Expanding telemedicine for spinal care: 3 spine surgeons share insights

Written by Alan Condon | March 25, 2020 | Print  |

Telemedicine services are rapidly increasing across the country after the Trump administration's March 13 declaration to expand Medicare coverage for the technology in the wake of the COVID-19 pandemic.

Three spine surgeons discuss how they see telemedicine developing in spine.

Ask Spine Surgeons is a weekly series of questions posed to spine surgeons around the country about clinical, business and policy issues affecting spine care. We invite all spine surgeon and specialist responses.

Next week's question: What do you see as the biggest potential threat to your spine practice?

Please send responses to Alan Condon at acondon@beckershealthcare.com by Wednesday, April 1, 5 p.m. CST.

Note: The following responses were lightly edited for style and clarity.

Question: What are the biggest telemedicine trends in spinal care? Where do its obstacles and opportunities lie?

Srdjan Mirkovic, MD. Northshore Orthopaedic & Spine Institute (Chicago): There is a current shift with telemedicine in spinal care due to the COVID-19 pandemic. The recent change in Medicare policy will enable spine surgeons to implement telemedicine in a greater way. Government reimbursements give specialists an opportunity to remotely screen, treat and monitor patients with chronic conditions. I anticipate a call from a person experiencing lower back pain will be handled over the phone by a nurse initially, making way for teleconferencing. But a spine specialist will still be able to talk to patients and authorize testing like an MRI. 

I expect more tele-diagnoses for straightforward cases. There will always be clinical care, but it will be more limited, and that's where I see some obstacles. There will be few physical exams, which is a big part of what physicians do and how we make our diagnosis. Also, insurance companies will authorize inpatient surgeries, but I expect it will get tougher as trends point to more minimally invasive and outpatient care. The more telemedicine integrates into the healthcare system during this crisis the more likely it will become permanent. 

Brian Gantwerker, MD. Craniospinal Center of Los Angeles: Telemedicine in spinal care was an inevitability. Its responsible application is crucial to its dawn and descent. Obstacles abound. Physician liability and duty to treat remain thorny, especially in states like California. Obtaining insurance coverage for a treating physician is a deterrent of even downright prohibitive. Other issues are HIPAA compliance for telemedicine and having access to imaging. I am currently using a platform that allows HIPPAA compliant sharing of DICOM films. Online consults need to be compliant as well. Creative use of currently available technology and judicious use and discretion will allow it to expand its footprint.  

Gregory Schroeder, MD. Rothman Orthopaedic Institute (Philadelphia): Telemedicine in spine surgery is seeing a dramatic increase in usage in the COVID-19 era. At the Rothman Orthopaedic Institute, we have rapidly ramped up our telemedicine visits. Importantly, my patients have been extremely satisfied with their telehealth visits. Many of the rules have been relaxed so that some previously non-HIPPA compliant platforms such as FaceTime can be utilized now. However, it is not clear for how long this will be permitted. While there are many different platforms that are HIPPA compliant, some of these such platforms require patients to download an app on their phone. These applications have proven challenging to use in my practice and I prefer applications such as doxy.me that do not require an app for the patient. 

Regardless of what application you find to be the best for you and your patients, the most challenging part of a telemedicine visit is the physical exam. It is helpful to understand what can and cannot easily be tested on telemedicine visits. For instance, when evaluating a patient for myelopathy, rapidly alternating movements and tandem gait are easy to perform, whereas reflexes and a Hoffman's sign are not possible. Similarly testing motor strength for levels zero, one, two and three is easy, but it is challenging to judge strength between level three, four and five. Last year at the Cervical Spine Research Society, we presented a pilot study validating a telehealth neurologic exam, but it requires the use of therabands. If telehealth becomes increasingly common, further studies are needed to determine the best way to perform a good virtual physical exam.

More articles on spine:
NuVasive recalls Magec system for scoliosis, advises surgeons to perform clinical follow-ups
Zimmer Biomet asks European hospitals to remove orthopedic spacer molds
Resurgens Orthopaedics postpones elective surgeries, remains open for urgent care

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