The Digital Revolution: Telehealth Might Reshape Same-Day Surgical Practice
EXECUTIVE SUMMARY
Technology solutions are revolutionizing surgery, making it easier to communicate with patients and monitor their recovery.
• The benefits promised by the introduction of electronic medical records is finally beginning to be realized.
• Apps can track patients’ vital signs, exercise, diet, and pain levels.
• There also are apps that provide ready information to surgeons, making their practice more efficient.
Technological solutions, including those that make telemedicine easier than ever before, have been transforming the healthcare system, including ambulatory surgery.
“Healthcare, over the last 10 years, has undergone a revolution where our paper charting and administrative processes at the hospital level have been digitized and moved into the computer age,” observes Jonah Stulberg, MD, PhD, MPH, FACS, clinical director of innovation for Northwestern Feinberg School of Medicine and general surgeon at Northwestern Memorial Hospital in Chicago. “We’re on the cusp of a digital revolution that will finally help us realize some of the promise that was built up in the transition to electronic medical records [EMRs].”
“It’s a remarkable revolution in technology in the way we do our day-to-day work,” says Heather Evans, MD, MS, FACS, vice chair, clinical research and applied informatics, and professor of surgery at the Medical University of South Carolina. “The access we have now to electronic medical records and to apps on our phones is remarkable. We have the ability to record biometric data so easily and submit that data through some of the major EMRs.”
The question everyone is asking is how can the current digital tools help quality improvement, Stulberg says. “How do we provide better quality care to our patients?”
Digitization occurred first in the private sector, and hospitals were delayed in making the change to EMRs, he notes. “As a clinician, you often hear frustration from clinical providers about how the promise of that digitization and the moving to an electronic medical record was supposed to solve all these problems, but instead it added to the burden,” Stulberg says.
EMRs have benefited administrative processing, but have not necessarily benefited clinical care. There were some early benefits, such as faster access to lab results. But that is changing as new products and technology are allowing clinicians to monitor remotely and diagnose sooner, Stulberg observes.
“One thing I do in my role in innovation is try to find digital and electronic and forward-leaning solutions that make a clinician’s job easier,” he says. “We should help a clinician work more seamlessly with digital products to deliver higher-quality care.”
Surgeons and others are developing new apps that help physicians with their day-to-day workflow, improving their access to necessary information and providing quick educational tips.
One of the chief problems with new technology and apps is determining which products are useful and which are not. Evans is the chair of the American College of Surgeons’ (ACS) health information technology committee, which is working on a toolkit resource surgeons can use to improve their practice.
ACS is not looking at the communication apps that involve monitoring and educating patients, only those designed for surgeons’ use. “We are a group of surgeons who are all interested in not just health information technology in general but in how we can apply it to our daily practice as surgeons,” Evans explains. “We’re trying to develop some guidance for surgeons to be able to identify apps that are useful and are vetted by a group that understands how these apps work and how they might apply in surgical practice.”
The vetting is underway, and the toolkit is expected to be available later this year, she adds. (See story about surgeon apps later in this issue.) There are multiple patient apps that track patients’ exercise, diet, medication use, vital signs, and heart rates, Stulberg says.
“If a person has an abnormal heartbeat at home, the app automatically notifies the clinician, providing data to the clinical center,” he says. “Then, the center reaches out to the patient.” This technology eases patient care concerns related to sending patients home sooner than they were in previous decades.
Telehealth also is improving, becoming easier and more effective as the technology advances. It remains a cost-effective way to make presurgery visits and post-surgery visits easier for patients, says Ryan Spaulding, PhD, vice chancellor, Institute for Community Engagement, and acting director, Center for Telemedicine and Telehealth at the University of Kansas Medical Center.
“It saves travel distance and time for patients,” Spaulding says. “It also creates a fairly routine visit by technology.” (See story on presurgery certification visits via telehealth later in this issue.) Telemedicine is an interesting and exciting area of medicine right now, Evans offers.
“A lot of us are focusing on these remote patient monitoring platforms because it’s a way to deliver care that is personalized to the patient’s situation,” she adds.
“For insurance purposes, surgery has to be precertified, and it requires the patient to come into the clinic for a routine visit,” Spaulding says. “Those can be done by telemedicine.”
One of the biggest improvements in telemedicine involves video calls. These can occur by asking patients to visit a local provider, who sets up a teleconference with the surgery center. Or, these calls can be handled via video conferencing to patients’ cellphones, which brings telehealth to their homes.
Telehealth via cellphones still faces funding issues, but once payers start to recognize these in-home, telemedicine visits, the potential benefit to patients is great. “We want to get into the patient’s home for these kinds of consults,” Spaulding says. “The way it works now, patients still have to go somewhere else, like a local clinic or hospital, to have a facilitated visit.”
These telemedicine visits may become routine if physicians could talk to patients in their homes and cut out the middle facilitator, he adds. “That’s where we would like to go and where it would make the most sense,” Spaulding explains. “But right now, reimbursement doesn’t cover that, and we want to make sure the fidelity of the visit is high, the video is good, the lighting is good.”
Spaulding predicts technological advances in cellphones will drive change in telemedicine: “Eventually, you will see a lot more video consults occur in patients’ homes because cellphones and smart devices will make it possible,” he offers. “Insurance companies are not there yet, but we’re working on it.”
Digital tools are available to improve quality improvement and clinical effectiveness in patient care, Stulberg says. “We are starting to use remote monitoring or digital activity to actually get closer to realization of quality improvement,” he reports. “Clinical effectiveness is better than before these technological solutions were available.”
For example, one pilot project is about improving opioid prescribing. An app called GetWell Loop prompts patients to answer questions about their medication use after surgery. There is a two-way, automated communication, Stulberg explains. Starting on the first day after surgery, the app’s care pathway asks patients how many opioid pills and other medications they have taken. On day five after surgery, the app asks patients about whether they have a fever and drainage.
These data provide clinical feedback that helps physicians make prescribing decisions. “The big concern is the public. Those who have not undergone surgery cannot understand why surgeons are still prescribing opioids,” Stulberg says. “Surgeons say, ‘We just operated, and we see the consequences of pain and cutting, and we need to provide pain relief.’ But how do you know that patient is getting adequate pain relief and not just going home and suffering?”
The solution was digital monitoring. An app can ask about pain and activity levels, and whether they are getting out of bed, sitting, or walking. It provides this information, along with the opioid use data, to doctors.
Using this information, Stulberg decided to stop giving opioids to patients undergoing robotic inguinal hernia repair, which requires making only a small incision. “I had data from multiple patients in a row, showing they had never used their opioid medication,” Stulberg reports. “Because I knew they weren’t using the opioid, I knew I didn’t need to provide it to them anymore.”
Instead of opioids, robotic inguinal hernia patients take scheduled Tylenol or ibuprofen, and they receive instructions to use ice 20 minutes at a time for the first 48 hours. They also are instructed to move every hour, he says. “We found stiffness causes a lot of pain,” Stulberg says. “For those patients, that was adequate.”
The app can be used for additional purposes and surgeries. It also can be set to check on patients over various periods. Some surgeries might require two weeks follow-up; others would benefit from 60 days.
“The digital solution gives real-time digital feedback that otherwise would be very expensive,” Stulberg says. “We are in the process of rolling it out to all surgeries. We will use the data to investigate and see what is helpful for clinicians.”
Technology solutions are revolutionizing surgery, making it easier to communicate with patients and monitor their recovery.
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