At the 2021 virtual annual American College of Surgeons Clinical Congress, current and future trends in telemedicine in surgery and surgical education were discussed by three experts: Aaron Lesher, MD, an associate professor of surgery and pediatrics at Medical University of South Carolina, in Charleston; Joe Sharma, MD, the vice chair of quality, patient safety and care innovation at Emory University, in Atlanta; and Christopher Schlachta, MD, a professor of surgery at Schulich School of Medicine and Dentistry, in Western University, London, Ontario.
After the presentations, these experts fielded questions from the co-moderators of the session, Russell K Woo, MD, a pediatric surgeon and professor of surgery at the John A. Burns School of Medicine, University of Hawaii in Honolulu, and Patricia Sylla, MD, a colorectal surgeon and professor of surgery at Mount Sinai Hospital, in New York City.
The following is a sample of the questions and answers, which have been edited for brevity.
Q Dr. Woo: Where do you see the telehealth landscape settling after the COVID-19 public health emergency ends, specifically with video visits outside of the doctor’s office? Is this something that will stay with us?
A Dr. Lesher: I think that remains to be seen. In my view, the main change to telehealth regulations during the public health emergency was lifting the originating-site restrictions. I would hope that we have come so far through this and people have seen the benefits of ambulatory video visits, particularly for rural and underserved patients, that we will be able to maintain ambulatory video visits in the home or noninstitutional setting even after the public health emergency ends.
Q Dr. Sylla: Dr. Lesher, you mentioned that we don’t have any evidence that telehealth is associated with improved clinical outcomes, and I think that will be an important factor to be able to justify the development and reimbursement of new platforms. But I recently saw an interesting podium presentation where they were talking about the issues that they have with postoperative compliance, specifically with bariatric patients not coming back for their follow-up visits. I thought, what about telehealth visit being a solution, because you might think there might be some psychological components or issues with transportation that interfere with patients coming in for visits. Do you think that telehealth modalities may help increase compliance within the surgical realm relative to in-person visits?
A Dr. Lesher: I certainly do think telehealth increases access, and there are good studies demonstrating improved compliance with medical therapy using telehealth. Early on, our telemedicine data were generally focused on usability, patient satisfaction and provider satisfaction. Surely, we are seeing little reports trickle in on things like improved compliance with postoperative visits. I also read a manuscript recently that the access to care improved so much in a foreign country that their no-show rate went to zero after they applied ambulatory video visits, so that by definition will improve outcomes. The onus is on us as the providers to provide those data and prove to the third-party payors that this is really the way that we should pivot and improve access to care, particularly for people who have impaired access.
Q Dr. Sylla: The feeling from the ACS board of governors survey was that you have improved access with telemedicine. [More than 88% of the board of governors reported being moderately satisfied or extremely satisfied using telemedicine for follow-up appointments.] However, is this among academic centers, rural centers, academic versus community centers? I haven’t seen granular feedback from these different types of practices. Can you comment on that?
A Dr. Sharma: The board of governors survey is a pretty good representation of practicing surgeons across the country, and it clearly showed that a large segment found telehealth to be useful. But it is not discrete enough for what we really need to answer. There is some early disparity data coming out with the use of telehealth. To put this in best context, we need a level of granularity. Without that level of true attribution of saying where access has been improved and where it has been limited, who it has been limited for, we are not able to answer the disparity in access issue. I think it is going to improve access for a dramatic proportion of our population. However, the ones that need it the most, are we really impacting them? I think about Atlanta, which is an inner-city population, it’s not distance that is keeping people away; it’s access. I always look at it in two ways: there are advantages and disadvantages, and we need to catalog both of them as we move forward.
Q Dr. Sylla: I’ve been really intrigued by the early data showing disparities [in access to telemedicine]. Are there any thoughts with the ACS to try to tackle this now? Now would be a good time to think about pathways to reduce disparities.
A Dr. Sharma: I think part of the mission for us as the board of governors is to do that and encourage research in this area. We are lucky that we don’t have to do the work at times. We have an amazing group of surgeons in disparity committees and access committees that can take these issues head-on. We need to ask people who are truly experts in the field to develop those surveys.
Q Dr. Woo: Do you think third-party payors are going to get to the point where they need to decrease the reimbursement for telemedicine visits, given the fact that hospitals and clinics are not going to be spending the same kind of money on infrastructure and staff and we are going to see more and more of these visits happening?
A Dr. Lesher: We have a very complicated system, where we have disparate payment strategies for different patients and different insurances. I think it would be a mistake on the part of the insurers to try to decrease reimbursement for telehealth, especially at the beginning when we really don’t understand the cost of providing the service. At the federal level, there is bipartisan support for telehealth, but then at the payor level, they are already trying to roll back reimbursement. In the strict fee-for-service reimbursement models that we live under, telemedicine has been disincentivized because of these lower reimbursement strategies. Centers that are part of a delivery network or participate in value-based payment strategies are far more incentivized to use telehealth strategies. Telemedicine is going to decrease costs on some levels, certainly to the patients but also to the hospital or providers, because of the decreased nature of using a brick-and-mortar building. This hasn’t been well studied or well measured, in my opinion.
Q Dr. Woo: As we talk about how things are going to settle out, what aspects of telelearning and teleproctoring will stay, and are there elements that will go away after the current crisis is over?
A Dr. Schlachta: At my own institution and others, by necessity, we are working very hard on trying to shift more to virtual clinical care and away from in-person care. On the education side, there are a few things we have learned. One is that there is a lot of innovation going on right now and we are trying a lot of approaches now that we probably wouldn’t have been as quick to try before. We have embraced technologies and solutions at an accelerated pace that we were certainly going to pursue in the longer run. When we think about the breadth of education, I think this is going to allow us to make rapid progress on the telementoring and teleproctoring front, and certainly on the virtual coaching side as well. As far as medical school and resident training, I don’t think we are going to see a lot of enthusiasm for permanently replacing the hands-on skill training that we do in the simulation labs. While there has been some necessity-driven clever innovations, I think the personal connectedness is missed. I expect more didactic lectures to persist on Zoom-like platforms, as a flipped classroom, prior to hands-on training.