Telemedicine and plastic surgery: A review of its applications, limitations and legal pitfalls

ChatGPT Virtual Assistant for Breast Reconstruction: Assessing Preferences for a Traditional Chatbot versus a Human AI VideoBot

Background

Recent advancements in artificial intelligence (AI) have reshaped telehealth, with AI chatbots like Chat Generative Pretrained Transformer (ChatGPT) showing promise in various medical applications. ChatGPT is capable of offering basic patient education on procedures in plastic and reconstructive surgery (PRS), yet the preference between human AI VideoBots and traditional chatbots in plastic and reconstructive surgery remains unexplored.

Methods

We developed a VideoBot by integrating ChatGPT with Synthesia, a human AI avatar video platform. The VideoBot was then integrated into Tolstoy to create an interactive experience that answered four of the most asked questions related to breast reconstruction. We used Zapier to develop a ChatGPT-integrated chatbot. A 16-item survey adapted from the 2005 validated measurement of online trust by Corritore et al was distributed online to female participants via Amazon Mechanical Turk.

Results

A total of 396 responses were gathered. Participants were 18 to 64 years old. Perceptions of truthfulness, believability, content expertise, ease of use, and safety were similar between the VideoBot and chatbot. Most participants preferred the VideoBot compared with the traditional chatbot (63.5% versus 28.1%), as they found it more captivating than the text-based chatbot. Of the participants, 77% would have preferred to see someone who they identified with in terms of gender and race.

Conclusions

Both the VideoBot and text-based chatbot show comparable effectiveness, usability, and trust. Nonetheless, the VideoBot's human-like qualities enhance interactivity. Future research should explore the impact of race and gender concordance in telehealth to provide a more personalized experience for patients.

Interrater reliability of face-to-face, tele- and video-based assessments with the modified Mallet classification in brachial plexus birth injuries

The modified Mallet classification is widely used to measure motor function in brachial plexus birth injuries. The aim of the study was to investigate agreement and reliability of this classification under three different evaluation conditions: face-to-face; live tele-assessment; and delayed video-based assessment. A total of 100 children aged 4-15 years were included. Children were assessed by two raters except for live tele-assessment, which was performed by four raters. Agreement between the three different assessment conditions for the same rater were between strong and excellent for both raters 1 and 2. The interrater reliability for raters 1 and 2 under different assessment conditions was strong to excellent. Interrater reliability among the four raters was moderate to strong in tele-assessment. The modified Mallet classification may have appropriate reliability to be used in remote medical follow-up.Level of evidence: III.

The Impact of COVID-19 on the Surgical Wait Times for Plastic and Reconstructive Surgery in Ontario

Purpose: The aim of this study was to assess the impact of COVID-19 on surgical wait times for Plastic and Reconstructive Surgery (PRS) in Ontario, Canada. Methods: Ontario's wait time data has fourteen reporting categories for PRS. For each category, the mean wait time for consultation and for surgery were reported. Each category was given a priority ranging from 1 to 4. Two periods, three-month and six-month, were selected and compared to the same calendar months of the previous year. Wait times, surgical volume and percent change to the provincial wait time target were reported and compared to the baseline data. Results: This study reviewed 9563 consults and 15,000 operative cases. There was a 50% reduction in the volume of surgical consults during the study period compared to the baseline period (P = 0.004). The reduction ranged from 46% to 75% based on the reporting category. The volume of surgical cases decreased by 43% during the study period compared to the baseline period (P = 0.005). A statistically significant increase in the mean wait times for surgery was observed, involving priorities 2 to 4 (overall mean = 32 days, P ≤ 0.01). There was a 15% decrease in the percentage of surgeries meeting the provincial target times (P < 0.0001). Conclusion: COVID-19 has caused a significant reduction in the volume of cases performed in the majority of PRS categories with an overall increase in the wait times for consultation and for surgery. Recovery following COVID-19 will require strategies to address the growing volume of cases and wait times for surgery across all PRS categories.

Global Plastic Surgery: A Review of the Field and a Call for Virtual Training in Low- and Middle-Income Countries

Lack of surgical access severely harms countless populations in many low- and middle-income countries (LMICs). Many types of surgery could be fulfilled by the plastic surgeon, as populations in these areas often experience trauma, burns, cleft lip and palate, and other relevant medical issues. Plastic surgeons continue to contribute significant time and energy to global health, primarily by participating in short mission trips intended to provide many surgeries in a short time frame. These trips, while cost-effective for lack of long-term commitments, are not sustainable as they require high initial costs, often neglect to educate local physicians, and can interfere with regional systems. Education of local plastic surgeons is a key step toward creating sustainable plastic surgery interventions worldwide. Virtual platforms have grown popular and effective-particularly due to the coronavirus disease 2019 pandemic-and have shown to be beneficial in the field of plastic surgery for both diagnosis and teaching. However, there remains a large potential to create more extensive and effective virtual platforms in high-income nations geared to educate plastic surgeons in LMICs to lower costs and more sustainably provide capacity to physicians in low access areas of the world.

Thinking like a Lawyer-Human Rights and Their Association with the Plastic Surgeon of Today

Plastic surgeons are trained to perform a wide repertoire of surgeries-ranging from standard local procedures to highly specialized operations. Therefore, plastic surgeons treat a plethora of clinical presentations and address multiple patient needs. Their daily workflow is increasingly entwined with legal topics. The concrete legal interpretation falls within the remit of legal experts. However, by understanding the legal basics of selected surgical procedures, plastic surgeons may generate synergies in patient care and clinical practice. The legal situation is to be elucidated based on the German Basic Law (GBL) and the European Convention on Human Rights (ECHR). LEVEL OF EVIDENCE V: "This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ."

Telemedicine for Gender-Affirming Medical and Surgical Care: A Systematic Review and Call-to-Action

Telemedicine has facilitated the delivery of affordable and accessible health care. However, little has been discussed about its use in gender-affirming care (GAC). Telemedicine has the potential to overcome many barriers encountered by transgender individuals such as limited geographic access to care and financial constraints, which have both been exacerbated by the COVID-19 pandemic. Telemedicine may also enhance opportunities for training in gender-affirming surgery. A systematic review of the literature on telehealth and GAC was performed. Identified uses of telehealth included: an electronic teleconsultation service, a virtual peer health consultation service, and an open online course on LGBT+ rights and health care for health care providers and laypeople. As the medical and health care communities adjust to the new reality of health care, efforts should be made to effectively incorporate telemedicine into GAC.

Implementation of telemedicine in the care of patients with aortic dissection

Telemedicine uses telephone-based or any form of digital communication for remote clinical services. It has been a field of interest for the last century, with broader implementation of telemedicine technologies during the last 25 years. The COVID-19 pandemic was an impetus for the adoption of these technologies globally across all health care services, including patient care, surgical practice, and workflow. As part of the patient engagement work in the Aortic Dissection Collaborative, this topic was identified as an important patient-centered research topic. Telemedicine has been adopted increasingly in vascular surgery; however, there is little evidence on appropriate use of these technologies pertaining to treating patients with aortic dissection or aortopathy in general. This landscape review summarizes the uses of telemedicine applications pre and post pandemic in medicine and vascular surgery, with a particular focus on uses in aortopathy. Using common resource databases, we identified articles related to the history of telemedicine, its current utilization, and application to vascular surgery and/or aortopathy. We briefly review the history of telemedicine and illustrate a range of applications in medicine before the pandemic, along with its rapid uptake globally during the COVID-19 pandemic. The enablers and barriers to using telemedicine are explored, although as a whole there is satisfaction with its integration among patients and providers. To address these, we offer recommendations to address future research as it pertains to telemedicine technologies in aortic dissection.

Impact of COVID -19 Pandemic on Plastic Surgery Practices in a Tertiary Care Set Up in Southern India

Background

The COVID-19 pandemic has modified the way, plastic surgeons treat their patients. This article depicts how we as a plastic surgery department in a tertiary care setup handled the pandemic with an emphasis on infection control policy.

Methods

Data was collected from hospital records and quality assurance cell from March 21, 2020 to June 19, 2020 in terms of patient triaging, consultations, perioperative protocols, duty rosters, and academic activities. The changes on these with the impact of COVID-19 were studied with the same period of previous year.

Results

Outpatient clinics were closed and emergency consultations were reduced. Number of consultations reduced from 2591 to 75 and surgeries from 320 to 46 during the same period in 2019 and 2020 respectively. Though tele-consultations were helpful, the overall benefits were subpar. Emergency services continued with the guidelines of institute's infection control committee, such as area specific personal protective equipment, allotment of operating rooms, minimizing the crowd in operating room. There was some compromise in using accessories for microsurgical procedures. Duty rosters were designed to maintain uninterrupted services. Academic activities were continued with virtual platforms.

Conclusion

Adequate preparation of health care setup and nation-wide lockdown has helped to handle emergency cases and in reduction of trauma-surgeries respectively. Though there were obstacles for some patients in accessing health care, our institutional response made us to render maximum possible care. Advancements in virtual platform helped in consultations and academics. Delayed conservative approach was used in most cases at the expense of cosmetic compromise.

What are the medicolegal implications of virtual clinics?

Recently there has been increased interest in the use and development of virtual clinics, particularly in the wake of the COVID-19 pandemic. The need to provide clinical care, while minimising patient interaction, has led to wider adoption of both telephone and online consultations, with the potential complications and pitfalls that accompany such a change in practice. A literature search was performed using the Pubmed, MEDLINE and Embase databases, from database inception up to 25 January 2021. A total of 21 papers were identified as discussing virtual clinical assessment and the medicolegal implications. The main areas of concern included consent, misdiagnosis, lack of physical examination, privacy and patient satisfaction. This article assesses these areas and suggests techniques to address them.

Impact of COVID-19 on Aesthetic Plastic Surgery Practice in the United Kingdom

BACKGROUND

The COVID-19 pandemic has transformed the delivery of medical and surgical services globally. Subsequently, all elective and aesthetic procedures have been cancelled or deferred in accordance with government-mandated quarantine measures. The Cosmetic Surgery Governance Forum (CSGF) is a network of aesthetic plastic surgery consultants which has enabled a sharing of expertise during challenging times. We conducted a cross-sectional survey to assess the impact of the COVID-19 pandemic on aesthetic plastic surgeons and their practice in the UK.

METHODS

On 15 June 2020, 131 respondents from the CSGF and wider aesthetic plastic surgeons in the UK were invited to respond to an online survey. An anonymised questionnaire was created using SmartSurveyTM and distributed at the end of the quarantine period. Questions regarding their current scope of practice, willingness to recommence face-to-face consultations, financial loss and psychological impact were asked.

RESULTS

A total of 101 Consultant Plastic surgeons (76%) completed the questionnaire. If strict protocols and adequate personal protective equipment were available, 50-55% of respondents would consider offering non-surgical treatments as soon as the private clinic was open. Furthermore, 51% would consider procedures under general anaesthetic, whilst 89% of respondents would offer local anaesthetic only in the initial phase. Moreover, 66% reported experiencing a psychological impact and 100% of respondents reported a significant financial impact.

CONCLUSIONS

This survey aims to give an account of the current state (May-July 2020) of aesthetic plastic surgery in the UK. There is ongoing uncertainty and deliberation regarding the timing and organisational changes required for aesthetic practice to restart.

Safe clinical photography: best practice guidelines for risk management and mitigation

Clinical photography is an essential component of patient care in plastic surgery. The use of unsecured smartphone cameras, digital cameras, social media, instant messaging, and commercially available cloud-based storage devices threatens patients’ data safety. This paper Identifies potential risks of clinical photography and heightens awareness of safe clinical photography. Specifically, we evaluated existing risk-mitigation strategies globally, comparing them to industry standards in similar settings, and formulated a framework for developing a risk-mitigation plan for avoiding data breaches by identifying the safest methods of picture taking, transfer to storage, retrieval, and use, both within and outside the organization. Since threats evolve constantly, the framework must evolve too. Based on a literature search of both PubMed and the web (via Google) with key phrases and child terms (for PubMed), the risks and consequences of data breaches in individual processes in clinical photography are identified. Current clinical-photography practices are described. Lastly, we evaluate current risk mitigation strategies for clinical photography by examining guidelines from professional organizations, governmental agencies, and non-healthcare industries. Combining lessons learned from the steps above into a comprehensive framework that could contribute to national/international guidelines on safe clinical photography, we provide recommendations for best practice guidelines. It is imperative that best practice guidelines for the simple, safe, and secure capture, transfer, storage, and retrieval of clinical photographs be co-developed through cooperative efforts between providers, hospital administrators, clinical informaticians, IT governance structures, and national professional organizations. This would significantly safeguard patient data security and provide the privacy that patients deserve and expect.

Patient and surgeon experiences with video visits in plastic surgery-toward a data-informed scheduling triage tool

BACKGROUND

Coronavirus disease 2019 provided the impetus for unprecedented adoption of telemedicine. This study aimed to understand video visit adoption by plastic surgery providers; and patient and surgeon perceptions about its efficacy, value, accessibility, and long-term viability. A secondary aim was to develop the proposed 'Triage Tool for Video Visits in Plastic Surgery' to help determine visit video eligibility.

METHODS

This mixed-methods evaluation assessed provider-level scheduling data from the Division of Plastic and Reconstructive Surgery at Stanford Health Care to quantify telemedicine adoption and semi-structured phone interviews with patients (n = 20) and surgeons (n = 10) to explore stakeholder perspectives on video visits.

RESULTS

During the 13-week period after the local stay-at-home orders due to coronavirus disease 2019, 21.4% of preoperative visits and 45.5% of postoperative visits were performed via video. Video visits were considered acceptable by patients and surgeons in plastic surgery in terms of quality of care but were limited by the inability to perform a physical examination. Interviewed clinicians reported that long-term viability needs to be centered around technology (eg, connection, video quality, etc) and physical examinations. Our findings informed a proposed triage tool to determine the appropriateness of video visits for individual patients that incorporates visit type, anesthesia, case, surgeon's role, and patient characteristics.

CONCLUSION

Video technology has the potential to facilitate and improve preoperative and postoperative patient care in plastic surgery but the following components are needed: patient education on taking high-quality photos; standardized clinical guidelines for conducting video visits; and an algorithm-assisted triage tool to support scheduling.

Diagnostic concordance of telemedicine for otolaryngology, head and neck surgery in regional Australia

BACKGROUND

The use of telehealth during the COVID-19 pandemic has emerged as both a necessary and significant tool in the provision of safe and timely healthcare in the field of otolaryngology. Increased access to specialist care in a regional setting is an additional benefit. Variation in diagnostic accuracy of telehealth consultations may affect diagnosis and management. Therefore, our aim is to determine the diagnostic concordance of telemedicine for otolaryngology in an Australian regional setting with physical consultations.

METHODS

Retrospective review was conducted for all patients who received an initial telemedicine appointment over a 7-month period during the COVID-19 pandemic in regional Victoria, Australia. Data were collected regarding initial diagnosis and management from telemedicine consultations, subsequent physical appointment findings and management and intraoperative findings. Statistical analysis was performed using Prism (version 8.0, GraphPad).

RESULTS

Two hundred and fifty-nine patients were included. The most common conditions referred were for consideration of tonsillectomy with or without adenoidectomy (44.0%). Overall diagnostic concordance of the initial referrer was 63.3% and for telephone appointments, it was 81.9%. Concordance of recommended treatment plans between telephone and physical appointments was 96.9%.

CONCLUSION

Although physical appointments are an essential aspect of practice in OHNS, there are significant benefits of phone only telemedicine within the context of a global pandemic which were compounded by a regional setting. Paediatric patients were found to have the highest concordance of diagnosis and treatment plans.

Postdischarge Virtual Visits for Low-risk Surgeries: A Randomized Noninferiority Clinical Trial

Importance

Postdischarge video-based virtual visits are a growing aspect of surgical care and have dramatically increased in the setting of the coronavirus disease 2019 (COVID-19) pandemic.

Objective

To evaluate the outcomes of all-cause 30-day hospital encounter proportion among patients who have a postdischarge video-based virtual visit follow-up compared with in-person follow-up.

Design, Setting, and Participants

Randomized, active, controlled noninferiority trial in an urban setting, including patients from a small community hospital and a large, tertiary care hospital. Patients who underwent minimally invasive appendectomy or cholecystectomy by a group of surgeons who cover emergency general surgery at these 2 hospitals were included. Patients undergoing elective and nonelective procedures were included.

Interventions

Patients were randomized in a 2:1 fashion to video-based virtual visit or in-person visit.

Main Outcomes and Measures

The primary outcome is the percentage of patients with 30-day hospital encounter, and we hypothesized that there would not be a significant increase in the 30-day hospital encounter proportion for patients who receive video-based virtual postdischarge care compared with patients who receive standard (in-person) care. Hospital encounter includes emergency department visit, observation, or inpatient admission.

Results

A total of 1645 patients were screened; 289 patients were randomized to the virtual group and 143 to the in-person group. Fifty-three patients crossed over to the in-person follow-up group. The percentage of patients who had a hospital encounter was noninferior for virtual visits (12.8% vs 13.3% for in-person, Δ 0.5% with 1-sided 95% CI, -∞ to 5.2%). The amount of time patients spent with the clinician (mean of 8.4 minutes virtual vs 7.8 minutes in-person; P = .30) was not different, but the median overall postoperative visit time was 27.5 minutes shorter (95% CI, -33.5 to -24.0).

Conclusions and Relevance

Postdischarge video-based virtual visits did not increase hospital encounter proportions and provided shorter overall time commitment but equal time with the surgical team member. This information will help surgeons and patients feel more confident in using video-based virtual visits.

Trial Registration

ClinicalTrials.gov Identifier: NCT03258177.

The Doctor Will "See" You Now - Unmet Expectations of Telemedicine in Plastic Surgery

ABSTRACT

Social distancing protocols during the COVID-19 pandemic have resulted in a rapid expansion of telemedicine. It has allowed patients to save time and money on clinic visits, and physicians to communicate with patients who live remotely. Telemedicine has also been valuable in plastic surgery during initial consultations, transfers, and follow up visits. However, given the often-sensitive nature of plastic surgery, the professionalism and expectations of telemedicine have to be reviewed. A comprehensive literature search of the MEDLINE, PubMed, Google Scholar, EMBASE, and Cochrane Central Register of Controlled Trials was conducted for studies published through October 2020 with multiple search terms related to telemedicine and its use in plastic surgery. Data on the effectiveness, challenges, and professionalism of telemedicine were collected. Our review suggests that telemedicine can be an effective mode of communication in many realms of plastic surgery, including cleft care and craniofacial deformities. However, many plastic surgeons are unfamiliar with the existing platforms, and there are no clear guidelines on the most optimal platforms. Physicians have to recognize that patients might have low digital health literacy or may not even possess digital device for telemedicine. There also needs to be an overall improvement in patient education. Given that telemedicine use will continue to increase after the COVID-19 pandemic, regulations on Health Insurance Portability and Accountability Act-compliant platforms and specific guidelines on telemedicine visits, such as undressing, chaperones, privacy matters, need to be established while maintaining a professional relationship between the patient and the physician.

Telehealth: Could It Be an Avenue to Microvascular Breast Reconstruction for Patients with Geographical Barriers?

BACKGROUND

 All women undergoing a mastectomy have the right to reconstruction. However, many women do not receive reconstruction and many more are not aware of all the reconstructive options available to them. Travel distance to a center that provides reconstruction and subsequent follow-up may be a contributing factor to this disparity especially among those who seek microsurgical options. Telehealth, which provides patients with remote video consultations and decreases the travel burden, may be a solution to optimize the accessibility of breast reconstruction for these patients. The purpose of this study was to discuss the efficacy and reliability of telehealth to overcome geographic barriers.

METHODS

 Patients who received breast reconstruction and participated in video telehealth visits between February and May 2020 were included in this study. Patient demographics, comorbidities, and clinical outcomes were collected. Video telehealth encounters were reviewed to determine specific concerns and questions discussed during these encounters.

RESULTS

 A total of 235 breast reconstruction surgery patient encounters were recorded for 4 plastic surgeons who offer microsurgical breast reconstruction. Eighty-eight patients (37.4%) were seen as telehealth visits, 20 (22.7%) of which were new patient visits. Eight (9.09%) patients were microsurgical breast reconstruction candidates and 25 (28.4%) were following-up after microsurgical breast reconstruction. The majority of telehealth visits included normally healing wounds in the postoperative patient.

CONCLUSION

 Telehealth provides an avenue for premastectomy consultation, second opinion visits, and postoperative follow-up for patients who have geographical barriers precluding them from reaching plastic surgeons who perform all types of breast reconstruction.

e-Health and telemedicine implementation in facial paralysis: challenges and pitfalls

During the current Covid-19 pandemic, a lot of changes had to be made in the care of patients with facial nerve paralysis (FNP). FNP is a life-changing condition with effects on both physical (both esthetic and functional) and psychological aspects of the patient's life. Telemedicine could be a suitable alternative in the therapy for these patients, since it is often not possible to travel to outpatient clinics or to have normal face-to-face appointments with treating physicians because of pandemic restrictions. This review provides an overview of the current literature in the treatment of FNP during the pandemic and the role of telemedicine/e-Health. Secondly, we will discuss the challenges and pitfalls of implementing e-Health and telemedicine applications in clinical practice. Level of evidence: Not ratable.

Telemedicine in the Wake of the COVID-19 Pandemic: Increasing Access to Surgical Care

The COVID-19 pandemic has brought seismic shifts in healthcare delivery. The objective of this study was to examine the impact of telemedicine in the disadvantaged population.

Telemedicine Practice: Review of the Current Ethical and Legal Challenges

Background: Telemedicine involves medical practice and information and communications technology. It has been proven to be very effective for remote health care, especially in areas with poor provision of health facilities. However, implementation of these technologies is often hampered by various issues. Among these, ethical and legal concerns are some of the more complex and diverse ones. In this study, an analysis of scientific literature was carried out to identify the ethical and legal challenges of telemedicine. Materials and Methods: English literature, published between 2010 and 2019, was searched on PubMed, Scopus, and Web of Science by using keywords, including "Telemedicine," "Ethics," "Malpractice," "Telemedicine and Ethics," "Telemedicine and Informed consent," and "telemedicine and malpractice." Different types of articles were analyzed, including research articles, review articles, and qualitative studies. The abstracts were evaluated according to the selection criteria, using the Newcastle-Ottawa Scale criteria, and the final analysis led to the inclusion of 22 articles. Discussion: From the aforementioned sample, we analyzed elements that may be indicative of the efficacy of telemedicine in an adequate time frame. Ethical aspects such as informed consent, protection data, confidentiality, physician's malpractice, and liability and telemedicine regulations were considered. Conclusions: Our objective was to highlight the current status and identify what still needs to be implemented in telemedicine with respect to ethical and legal standards. Gaps emerged between current legislation, legislators, service providers, different medical services, and most importantly patient interaction with his/her data and the use of that data.

Medicolegal Aspects of Teledermatology

Teledermatology has facilitated specialist care during the crisis caused by the coronavirus disease 2019 pandemic, eliminating unnecessary office visits and the possible exposure of patients or dermatologists. However, teledermatology brings forward certain ethical and medicolegal questions. A medical consultation in which the patient is not physically present is still a medical act, to which all the usual ethical and medicolegal considerations and consequences apply. The patient's right to autonomy and privacy, confidentiality, and data protection must be guaranteed. The patient must agree to remote consultation by giving informed consent, for which a safeguard clause should be included. Well-defined practice guidelines and uniform legislation are required to preserve the highest level of safety for transferred data. Adequate training is also needed to prevent circumstances involving what might be termed «telemalpractice».

Telemedicine and Plastic and Reconstructive Surgery: Lessons from the COVID-19 Pandemic and Directions for the Future

Telemedicine holds vast amounts of potential in changing the way outpatient plastic and reconstructive surgery is practiced. Before the coronavirus disease 2019 (COVID-19) pandemic, video conferencing was used by a small fraction of medical specialties. However, since the start of the pandemic, the Centers for Medicare and Medicaid Services and the largest private health insurance companies have relaxed regulations to allow the majority of specialties to use video conferencing in lieu of in-person visits. Most importantly, video conferencing minimizes patient and physician exposure in situations such as these, and decreases risk in the immunocompromised population. Video conferencing, which has been shown to be just as safe and efficacious in treating patients, offers the ability to follow up with physicians while saving travel time and travel-related expenses. This in turn correlates with increased patient satisfaction. Video conferencing also allows physicians to expand their reach to patients in rural areas seeking advanced professional advice. Incorporating video conferencing into existing practices will make for a more efficient practice, improve patient satisfaction, and decrease cost to patients and the health care system.

Digital Otoscopy Videos Versus Composite Images: A Reader Study to Compare the Accuracy of ENT Physicians

OBJECTIVES/HYPOTHESIS

With the increasing emphasis on developing effective telemedicine approaches in Otolaryngology, this study explored whether a single composite image stitched from a digital otoscopy video provides acceptable diagnostic information to make an accurate diagnosis, as compared with that provided by the full video.

STUDY DESIGN

Diagnostic survey analysis.

METHODS

Five Ear, Nose, and Throat (ENT) physicians reviewed the same set of 78 digital otoscope eardrum videos from four eardrum conditions: normal, effusion, retraction, and tympanosclerosis, along with the composite images generated by a SelectStitch method that selectively uses video frames with computer-assisted selection, as well as a Stitch method that incorporates all the video frames. Participants provided a diagnosis for each item along with a rating of diagnostic confidence. Diagnostic accuracy for each pathology of SelectStitch was compared with accuracy when reviewing the entire video clip and when reviewing the Stitch image.

RESULTS

There were no significant differences in diagnostic accuracy for physicians reviewing SelectStitch images and full video clips, but both provided better diagnostic accuracy than Stitch images. The inter-reader agreement was moderate.

CONCLUSIONS

Equal to using full video clips, composite images of eardrums generated by SelectStitch provided sufficient information for ENTs to make the correct diagnoses for most pathologies. These findings suggest that use of a composite eardrum image may be sufficient for telemedicine approaches to ear diagnosis, eliminating the need for storage and transmission of large video files, along with future applications for improved documentation in electronic medical record systems, patient/family counseling, and clinical training.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:E1668-E1676, 2021.

Medicolegal aspects of teledermatology

Teledermatology has facilitated specialist care during the crisis caused by the coronavirus disease 2019 pandemic, eliminating unnecessary office visits and the possible exposure of patients or dermatologists. However, teledermatology brings forward certain ethical and medicolegal questions. A medical consultation in which the patient is not physically present is still a medical act, to which all the usual ethical and medicolegal considerations and consequences apply. The patient's right to autonomy and privacy, confidentiality, and data protection must be guaranteed. The patient must agree to remote consultation by giving informed consent, for which a safeguard clause should be included. Well-defined practice guidelines and uniform legislation are required to preserve the highest level of safety for transferred data. Adequate training is also needed to prevent circumstances involving what might be termed "telemalpractice."

Facial Surgery in the Era of SARS-CoV-2 and Beyond: Challenges, Considerations, and Initiatives

The SARS-CoV-2 pandemic resulted in the implementation of healthcare practice regulations and restrictions across the United States. To facilitate safe patient management practices for facial plastic and reconstructive surgeons, appropriate guidelines and recommendations should be followed. Guidelines and recommendations should include a synthesis of the best evidence available from public health authorities and respected members in the surgery community. This review contains evidence-based suggestions that prioritize the safety of healthcare professionals and patients to help guide facial and reconstructive surgeons toward safe patient management.

A Review of the Use of Telemedicine in Dermatologic Surgery

BACKGROUND

Telemedicine is an emerging field with numerous applications within medicine. Previous review articles describe its use within plastic surgery and otolaryngology but none, to the authors' knowledge, within dermatologic surgery.

OBJECTIVE

To provide a review of the applications of telemedicine within dermatologic surgery.

MATERIALS AND METHODS

A PubMed search of articles published on teledermatology was conducted in July 2018. Articles were selected based on their relevance to dermatologic surgery and reviewed for their discussion of the applications of telemedicine in surgical and cosmetic dermatology.

RESULTS

The initial search resulted in 156 articles. Eleven ultimately met inclusion criteria: 2 in referral and consultation, 5 in telepathology, 2 in intraoperative uses, and 2 in postprocedural care.

CONCLUSION

For preoperative consultation, teledermatology enables the surgeon to plan ahead and increases access to care by reducing the number of clinic visits. Telepathology has the potential to allow intraoperative consultation with a dermatopathologist to achieve accurate tumor clearance without delay. Smartglasses represent a promising technology for greater care coordination and a teaching tool. Postprocedural monitoring via text messaging provides convenient access to expert advice and early detection of postoperative complications. With increasing technologic advancements, telemedicine holds great potential to augment the dermatologic surgeon's daily practice.

Telemedicine Practices of Facial Plastic and Reconstructive Surgeons in the United States: The Effect of Novel Coronavirus-19

Introduction: The objectives of this study among facial plastic and reconstructive surgeons (FPRS), include (1) quantifying the use of telemedicine, (2) examining the impact of novel coronavirus-19 (COVID-19) on telemedicine practices, (3) highlighting the types of telemedicine employed, (4) anticipating how telemedicine will be utilized in the future, and (5) describing FPRS' attitudes and understanding of telemedicine technologies. Study Type: Cross-sectional survey. Methods: A 6-13 question survey was sent to the American Academy of Facial Plastic and Reconstructive Surgery membership. Descriptive analyses were performed, along with a Fisher's exact test. Results: We received 100 responses from a diverse group of surgeons across the United States. Overall, 91% of responders utilize telemedicine, of which 76.9% began during the COVID-19 pandemic. 33.3% of responders thought that their platforms were not Health Insurance Portability and Accountability Act compliant or were unsure. Of those that utilize telemedicine, the two biggest concerns were difficulties with physical examination (69.2%) and lack of human connection (44%). 75.8% of telemedicine utilizers plan to incorporate telemedicine into their practice moving forward. Of all responders, 71% believed that telemedicine will have a positive effect on the field of FPRS, although on univariate analysis those in practice >20 years were more likely to believe that there will be no effect or a negative effect (p = 0.014). Conclusions: The COVID-19 pandemic has accelerated the adoption of telemedicine among FPRS in the United States. The great majority of responders plan to incorporate telemedicine into their practice even after the pandemic subsides and believe that telemedicine will have a net positive effect on the field of FPRS.

A Review of Telemedicine Applications in Otorhinolaryngology: Considerations During the Coronavirus Disease of 2019 Pandemic

OBJECTIVE/HYPOTHESIS

Review the published literature of telemedicine's use within otorhinolaryngology (ORL), highlight its successful implementation, and document areas with need of future research.

STUDY DESIGN

State of the Art Review.

METHODS

Three independent, comprehensive searches for articles published on the subject of telemedicine in ORL were conducted of literature available from January 2000 to April 2020. Search terms were designed to identify studies which examined telemedicine use within ORL. Consensus among authors was used to include all relevant articles.

RESULTS

While several, small reports document clinical outcomes, patient satisfaction, and the cost of telemedicine, much of the literature on telemedicine in ORL is comprised of preliminary, proof-of-concept reports. Further research will be necessary to establish its strengths and limitations.

CONCLUSIONS

Particularly during the coronavirus disease of 2019 pandemic, telemedicine can, and should, be used within ORL practice. This review can assist in guiding providers in implementing telemedicine that has been demonstrated to be successful, and direct future research. Laryngoscope, 131:744-759, 2021.

Plastic surgery practices amidst global COVID-19 pandemic: Indian consensus

INTRODUCTION

The COVID-19 pandemic having spread globally has profound implications on medical and surgical care, which is given by the health care providers. At this time, though there are guidelines and recommendations for medical management of these patients, there is a lack of guidance on how a plastic surgeon should approach the COVID-19 suspect or infected patient who presents either in an elective or emergency setting. We aim to provide a consensus guideline based on the current recommendations of the Indian Council of Medical Research (ICMR) and the pooled experience of the major centers performing plastic and reconstructive surgery in India.

METHODS

The current guidelines and recommendations on the COVID-19 pandemic were studied from both government and nongovernment sources including ICMR. The problems in the specialty of plastic surgery were categorized into four groups and for each group, separate and individual guidelines have been formulated.

GUIDELINES

Consensus guidelines have been formulated for the specialty of Plastic and Reconstructive surgery. The patients requiring plastic surgery service have been categorized into four groups of acute, subacute, chronic, and late category. Acute cases are the ones who require intervention within 24-48 h. Subacute cases are the ones who require intervention in the next 3-10 days, while the chronic are the ones who need plastic surgery preferably within a month. The late category are the ones who need surgery within the next six months. This has been done based on the urgency and priority of surgical intervention titrated against the risks of operating and inadvertently acquiring the exposure of COVID-19-positive patients.

CONCLUSION

Currently, in the wake of COVID-19 pandemic, there are no clear guidelines specific to the vast majority of patients who come for a plastic surgery intervention. This puts the patients at risk due to the impending plastic surgery problem while at the same time it poses a risk of exposure to COVID-19 for the surgical team. Consensus guidelines are presented, to steer the plastic surgeon in his work, in the wake of COVID-19 crisis. The guidelines are based on firm scientific evidence from the reputed research and regulatory bodies and have been made in consonance with plastic surgery experts around the country, so that these practices best suit the needs of the patients, while being mindful of resource limitations and infection risks. The approach of "delayed conservative treatment" works best in the present case scenario.

How the COVID-19 pandemic changed the Plastic Surgery activity in a regional referral center in Northern Italy

The Covid 19 epidemic has modified the way that plastic surgeons can treat their patients. At our hospital all elective surgery was canceled and only the more severe cases were admitted. The outpatient department activity has been reduced also. We present the number and diagnoses of patients, treated as in- and out-patients, during seven weeks from the onset of the epidemic, comparing our activity from the lockdown of elective surgery with the numbers and diagnoses observed during the same weeks of last year. Finally we underline the importance of using telemedicine and web-based tools to transmit images of lesions that need the surgeon's evaluation, and can be used by the patient to keep in touch with a doctor during the distressing time of delay of the expected procedure.

Impact of telemedicine on diagnosis, clinical management and outcomes in rural trauma patients: A rapid review

Introduction

Rural trauma patients are at increased risk of morbidity and mortality compared to trauma patients treated in urban facilities. Factors contributing to this disparity include differences in resource availability and increased time to definitive treatment for rural patients. Telemedicine can improve the early management of these patients by enabling rural providers to consult with trauma specialists at urban centres. The purpose of this study was to assess the impact of telemedicine utilisation on the diagnosis, clinical management and outcomes of rural trauma patients.

Materials and Methods

A rapid review of the literature was performed using the concepts 'trauma', 'rural' and 'telemedicine'. Fifteen electronic databases were searched from inception to 29^th June 2018. Manual searches were also conducted in relevant systematic reviews, key journals and bibliographies of included studies.

Results

The literature search identified 187 articles, of which 8 articles were included in the review. All 8 studies reported on clinical management, while the impact of telemedicine use on diagnosis and outcomes was reported in 4 and 5 studies, respectively. Study findings suggest that the use of telemedicine may improve patient diagnosis, streamline the process of transferring patients and reduce length of stay. Use of telemedicine had minimal impact on mortality and complications in rural trauma patients.

Conclusions

The evidence identified by this rapid review suggests that telemedicine may improve the diagnosis, management and outcomes of rural trauma patients. Further research is required to validate these findings by performing large and well-designed studies in rural areas, ideally as randomised clinical trials.

Establishing a Telemedicine Program for Breast Reconstruction

Telemedicine is an application of modern technology that allows for the remote delivery of healthcare services to diagnose and treat patients. The potential patient benefits of such a program include added convenience, lowered costs, and improved access. From a practical standpoint, establishing a telemedicine program may seem daunting to the plastic surgeon; success requires not only patient and provider adoption, but also integration of new technology. Despite these challenges, breast reconstruction patients are among those who stand to benefit most from telemedicine technology, as this patient population remains vulnerable to limitations to access following an emotion-provoking breast cancer diagnosis. Geographical limitation, especially in rural areas, represents a major barrier to access. To date, the application of telemedicine in caring for breast reconstruction patients has not been described in the literature. In this article, we describe the protocol developed and implemented by our academic plastic surgery group to care for new breast reconstruction candidates and discuss the role of telemedicine in improved access to breast reconstruction care.

Innovations in the Plastic Surgery Care Pathway: Using Telemedicine for Clinical Efficiency and Patient Satisfaction

BACKGROUND

Telemedicine delivers clinical information and permits discussion between providers and patients at a distance. Postoperative visits may be a burden to patients-many of whom travel long distances and miss work opportunities. By implementing a telehealth opportunity, the authors sought to develop a process that optimizes efficiency and provides optimal patient satisfaction.

METHODS

Using quality improvement methods that have been highly effective in the business sector, we developed a testable workflow for patients in the postoperative telehealth setting. Seventy-two patients were enrolled and surveyed. A preoperative survey sought to determine travel distance, comfort with technology, access to the Internet and video-enabled devices, and the patient's interest in telehealth. A postoperative survey focused on patient satisfaction with the experience.

RESULTS

Using the Lean Six Sigma methodology, the authors developed a telehealth workflow to optimize clinical efficiency. Preoperative surveys revealed that the majority (73 percent) of patients preferred in-person follow-up visits in the clinic. However, the postoperative survey distributed after the telehealth encounter found that nearly 100 percent of patients were satisfied with the telehealth experience. Ninety-six percent of patients said that their questions were answered, and 97 percent of patients stated that they would use telehealth again in the future.

CONCLUSIONS

Telehealth encounters enable real-time clinical decision-making by providing patients and visiting nurses access to providers and decreasing patient transportation needs and wait times. Although initially hesitant to opt for a telehealth encounter in lieu of a traditional visit, the great majority of patients voiced satisfaction with the telehealth experience.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Avoiding Breach of Patient Confidentiality: Trial of a Smartphone Application That Enables Secure Clinical Photography and Communication

Background

To evaluate a smartphone application for clinical photography that prioritizes and facilitates patient security.

Methods

Ethics was obtained to trial the application Sharesmart. Calgary plastic surgeons/residents used the application for clinical photography and communication. Surveys gauging the application usability, incorporated consent process, and photograph storage/sharing were then sent to surgeons and patients.

Results

Over a 1-year trial period, 16 Calgary plastic surgeons and 24 residents used the application to photograph 84 patients. Half (56%) of the patients completed the survey. The majority of patients found the applications consent process acceptable (89%) and felt their photograph was secure (89%). Half (51%) of the surgeons/residents completed the survey and would use the application as is (67%) or with modifications (33%). The consent process was felt to be superior (73%) or equivalent (23%) to participant's prior methods and was felt to resolve issues present with current photography practices of secure transmission and storage of photographs by 100% and 95% of respondents, respectively. Perceived limitations of the application included difficulties in use with poor cellphone service or Internet, decreased speed compared to current practices, the lack of a desktop platform, video capability, and ability to transmit the photograph directly to the patient's medical record.

Conclusions

A smartphone clinical photography application addresses the risks of patient confidentiality breach present with current photography methods; broad implementation should be considered.

A pilot feasibility randomised clinical trial comparing dialkylcarbamoylchloride-coated dressings versus standard care for the primary prevention of surgical site infection

A surgical site infection (SSI) may occur in up to 30% of procedures and results in significant morbidity and mortality. We aimed to assess the feasibility of conducting a randomised controlled trial (RCT) examining the use of dialkylcarbamoylchloride (DACC)-impregnated dressings, which bind bacteria at the wound bed, in the prevention of SSI in primarily closed incisional wounds. This pilot RCT recruited patients undergoing clean or clean-contaminated vascular surgery. Participants were randomised intraoperatively on a 1:1 basis to either a DACC-coated dressing or a control dressing. Outcomes were divided into feasibility and clinical outcomes. The primary clinical outcome was SSI at 30 days (assessed using Centers for Disease Control criteria and Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of the deep tissues, Isolation of bacteria and duration of inpatient Stay scoring methods). This study recruited 144 patients in 12 months at a median rate of 10 per month. Eligibility was 73% and recruitment 60%. At 30 days, there was a 36.9% relative risk reduction in the DACC-coated arm (16.22% versus 25.71%, odds ratio 0.559, P = 0.161). The number needed to treat was 11 patients. A large-scale RCT is both achievable and desirable given the relative risk reduction shown in this study. Further work is needed to improve the study protocol and involve more centres in a full-scale RCT.

The use of teleradiology for triaging of maxillofacial trauma

PURPOSE

The aim of this study was to assess and discuss our experience with a teleradiology technique applied to facial trauma patients referred to an oral and maxillofacial surgery hub center.

MATERIALS AND METHODS

All trauma patients with maxillofacial fractures from the hospitals of Vercelli, Biella, Borgosesia, Borgomanero, Verbania, and Domodossola who were referred between July 2014 and September 2018 to the hub maxillofacial center of Novara were reviewed. The following data were recorded for each patient: sex, age, referral hospital, etiology, etiology mechanisms, site of facial fractures, date of injury, indications for surgery according to teleradiology consultation, indications for surgery following clinical maxillofacial assessment, date of eventual surgery, timing of surgery from trauma, type of surgical intervention.

RESULTS

A total of 467 patients with a total of 605 fractures were triaged and managed by the Tempore telemedicine system. The most frequent cause of maxillofacial injury was fall. The most frequently observed fracture involved the zygoma. Following remote computed tomography assessment, surgical indications were suggested in 68 patients; 223 patients were not considered suitable candidates for surgery; and 176 patients needed a clinical assessment for the establishment of definitive eventual indications for surgery. Following clinical assessment, the absence and presence of surgical indications was confirmed in all 223 and 68 patients, respectively. Within the 176 patients with "possible" surgical indications, only 27 patients were referred for surgery.

CONCLUSION

Teleradiology may be helpful for an appropriate triaging of trauma patients from peripheral hospitals for the correct referral to a maxillofacial trauma hub center.

The Aesthetic Oculoplastic Surgery Video Teleconference Consult

BACKGROUND

Skype video telemedicine consults are gaining popularity to evaluate patients from distant locations. No study has analyzed the utility of this means of patient evaluation in a cosmetic oculoplastic patient population.

OBJECTIVES

The authors sought to provide an evidence-based analysis of the utility of Skype video consults in a cosmetic oculoplastic surgery patient population with regards to patient demographics, reasons for consult, and procedural conversion rate.

METHODS

A 1-year retrospective chart review (May 2016 to May 2017) of patients who underwent aesthetic oculoplastic Skype consults from 2 authors' practices was performed. The authors analyzed patient demographics, referral source, chief complaint, location of residence, length of consult, and conversion to face-to-face consultation and intervention.

RESULTS

Seventy-nine patients (60 women and 19 men) underwent Skype evaluations. Mean age was 49 years. Sixty-four consults (81%) lasted 15 minutes or less. Referral sources included the internet (67%), another physician (19%), self-referral (7.5%), referred by former patients (4%), and social media sites (2.5%). Consultations were obtained for revision (49%), or first-time (30%) eyelid/eyebrow surgery, cosmetic ptosis surgery (6%), laser skin procedures (5%), cosmetic orbital decompression (5%), and lower eyelid fat prolapse (5%). Twenty patients (25%) followed-up with in-person consultation. Sixteen of these patients (80%) had surgical (56%) or nonsurgical (44%) interventions.

CONCLUSIONS

Skype consults are an efficient, in-office modality to increase patient flow through the office, expand patient base, and generate income. In this report, 25% of Skype contacts followed-up with formal in-person consultations, of which 80% had surgical or nonsurgical interventions.

Disseminating technology in global surgery

Background

Effective dissemination of technology in global surgery is vital to realize universal health coverage by 2030. Challenges include a lack of human resource, infrastructure and finance. Understanding these challenges, and exploring opportunities and solutions to overcome them, are essential to improve global surgical care.

Methods

This review focuses on technologies and medical devices aimed at improving surgical care and training in low- and middle-income countries. The key considerations in the development of new technologies are described, along with strategies for evaluation and wider dissemination. Notable examples of where the dissemination of a new surgical technology has achieved impact are included.

Results

Employing the principles of frugal and responsible innovation, and aligning evaluation and development to high scientific standards help overcome some of the challenges in disseminating technology in global surgery. Exemplars of effective dissemination include low-cost laparoscopes, gasless laparoscopic techniques and innovative training programmes for laparoscopic surgery; low-cost and versatile external fixation devices for fractures; the LifeBox pulse oximeter project; and the use of immersive technologies in simulation, training and surgical care delivery.

Conclusion

Core strategies to facilitate technology dissemination in global surgery include leveraging international funding, interdisciplinary collaboration involving all key stakeholders, and frugal scientific design, development and evaluation.

Bootstrapping Your Telehealth Program

Telehealth is a proven modality to better patient care, reduce health care cost, and increase provider efficiency. This article outlines the necessary steps for starting a telehealth program at a medical center or practice. A review of the current literature and health care-related laws was undertaken to identify the necessary steps and considerations for starting a telehealth program. Bootstrapping a telehealth program starts with the creation of concept and identification of need. Generation of a hotbed of support, from providers and patients, is key in gaining executive interest and idea investment. Development of a defined plan of implementation with the utilization of already available technologic assets facilitates ease of execution. Creation of a televisit platform, a patient portal for enrollment, and dedicated provider time for televisits to occur are the next steps in plan realization. Measuring results of patient satisfaction, number of visits, cost reduction, and scheduled procedures are powerful tools in support of the multifaceted expansion of a telehealth program. The authors believe that telehealth programs are critical to advancing patient care, reduction of costs, and increased productivity in the future of medicine.

Telehealth in Plastic Surgery: A Veterans Affairs Hospital Perspective

Supplemental Digital Content is available in the text.

Background:

Telemedicine is a rapidly growing tool since its invention in the 1950s. Recently, it has expanded to the field of plastic surgery. In the Connecticut VA System, there is 1 plastic surgeon at a central location for the state of Connecticut and southern Massachusetts. Our aim was to pilot a telehealth program for plastic surgery consultation within the VA to improve access to subspecialty care. We intend to discuss the value of telehealth as part of consultation services, and assess patient attitudes toward telemedicine.

Methods:

Patients in the Connecticut VA System referred for plastic surgery consultation for evaluation of nonurgent diagnoses, such as skin lesions, carpal tunnel syndrome, and chronic wounds, were invited to participate. After being appropriately consented according to Connecticut state law, patients completed a postvisit questionnaire rating their overall satisfaction, quality of interaction, and ability to communicate using a modified 10-point Likert scale. Means were calculated for numerical responses. Preference for future telehealth visits was reported as a percentage.

Results:

Forty-one of 44 eligible patients elected to participate. Of those patients, 83% (n = 34) stated they prefer telemedicine services for future visits. Patients rated overall satisfaction 9.2/10, overall quality of interaction 9.2/10, ability to communicate 9.3/10, and sound and video quality 8.6/10 and 9.0/10, respectively.

Conclusion:

Remote video telemedicine is a feasible method of plastic surgery consultation and results in high patient satisfaction. Further studies should focus on cost-effectiveness and ways to broaden the use of telehealth services in plastic surgery.

Augmented reality in dentistry: a current perspective

Augmentation reality technology offers virtual information in addition to that of the real environment and thus opens new possibilities in various fields. The medical applications of augmentation reality are generally concentrated on surgery types, including neurosurgery, laparoscopic surgery and plastic surgery. Augmentation reality technology is also widely used in medical education and training. In dentistry, oral and maxillofacial surgery is the primary area of use, where dental implant placement and orthognathic surgery are the most frequent applications. Recent technological advancements are enabling new applications of restorative dentistry, orthodontics and endodontics. This review briefly summarizes the history, definitions, features, and components of augmented reality technology and discusses its applications and future perspectives in dentistry.

Teleburn: Designing A Telemedicine Application to Improve Burn Treatment

Background

Due to the increasing rate of the burn injuries and a limited number of specialized treatment centers, providing medical advice and medical care at the point of need is necessary. The aim of the present study was to design and implement a teleburn system to enhance the quality of care for the burn patients.

Methods

This study was completed in 2016. In order to design the system, information needs assessment was conducted by using a questionnaire. The participants of this phase were five specialists, five general practitioners, and 12 nurses. The setting of the study was the burn department of a public hospital and a burn center. The prototype of the system was designed based on the findings derived from the first phase, and the usability of the system was evaluated later.

Results

The teleburn system was a web-based system with different sections for GPs/nurses and specialists. In total, 28 burn consultations were made successfully by using the system. The findings of the usability testing showed that most of the participants evaluated the system at a good level. The mean score for the specialists, general practitioners and nurses was 8.4±0.46, 7.7±0.39, and 7.5±0.51, respectively.

Conclusion

Although it was the first time in the country that the teleburn system was designed and introduced to the clinicians, they seemed to be satisfied with using the system. This system could help general practitioners and nurses to receive specialist's advice on a timely manner to improve the treatment of the burn patients. However, more research should be conducted to determine the effectiveness of using this technology in the real work environment.

Balancing the Need for Clinical Photography With Patient Privacy Issues: The Search for a Secure SmartPhone Application to Take and Store Clinical Photographs

Background

Physicians are increasingly using smartphones to take clinical photographs. This study evaluates a smartphone application for clinical photography that prioritizes and facilitates patient security.

Methods

Ethics approval was obtained to trial a smartphone clinical photography application, PicSafe Medi. Calgary plastic surgeons and residents used the application to obtain informed consent and photograph patients. Surveys gauging the application's usability, consent process, and photograph storage/sharing were then sent to surgeons and patients.

Results

Over a 6-month trial period, 15 plastic surgeons and residents used the application to photograph 86 patients. Over half of the patients (57%) completed the survey. The majority of patients (96%) were satisfied with the application's consent process, and all felt their photographs were secure. The majority (93%) of surgeons/residents completed the survey. The application was felt to overcome issues with current photography practices: inadequate consent and storage of photographs (100%), risk to patient confidentiality (92%), and unsecure photograph sharing (93%). Barriers to regular use of the application included need for cellphone service/Internet (54%), sanitary concerns due to the need for patients to sign directly on the phone (46%), inability to obtain proactive/retroactive consent (85%), and difficulty viewing photographs (80%). The majority of surgeons (85%) believe a smartphone application would be suitable for clinical patient photography, but due to its limitations, only 23% would use the trialed application.

Conclusions

A smartphone clinical photography application addresses the patient confidentiality risks of current photography methods; however, limitations of the trialed application prevent its broad implementation.

Scenario-Based Assessment of User Needs for Point-of-Care Robots

Objectives

This study aimed to derive specific user requirements and barriers in a real medical environment to define the essential elements and functions of two types of point-of-care (POC) robot: a telepresence robot as a tool for teleconsultation, and a bedside robot to provide emotional care for patients.

Methods

An analysis of user requirements was conducted; user needs were gathered and identified, and detailed, realistic scenarios were created. The prototype robots were demonstrated in physical environments for envisioning and evaluation. In all, three nurses and three clinicians participated as evaluators to observe the demonstrations and evaluate the robot systems. The evaluators were given a brief explanation of each scene and the robots' functionality. Four major functions of the teleconsultation robot were defined and tested in the demonstration. In addition, four major functions of the bedside robot were evaluated.

Results

Among the desired functions for a teleconsultation robot, medical information delivery and communication had high priority. For a bedside robot, patient support, patient monitoring, and healthcare provider support were the desired functions. The evaluators reported that the teleconsultation robot can increase support from and access to specialists and resources. They mentioned that the bedside robot can improve the quality of hospital life. Problems identified in the demonstration were those of space conflict, communication errors, and safety issues.

Conclusions

Incorporating this technology into healthcare services will enhance communication and teamwork skills across distances and thereby facilitate teamwork. However, repeated tests will be needed to evaluate and ensure improved performance.

Factors Affecting Appropriateness of Interfacility Transfer for Hand Injuries

BACKGROUND

Transfers of patients with higher acuity injuries to trauma centers have helped improve care since the enactment of Emergency Medical Treatment and Active Labor Act. However, an unintended consequence is the inappropriate transfer of patients who do not truly require handover of care.

METHODS

We retrospectively reviewed the records of all patients transferred to our level I trauma center for injuries distal to the ulnohumeral joint between April 1, 2013, and March 31, 2014; 213 patients were included. We examined the records for appropriateness of transfer based on whether the patient required the care of the receiving hospital's attending surgeon (appropriate transfer) or whether junior-level residents treated the patient alone (inappropriate transfer) and calculated odds ratios. We performed logistic regression to identify factors associated with appropriateness of transfer; these factors included specialist evaluation prior to transfer, age, insurance status, race, injury type, sex, shift time, distance traveled, and median income.

RESULTS

The risk of inappropriate transfers was 68.5% (146/213). Specialist evaluation at the referring hospital was not associated with a lower risk of inappropriate transfers (odds ratio 1.62 [95% CI: 0.48-5.34], P = .383). Only evening shift (15:01 to 23:00) was associated with inappropriate transfers. Amputations and open fractures were associated with appropriate transfers.

CONCLUSION

Second shift and type of injury (namely, amputations and open fractures) were significant factors to appropriateness of transfer. No significant association was found between specialist evaluation and appropriate transfers. Future studies may focus on finding reasons and aligning incentives to minimize inappropriate transfers and associated systems costs.