University of Colorado implements virtual spine physical exam during COVID-19 pandemic

Issue: July 2020

ByCasey Tingle

As a way to limit patient risk of exposure during the COVID-19 pandemic, CMS expanded Medicare telehealth coverage, enabling beneficiaries to receive a wider range of health care services from their doctors without having to travel to a health care facility. This expansion temporarily pays clinicians to provide telehealth services for beneficiaries across the country, which some said was helpful to orthopedic surgeons when state governors announced the delay of all elective surgeries, non-essential medical, surgical and dental procedures during the COVID-19 outbreak.

The relaxation of regulations and requirements of telemedicine from CMS and some insurance companies allowed physicians at University of Colorado to convert their clinics from in-person to virtual appointments, according to Vikas V. Patel, MD, executive vice chair of the department of orthopedic surgery at the University of Colorado.

Vikas V.Patel

“We had a telehealth program set up prior to all of this happening, but it was rarely used and difficult,” Patel told Healio Orthopedics. “It was difficult not so much because the actual telehealth communication or process was that hard, but it was difficult because of all the legal issues.”

Design of a virtual physical examination

However, Patel noted that as they began to implement telemedicine in their practice, they quickly realized some evaluations were harder to perform virtually.

“We started seeing patients remotely and realized that one of the things that we could not do well was get a full physical exam in, especially for spine conditions where we need to assess strength and sensation and be able to evaluate the patients as we would as if they were in the office,” Patel, and Orthopedics Today Editorial Board Member, said.

Nolan M. Wessell

With limited research and information on how to perform a virtual physical exam for patients with spine pathology, Nolan M. Wessell, MD, Patel and their colleagues decided to create a virtual physical examination.

“We needed to have a good physical exam process so that, in the future, we can not only do a good physical exam, but we can bill for it and prove that this is going to be as effective or close to as effective as if you were seeing the patient in person,” Patel said.

Wessell said they identified the motor and sensory exams needed to perform a good physical evaluation and then adapted them virtually. He noted the exam begins with a visual assessment of the patient followed by assessment of the upper and lower extremities. These assessments involve watching the patient walk; assessing leg strength through squats and arm strength through biceps curls and overhead lifting; and by having the patient perform light touch sensation testing on both upper and lower extremities.

PAGE BREAK

“The actual design of the physical exam itself was not super difficult, but we wanted to capture as much as we could in terms of what we might do in the office,” Patel said.

Validation, implementation

Since the implementation of the virtual physical exam, Wessell said they have had an overwhelmingly positive response from both physicians and patients. Not only has the virtual physical exam allowed them to maintain contact with patients and begin the evaluation process of new patients, but it has also been useful in determining urgent and emergent treatment needs.

“We know that many patients and families are suffering for a multitude of reasons, whether it be health related or finance related, but this exam is allowing our providers or any provider with telemedicine capability to continue to see and evaluate patients,” Wessell, assistant professor in the department of orthopedic surgery and division of spine surgery at the University of Colorado School of Medicine, said. “Then, from there, [surgeons] can identify patients with critical issues who may still require urgent or emergent interventions like surgery and for the other patients ... we feel that we can direct and manage nonoperative care accordingly.”

Despite the current use of this virtual physical exam in their institution, Patel and Wessell noted they are conducting a formal study to validate the technique and assess patient satisfaction to see whether it is just as effective as seeing a patient in the office.

“We need to validate what we are doing. We need to be able to show that our assessments are better, worse or the same as an in-person assessment,” Patel said.

For orthopedic surgeons interested in utilizing telemedicine to implement their own virtual physical examination to diagnose and treat patients with musculoskeletal pathology during the COVID-19 pandemic, Wessell advises surgeons to be creative.

“Ask yourself what findings do I need at a bare minimum to make a diagnosis and safely guide treatment; because many times, we have multiple tests that will provide us with the same or similar information,” Wessell said. “So, we only need to select one or two of those tests that are most easily converted to telemedicine use and we can direct treatment from there.”