Adaptation of the Foot and Ankle Physical Exam for Telehealth

Comparison of Endocrinologists' Physical Examination Documentation for In-person vs Video Telehealth Diabetes Visits

Objective

Outpatient diabetes mellitus (DM) care over video telehealth (TH) requires modifications to how endocrinologists complete physical examinations (PEs). But there is little guidance on what PE components to include, which may incur wide variation in practice. We compared endocrinologists' documentation of DM PE components for in-person (IP) vs TH visits.

Methods

Retrospective chart review of 200 notes for new patients with DM from 10 endocrinologists (10 IP and 10 TH visits each) in the Veterans Health Administration between April 1, 2020, and April 1, 2022. Notes were scored from 0 to 10 based on documentation of 10 standard PE components. We compared mean PE scores for IP vs TH across all clinicians using mixed effects models. Independent samples t-tests were used to compare both mean PE scores within clinician and mean scores for each PE component across clinicians for IP vs TH. We described virtual care-specific and foot assessment techniques.

Results

The overall mean (SE) PE score was higher for IP vs TH (8.3 [0.5] vs 2.2 [0.5]; P < .001). Every endocrinologist had higher PE scores for IP vs TH. Every PE component was more commonly documented for IP vs TH. Virtual care-specific techniques and foot assessment were rare.

Conclusions

Our study quantifies the degree to which Pes for TH were attenuated among a sample of endocrinologists, raising a flag that process improvements and research are needed for virtual Pes. Organizational support and training could help increase PE completion via TH. Research should examine reliability and accuracy of virtual PE, its value to clinical decision-making, and its impact on clinical outcomes.

Unlocking Opportunities for Innovation and Digitization of Musculoskeletal Care Delivery

Telemedicine is an established method of providing health care through digital mediums and has recently gained much attention within the field of orthopaedic surgery because of the social and biologic pressures imposed by COVID-19. However, a more diverse and all-encompassing concept of healthcare digitalization, deemed Telehealth , has emerged simultaneously because both healthcare providers and industries have recognized the potential efficacy and breath of applications possible with the digitalization of health care. Telehealth is a distinct concept compared with telemedicine and can be conceptualized as an umbrella term which not only encompasses telemedicine, but several digital means of healthcare services, including remote patient monitoring and physical therapy. The purpose of the current work was to comprehensively introduce the various applications of Telehealth, their relevance in the current healthcare infrastructure, and future implications for orthopaedic surgery through an evidence-based discussion and commentary.

Age and socioeconomic status affect access to telemedicine at an urban level 1 trauma center

Objectives:

Despite clinical and economic advantages, routine utilization of telemedicine remains uncommon. The purpose of this study was to examine potential disparities in access and utilization of telehealth services during the rapid transition to virtual clinic during the coronavirus pandemic.

Design:

Retrospective chart review.

Setting:

Outpatient visits (in-person, telephone, virtual—Doxy.me) over a 7-week period at a Level I Trauma Center orthopaedic clinic.

Intervention:

Virtual visits utilizing the Doxy.me platform.

Main Outcome Measures:

Accessing at least 1 virtual visit (“Virtual”) or having telephone or in-person visits only (“No virtual”).

Methods:

All outpatient visits (in-person, telephone, virtual) during a 7-week period were tracked. At the end of the 7-week period, the electronic medical record was queried for each of the 641 patients who had a visit during this period for the following variables: gender, ethnicity, race, age, payer source, home zip code. Data were analyzed for both the total number of visits (n = 785) and the total number of unique patients (n = 641). Patients were identified as accessing at least 1 virtual visit (“Virtual”) or having telephone or in-person visits only (“No virtual”).

Results:

Weekly totals demonstrated a rapid increase from 0 to greater than 50% virtual visits by the third week of quarantine with sustained high rates of virtual visits throughout the study period. Hispanic and Black/African American patients were able to access virtual care at similar rates to White/Caucasian patients. Patients of ages 65 to 74 and 75+ accessed virtual care at lower rates than patients ≤64 (P = .003). No difference was found in rates of virtual care between payer sources. A statistically significant difference was found between patients from different zip codes (P = .028).

Conclusion:

A rapid transition to virtual clinic can be performed at a level 1 trauma center, and high rates of virtual visits can be maintained. However, disparities in access exist and need to be addressed.

The Telemedicine-Based Pediatric Examination of the Back and Lower Limbs: A Narrative Review

The COVID-19 pandemic has accelerated the transition to virtual healthcare while also prompting an abundance of new literature highlighting telemedicine's capabilities and limitations for various medical applications, notably musculoskeletal examinations. Telemedicine provides an opportunity to deliver timely patient- and family-centred care while maintaining physical distancing and improving access to remote communities. This review aims to narrate the current state of the literature on telemedicine applied in the context of a musculoskeletal examination for children aged 3 to 18 years. The PubMed and ScienceDirect databases were searched for relevant articles from January 2015 to August 2021 using a combination of keywords and nested searches. The general examination components relevant to the back and lumbosacral spine, hip, knee, ankle/foot, and gait are described. These components include inspection, palpation, range of motion, motor, and sensory examination as well as special testing. There is general feasibility, validity, and substantial reliability in performing most examination components, and primary diagnoses established virtually were found to be either the same or similar in the vast majority of cases. Despite the current literature focusing mainly on adult populations, we describe how each aspect of the exam can be reliably incorporated into a virtual appointment specific to the pediatric population. Currently available smartphone-based applications that measure joint range of motion were generally found to have high reliability and validity. Caregivers are needed for most of the consultation, especially in younger children, but select physical exam maneuvers can be self-performed by older children and adolescents alone. By providing an overview of the available smartphone tools as well as the reliability and validity of remote assessments, this review not only establishes a foundation for a structured pediatric musculoskeletal examination, but also aims to increase providers' confidence in incorporating telemedicine into their practice.