Discussion
During the past 15 years, there has been a dramatic increase in the utilization of telemedicine in the USA. Between 2004 and 2005 there were about 7000 telemedicine appointments completed by rural Medicare beneficiaries.14 By 2013, rural Medicare beneficiaries accounted for over 107 000 telemedicine visits, and in 2017 the use of telemedicine among privately insured individuals included more than 200 000 visits per year.14 15 This increased utilization of telemedicine can be attributed to many factors, including the exponential growth in the use of personal technology as well as the mandated use of an electronic health record that coincided with the implementation of the American Recovery and Reinvestment Act in 2009. However, the growth of telemedicine was predominantly in the primary care and behavioral health sectors, with specialists, including surgeons, only accounting for 8% of telemedicine visits in 2017.
Telemedicine offers an opportunity to help address disparities due to the inequity of access to pediatric surgeons based on locale and ability to travel. A recent survey of members of the American Pediatric Surgical Association found that 76% of members reside in the 50 largest metropolitan areas, leading to a relative shortage in rural America.16 In 2013, 55% of surgeries performed in North Carolina on patients less than 18 years of age were performed by a general surgeon.17 Studies have shown that pediatric patients requiring surgery experience fewer complications when their operation is performed by a high-volume pediatric surgeon.18–20 When geographic barriers or resource limitations prevent children from having access to pediatric specialists, the result is more frequent utilization of emergency services and worse long-term health outcomes.21 In the case of an emergency, the need to be seen urgently often outweighs the benefit of traveling to a pediatric facility. However, in the elective setting, telemedicine can offer an opportunity to increase access for patients when distance might otherwise make an in-person appointment impractical.
In addition to increasing access for patients, telemedicine also affords the opportunity to reduce the cost of care for patients, hospitals, and the healthcare system. Each visit with a surgeon requires that caregivers incur the direct cost of the services as well as the indirect expenses associated with travel and missed time from work. One study evaluating the burden associated with traveling to a pediatric surgery clinic found that almost one-third of patients spent more than 4 hours in transit and that for 75% of families at least one adult had to miss work.22 For patients requiring an operation, the traditional model of delivering care requires at least three visits to see a provider—one in the preoperative phase, one for the surgery, and one for postoperative evaluation. For some patients, there is no substitute for the face-to-face interaction that accompanies a traditional clinic visit. For others, telemedicine can offer a safe and effective method for diagnosing many surgical conditions while eliminating the indirect costs of preoperative in-person appointments, without compromising the care that patients receive.23 24 In most situations, the postoperative appointment equates to a cursory view of the operative site and provides limited benefit to the patient despite requiring the same indirect costs and stress associated with travel. Video is an effective method for identifying wound complications, and it can also be used to triage issues that arise prior to the scheduled appointment, preventing unnecessary utilization of emergency services and decreasing the cost for patients.12 25–27 There is benefit associated with the human contact that comes with an in-person appointment that cannot be replicated over video, but telemedicine does offer a chance to decrease the disparities in pediatric surgery by providing affordable and effective care for patients who chose to take advantage of it.
While telemedicine use within pediatric surgery in the USA has been limited, the results have been promising. At Children’s Mercy in Kansas City, a telemedicine initiative in pediatric surgery services was started in 2014. Within the first 2 years, over 170 telemedicine surgery appointments were carried out, with no reported limitations in establishing the correct diagnosis.3 28 In its report from 2016, the HHS postulated that inconsistencies in reimbursement remained one of the major barriers to increasing the prevalence of telemedicine services.4 In 2019, 42 states had telemedicine parity laws, mandating that private insurers compensate providers for remote visits.29 30 However, a report from Lacktman and Levine found that in only 10 states was compensation truly comparable between in-person and remote appointments for most services.31 With uncertain compensation and a lack of studies to show a clear benefit, it is not surprising that the use of telemedicine within pediatric surgery has failed to gain widespread support. In January 2020, a major barrier in compensation equality was removed with implementation of the 2018 Bipartisan Budget Act.7 Under the Act, requirements regarding physical locale of the patient and provider were removed for those covered under government-supported insurance, paving the way for the increased use of telemedicine within surgery and other specialties. Shortly after the Act went into effect, the rapid spread of COVID-19 mandated an acute change in the way that healthcare is delivered and provided an opportunity to study the effects of widespread telemedicine use.
By embracing a telemedicine option for patients, surgical specialties stand to benefit in ways that extend beyond direct patient care. A surgeon’s effectiveness is predicated on the number of patients treated, and when inappropriate or mistimed referrals are made the overall effect is a decrease in efficiency and a potential delay in care for some patients with legitimate surgical needs. Patients, surgeons, and primary care providers all stand to benefit when there is common ground between the surgeon and referring provider. A 2004 study of patients presenting to a pediatric surgeon found that 64.7% of referred cases were not consistent with recommended guidelines for referral.32 The result is a large proportion of patients presenting to clinic and requiring no treatment. Telemedicine promotes more frequent communication and can lead to an increase in satisfaction for both surgeons and referring providers.33 Within a year of implementing a telemedicine consult service, one large hospital system found that the average wait time for patients to be seen by a specialist decreased from 112 to 49 days, and the number of referrals made without a clear question dropped by 75% for surgical patients.34 Telemedicine represents a tool for pediatric surgeons to increase productivity by improving efficiency without demanding an increased workload for the individual surgeon. Similarly, a regional healthcare system can be improved by eliminating the unnecessary transfer of patients between facilities, a goal made feasible with the help of telemedicine. Under most circumstances, the decision to accept a transfer from an outside facility is made without the receiving facility having an opportunity to visualize the patient or access the complete medical record. Up to 20% of transfers result in no difference in care for the patient, but the financial implications can be devastating, as the cost of transfer alone can add more than $11 000 to medical expenses.35 One study of neurosurgical patients found that the use of video evaluation ultimately led to a cancellation of 33 potential transfers, resulting in an estimated savings of over $500 000.36 The addition of video when evaluating trauma, burn, and neurosurgical patients being considered for transfer can save millions of dollars and requires little to no change in workload for providers.37–39 Given the emphasis on decreasing the cost of care across the USA, it is prudent that we consider the potential benefits of including telemedicine evaluations for patients requiring consultation with a pediatric surgeon, including those where transfer to another facility is being considered.
Telemedicine offers a way for pediatric surgeons to embrace personalized medicine. The term is often poorly defined, but in general personalized medicine refers to the idea that patients benefit most when decisions are made with consideration of as many unique characteristics as possible.40 The needs of the individual patient presenting to a pediatric surgeon will vary, but there are shared characteristics among the population that make this group poised to benefit from the use of telemedicine. For one, there is the matter of comfort in a virtual space. Caregivers for pediatric patients are often younger than the patients presenting to an adult hospital and are more likely to engage with technology. A study by the Pew Research Center in 2015 found that 97% of the US population aged less than 30 years report having access to the internet, compared with 54% of senior citizens.41 Similarly, in a survey of caregivers presenting to a pediatric surgery clinic, 94% of respondents had a smartphone and 92% reported use of some form of mobile health.42 As with any proposed change, it is important to consider any limitations. The suitability of telemedicine appointments can vary widely by subspecialty, as evidenced by the range of usage at our institution. Surgeons who frequently perform office procedures or require specialized equipment for evaluation, such as those in ophthalmology or orthopedics, are less likely to use video appointments for routine care. However, many conditions requiring referral to a pediatric surgeon require a limited physical examination and can be effectively evaluated through video—allowing the patient to remain in the home environment and limiting the stress for the child while reducing the aforementioned cost of travel. Pediatric patients with complex medial conditions benefit from multidisciplinary care that includes consideration of their emotional and physical needs and can affect clinical outcomes and quality of life.43 44 Multidisciplinary treatment plans often require frequent visits to a clinic, which can lead to caregiver strain.45 46 With telemedicine, providers at different locations can interact with a patient during the same appointment, allowing for the patient and caregiver to receive the support needed from multiple specialists without the burden of frequent travel. Lastly, there is the matter of continuity of care for patients who relocate during the follow-up period, such as those pursuing postsecondary education or patients moving out of state for work or family. Telemedicine can be an effective tool for the longitudinal evaluation of postsurgical patients and offers an opportunity for adolescents to obtain access to a familiar provider while away from home or when transitioning to an adult surgeon.47
In the USA, legislative changes have been made in recognition of the need to modify healthcare delivery options in response to COVID-19. On 6 March 2020, an emergency government waiver went into effect that ensured that telemedicine video appointments for patients covered by Medicare would be paid at the same rate as in-person appointments.48 At the same time, the HHS issued an official statement announcing that enforcement of Health Insurance Portability and Accountability Act violations related to software breaches would be relaxed during the COVID-19 pandemic.49 These two measures have combined to provide assurance for providers that telemedicine can be used without loss of compensation or increased exposure to litigation. Across many institutions, the exponential growth in the use of telemedicine among pediatric surgeons during the COVID-19 period has taken place over the course of weeks—changes of this scale are typically carried out over the course of several months. Predictably, the accelerated transition has led to technological, logistical, and procedural challenges that will necessitate further study.
