedia information exchange (e.g., video conferencing), augmented reality supplementation, and biometric real-time monitoring.4 Communication platforms should ideally be clear, uninterrupted, easy to use, and capable of providing a channel for verbal and non-verbal interaction. Electronic medical records (EMR) and forward data transfer systems enable ease of access to critical information and investigations for each consult.

Communication hardware is readily accessible with the widespread availability of smartphones and computers with webcam video capabilities.5 Software advances in video conferencing include narrow data bandwidth and user-friendly interfaces (e.g., Zoom, Microsoft Teams, Google Meet).

Platforms may also be integrated with the EMR, which can directly provide scheduling information, results, and documentation all in one interface (e.g., Epic).6 Specifically, for surgical clinics, means are required for the explanation of investigations, education, consent for procedures, and review of their investigations and results. From this platform, advances include the ability to share results and diagrams/information for educational purposes,7 multi-user capabilities for multi-disciplinary consults,8–10 direct verbal translation via machine-learning software (e.g., Google Translate),11 and the integration of biometric examination components (electronic monitoring devices e.g., heart rate or blood pressure sensors)8,12,13 or virtual examinations (e.g., video-otoscopy).14

To further enhance telehealth access, health organizations are investing in streamlined telehealth workflow co-ordination.6,9,15 Telemedicine workflows can include automated processes that enable ease of access for consumers and providers. Physical telemedicine clinic hubs have been developed as hardware workspaces for telemedicine clinics.15–19 Alternatively, if workflows are adequately prepared, consultations are able to be performed at flexible times and locations (including working from home).

Increasingly, telehealth co-ordinators are employed with the specific role of workflow design, scheduling, troubleshooting, and providing education for users. Providers are paired with co-ordinators who screen and triage referral information and investigations so that the provider has all diagnostic information at hand.6 For consumers, co-ordinators can improve access so that appointments are made and confirmed via telemedicine interfaces such as messaging services or email, and consumer abilities to utilize the software are verified.6,9 Billing and follow-up may also be automated within the same workflow.6,11

Providers

Before COVID-19, providers have had a variable response to telemedicine.20,21 Barriers to uptake included unfamiliarity and poor usability, infrastructure issues, and lack of technical troubleshoot support.5,22–24 However, when embraced, providers can be the drivers for change and innovation. Flexibility and convenience of telemedicine is often reported as a key benefit, if within guidelines of telemedicine practice, particularly if working from outside the clinic environment.6,7,25

For provider education and improved digital literacy, a graded roll-out and assisted tutorials have enabled adequate transition and uptake.6,9,23 First, hospitals that have embraced telemedicine have normalized it as part of their clinic activities rather than a temporary adjunct.7 As mentioned, investment in telemedicine co-ordinators provides assistance with administrative tasks such as scheduling, troubleshooting, and billing. Co-ordinators also have an additional role in education and information technology (IT) support, and they are an important interface between telemedicine capabilities and the provider.

Second, the flexibility of telemedicine has been enhanced with the development of telemedicine “work from home” guidelines to maintain professionalism and privacy for providers when in a home environment.11 Efficiencies have also been improved by offsetting routine consultations performed by using a checklist style interview script.26–30 As many consultations may be routine reviews (e.g., symptom surveillance), a checklist of pertinent metrics can also enable the outsourcing of certain consultations to trained allied health providers. The safety profile of these methods has been investigated and confirmed as satisfactory when coupled with multidisciplinary support.16,31

Another provider concern, particularly in surgery, is the need for physical examination in preoperative planning. This can be partially overcome in a number of ways: virtual examination equipment such as electronic basic monitoring devices,8,13 video procedural equipment,14 and assisted examination via a trained health care professional.16,32 Entire virtual examinations rooms with video conferencing capabilities were developed for times when social distancing is mandated. These were further expanded with virtual ward rounds,33 where mobile video conferencing was performed assisted by allied health staff.

Augmented reality devices with point-of-view interaction have been used. One study trialed the use of virtual reality headsets worn by an allied health professional who performed the ward round, with real-time information viewed virtually by consultants.34,35 Similarly, assisted examinations can be performed by a trained health care professional or family member in real time as guided by the provider.36–39 In another version of a virtual consult, consumers attend a local community hub or primary care clinic, where a health care professional can incorporate an examination and provide a report to the specialist provider.38,40,41

An area of rapid expansion and innovation is e-consultation. This involves a virtual interaction between providers (such as a primary care provider and specialist) before and without the need for consumer interaction.10 Case reviews allow consultant providers to provide management advice to improve referral efficiency for patients in remote locations. Reported benefits include faster access to specialist advice, reduction in need for face-to-face referral visits, good provider acceptance and high adoption, adequate patient satisfaction, and general cost effectiveness due to improved efficiencies.

Concerns with e-consultation include follow-through management of the advice given, safety profile (as certain conditions maybe missed or inadequately assessed), and medicolegal aspects, particularly consent for the duty of care responsibilities.42 Remuneration models for specialists also need to be reviewed.

Before the pandemic, clinic efficiencies were noted with sub-specialist virtual review meetings, confirming that the virtual platform is equally able to permit management planning.10,43 During COVID-19, many multidisciplinary meetings (MDMs) were conducted via virtual means with reasonable effect.8,9,44 This only partially compromised communication (mainly due to trouble shooting) but benefiting convenience, scheduling, inclusion of more specialists, and ability to work remotely.8,21,44 Challenges with virtual MDMs include communication links, documentation, and remuneration.9 Overall, virtual or hybrid virtual MDM meetings are likely to remain post-pandemic.

Consumers

The consumer interface of telemedicine is continually innovating, as it adapts to changing expectations. Previously, consumers experienced a lack of access to technology (e.g., telecommunications equipment and reliable Internet) and technological illiteracy5,24,45–49 that resulted in a “digital divide.”50 However, as smartphone use and other digital media continues to proliferate in the community and its capabilities expand, consumers may engage with user-friendly and familiar application software (e.g., Facebook messenger) that facilitate high-quality telemedicine interactions.5

Although practical, the use of social media to facilitate health care interactions does entail potential cybersecurity vulnerabilities to sensitive patient information.5 Therefore, the preference may be to use secure medical applications that are still accessible via smartphones and computers, for example, MyChart application.51 In addition, the now mainstream use of videoconferencing software, such as “Zoom,” has normalized virtual transmission of information for consumers. Via the “share screen function” (displaying results and diagrams) some platforms can enhance the consumer–provider consultation and encourage patient involvement in their care.8,52 Surgical clinics have focused on educating consumers on the practicalities of implementing and using telemedicine,6,37,53 increasing its adoption irrespective of age or sensory impairment.24,54

Building on the previously discussed consumer–provider virtual interaction, DeAntonio et al. describe a “virtual home exam room” via an advanced medical tablet, to facilitate real-time, high-definition transmission and recording of patient vital signs to the clinician, while the consumer remains in their own home.13,55 This technology could be expanded to allow consumers to engage regularly with providers via a virtual hospital platform and may further be enhanced by visiting community nurses to perform practical tasks (e.g., supporting hospital in the home oncology and palliative patients).

Overall, favorability and high patient satisfaction with telemedicine use has been reported across surgical sub-specialties.31 Changing expectations are seen when surgical patients who use video conferencing in their personal life are significantly more likely to choose video consultation for follow-up.56 Outside of the consult, consumers may engage in innovative asynchronous platforms via medical mobile applications; monitoring vital signs and pain scores postoperatively in their own time for the provider to review.52

Consumers may also photograph their surgical wound for remote monitoring of progress by the provider.8,57 For long-term management, patients may engage with online-based self-monitoring platforms to evaluate the progress of their chronic conditions.48,58 A Web-based health care support tool is accessible from home and increases patient self-management and compliance.58,59 In addition, it may identify subtle changes in disease progression to enable timely preventative interventions.60 The ability for consumers to engage with health care services outside of the hospital environment via a telemedicine platform provides additional support in the community that has been shown to reduce the number of hospital presentations postoperatively.45

For the delivery of health care to consumers, particularly in rural and remote communities, telemedicine has been adopted via a “hub and spoke” design of health care delivery.18,61 Community “telemedicine hubs” have been developed for surgical patients in regional areas to engage with central tertiary centers, enabling consumers to significantly reduce their travel time and expenses.19,22,36,47,56,62–67 It is this patient population who is also most likely to benefit from convenient and accessible telemedicine25 as rural communities seek to address a growing provider shortage.48,68 Further, De Biase et al. highlight further application of telemedicine to allow for surgical consultation on an international scale, enhancing the consumer–provider interaction on a global scale.44

Implementation

Despite initial challenges, protocol development and advancing sophistication in technologies have allowed the smooth transition to online communication.31 An identified need is to develop best practices collated from the literature, to guide the successful implementation of a telemedicine program (Table 3).

Table 3. Summary of Stages of Implementation and Strategies
Establishment Approval within credentialing guidelines, regulation, costing
Technology infrastructure development
Consumer suitability and triaging protocol
Roll-out Scheduling
Education for provider and consumer
Adaptation to clinical encounter components, for example, physical examination
Evaluation Clinical outcomes and safety profile
Usability and satisfaction level
Economic viability

Approval and Regulation

Providers must ensure compliance with hospital credentialing, medical licensure, and reimbursement regulations.6,69 The telemedicine service should be verified to be within the credentialing guidelines of the clinic.6 As regulation on reimbursement for telemedicine services remains dynamic, regular updates on regulatory changes and answering frequently asked questions (FAQs) regarding billing and coding are recommended.6 Documentation of patient consent to a virtual appointment and billing, date of visit, and the duration of the consultation remain essential.9,11 The EMR software providers can also add “smart phrases” into the EMR’s lexicon to ensure efficiency and consistency with this process.6 Consent forms should be made easily available for providers and office staff to electronically send to consumers.6

Technological Infrastructure: Hardware and Software Choice

An online system must be convenient to use, multilingual,53 and tailored to departmental requirements (e.g., consumer demographics, surgical factors, accessibility, technological infrastructure).50,65 Telemedicine modalities are available via a synchronous or asynchronous platform, and clinics should initially determine the technology resources available in their practice.6 Internet bandwidth and server requirements should be determined and be capable of supporting simultaneous audio–visual consultations without interfering with administrative work. Practices may use routine consumer video applications (e.g., FaceTime, Skype, Zoom) or may select more sophisticated medical applications that interface with EMR platforms (“MDLink,” “SnapMD” etc.).6

Although advanced medical software comes with additional costs, software that is compliant with privacy act legislation addresses concerns about cybersecurity vulnerabilities.6,11,44 Moreover, EMR-linked telemedicine software may integrate with patient records for documentation and billing purposes, as well as likely have additional features including: E-prescribing, digital patient intake, and access to imaging investigations.6,11

Consumer Suitability: Triaging

Appropriate consumer selection is a key determinant for a successful telemedicine program. This may be best achieved by protocol development that is specialty specific and triages consumers with minimal ambiguity. For example, Loeb et al. created orthopedic guidelines for determining which consumers may require surgical in-person visits or may be served via telemedicine. Eligibility criteria for surgical telemedicine included: standard wound checks, range of motion checks, and standard postoperative visits; however, ineligible consumers required procedures or requirement for hands-on clinical examination, for example, trauma.6

Providers should also consider the purpose of the appointment (e.g., new, review, acute, emergency), availability of adequate investigations, allied health availability, and provision for a safety net face-to-face appointment if required.31 In addition, consumers should be screened for accessibility to the Internet, telecommunication equipment, and digital literacy.9 Key criteria for patient selection should not only center on departmental requirements, but also consider innovative solutions that plan for a remote interaction, for example, absorbable sutures37,51 or a self-removing neck drain while guided by a provider via videoconference.70

Scheduling and it Support

Administrative support is essential for protocol development that streamlines and automates workflow processes.6 Administrative staff must contact new and transitioning patients to explain the transition to telemedicine, confirm participation, provide information and instructions, assess accessibility to equipment and the internet, notify about billing details, and book an online appointment.6,9,11,38,44 Scheduling templates may remain the same as in-person visits, and appointment reminders should be sent 24 hr and 1 hr before the consult to limit non-attendance rates.37 Consumers should be scheduled to arrive 10 min before the appointment to allow a “virtual receptionist” to check their environment and equipment setup, address any technical issues, and provide educational material.6,69 Adequate IT support must be available for the provider and consumer to limit the impact of technical issues.14,23,71

Provider and Consumer Education

Informative “tip sheets” and FAQs should be made readily available to the consumer,6,37 to establish expectations about the encounter and explain how to use their devices when checking in remotely. Post-visit, the consumer should receive a consultation summary, supplementary documents, and patient education materials through an EMR application or similar.23 For the provider, learning modules and regular system practicing are important to familiarize providers with a telemedicine platform.6,9,23

Education should address: workflow scheduling, setting up the equipment, navigating the EMR system, engaging with the telecommunication software and how to best perform a remote consultation. Tip sheets and FAQs should be developed to address common troubleshooting issues, with IT support available to resolve difficulties on the spot.14,71

Physical Examination Adaptations

The physical examination has been adapted so the provider may perform a comprehensive visual examination while located remotely.9,68,72,73 Daggubati et al. presented a validated National Institutes of Health Stroke Scale (NIHSS) neurological examination via videoconference, highlighting that specific instructions, clear audio–visual connection and carer or family member assistance with the consumer, will elicit clinical outcomes.11

Further, a randomized control trial in Norway established a regional telemedicine center staffed by nurses, to perform orthopedic examinations and undertake practical tasks for the consumer (e.g., suture or plaster removal) while engaging with the clinician over videoconference.16 Appropriate patient selection should address suitability for virtual physical examination; however, if further assessment is required, a “safety net” in-person visit should be made available.69 Provider discretion is required to determine when a more detailed in-person examination is warranted.11

Evaluation

A means to evaluate a telemedicine service is essential to assess whether its implementation has been beneficial to health care delivery.20 Effectiveness of telemedicine has been evaluated in the literature via clinical outcome and safety profile, economic viability and sustainability, as well as provider and consumer satisfaction.31 An example of this, is surveys that have been used retrospectively to evaluate the telemedicine encounter. A questionnaire may be electronically sent to the consumer or provider to assess satisfaction with the consult, as well as to provide an opportunity for recommendations.6,9,23

Future Pathways

Current and future innovations in telemedicine will ensure it remains a significant component of surgical patient care. The National Health Service in the United Kingdom has begun planning for long-term strategies to virtually conduct outpatient clinics.54 The United States has seen a systemwide shift via a national strategic plan to increase accessibility to Veterans Health Administration health care using virtual formats.15 As these formats and modes of telemedicine further develop, interactivity and communication capacity will enhance virtual consumer–provider visits. Educational institutes plan to incorporate digital literacy and telemedicine as part of the curriculum for health science courses.

There is further potential in developing technologies. Jiang et al. describe the use of artificial intelligence (AI) in everyday devices, such that, “automatic surgical site infection detection and evaluation” can be made via the patient’s smartphone.74 Tanaka et al. suggest future directions in technological advancements to incorporate motion-capture imaging and remote dynamic testing.73

Both these articles expand on the potential improvement in diagnostic and follow-up capabilities.7 Surgically implanted monitoring devices with telemedicine monitoring capabilities may provide key information about the longevity of surgical implants or provide closer monitoring of internal biochemistry.

Study Strengths and Limitations

The review provides a current assessment of the challenges of telemedicine in outpatient surgical care and innovations to address this. This review was conducted via a systematic approach, including a broad range of studies from different health care systems and surgical sub-specialties. However, many of the studies were from Western countries and therefore may not be relevant for developing nations where technology, funding, and clinical context may differ. Changing regulatory frameworks and dynamic legislative agreements also pose a limitation of the study, as applicability and relevance of information may change before publication. Gray literature databases that may contain further relevant studies were excluded, and a quality analysis was not conducted.

Conclusion

The COVID-19 pandemic and subsequent social distancing restrictions mandated a shift to telemedicine for health care delivery. Many initial challenges arose, such as lack of technological infrastructure, remuneration concerns, cybersecurity vulnerabilities, and technology illiteracy.2 However, recent innovations have expanded on previous developments in this technology, to address the limitations of telemedicine and ensure its significance in health care delivery into the future.75

As telecommunications evolve and AI develops, further research is required to understand its applicability and safety profile in surgical patient consultations. As health care services continue to transition their systems to an online network, there is a significant knowledge gap in the ability of telemedicine to integrate. Access to EMR, secure data management, and effective virtual consumer–provider interactions must integrate to form future telemedicine platforms.65

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received.

Supplementary Material

Supplementary Appendix SA1

Supplementary Appendix SA2

Supplementary Appendix SA3

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