Virtual checklist prepares patients for virtual care at Massachusetts General
Click Here to Manage Email Alerts
As the COVID-19 pandemic limited options for musculoskeletal care by requiring practices to stratify patients based on the urgency of their injury, orthopedic surgeons at Massachusetts General Hospital began converting existing clinical protocols to telemedicine to meet the need for care for a wider range of patients in their practice.
“Our hospital system had been set up for [telehealth] in a select patient population, but we had to expand [it] within our orthopedic practices out of necessity,” Miho J. Tanaka, MD, director of the Women’s Sports Medicine Program at Massachusetts General Hospital and member of the faculty at Harvard Medical School, told Healio Orthopedics. “Having had a background in digital imaging and image analysis, I became interested in the utility of these virtual visits because there were a lot of onscreen tools and digital concepts that could be applied to the virtual exams.”
To achieve comparable examinations across practitioners, Tanaka and colleagues established a set of protocols to follow for virtual care visits, which were published in the Journal of Bone and Joint Surgery.
Virtual visit checklist
In the paper, Tanaka and colleagues noted a virtual visit can be optimized with the help of a virtual visit checklist provided to patients prior to the visit.
“Once we started – at least for my practice – implementing this checklist, I found that the visits were more efficient; I did not have to spend as much time explaining the setup and was able to focus on the examination findings [because] the patients were prepared,” Tanaka said.
The virtual visit checklist instructs patients to confirm their camera and microphone settings through a testing website, according to Tanaka and colleagues. The researchers also noted providing patients with guidelines on proper positioning of the camera, location and lighting, availability of tools (such as a chair) for the exam, as well as clothing to allow for appropriate visibility and examination of the affected body part, are important in helping patients prepare for a successful visit. Tanaka said supplying patients with pictures of more complicated maneuvers can also assist in a smoother virtual visit.
“Once you have set up properly, you can get a lot more information and, more importantly, ... standardize the exam to obtain reproducible assessments. This is important for those of us who are currently relying on this as our primary mode of care ... and we will probably continue doing it going forward in some capacity,” Tanaka said.
Knee, hip injuries
When assessing patients with knee injuries, Tanaka and colleagues suggested to begin by assessing alignment and range of motion supplemented with the use of a web-based goniometer to obtain accurate measurements.
“When it comes to measurements, ... just viewing the knee from any angle does not necessarily allow for reproducible assessments when evaluating onscreen from a 2-D perspective. Even for something seemingly simply, such as the assessment of range of motion, we wanted to standardize the view and make sure that the observer is viewing the knee from the same perspective, each time,” Tanaka said.
Furthermore, as surgeons rely heavily on physical examination maneuvers, Tanaka said some alternative techniques can be used to simulate such maneuvers for virtual visits. For example, hyperextension, which is typically assessed by manually hyperextending the knee, can be assessed by having the patients stand, plant the foot and push the knee backwards, which can then be measured with a goniometer. She added, the Thessaly test can be used in a virtual setting to assess for meniscal symptoms.
“[The Thessaly test] was a test my colleague recommended for telemedicine because it does not involve manual testing in a scenario where one would normally perform McMurray’s or Apley’s tests. Utilizing different tests, such as this one, allows us to get a little more information without being able to touch the patient,” Tanaka said.
Tanaka and colleagues noted many of the tools used to enhance the virtual examination of the knee can also be used for the hip. A virtual ruler can be used to measure leg length from the anterior superior iliac spine to the floor, while hip flexion can be measured with the patient lying back with one side to the camera and their knee pulled to their chest, the researchers wrote, again emphasizing the standardized view. The researchers added internal and external rotation can be measured with the patient rotating the hip from a seated position with the knee bent at 90°.
“Strength testing typically involves applying resistance, which can be difficult on a virtual exam, but having patients perform [activities] against gravity is an option,” Tanaka said. “We listed an example of standing from a chair to test hip extension and strength. Having patients perform such motions with their body weight can be helpful to identify weaknesses in specific muscle groups, which can indicate other sources of pathology or direct us toward targeted treatments in physical therapy.”
Future applications
Tanaka noted these virtual care protocols may be beneficial after the COVID-19 pandemic has been resolved for patients with limited mobility or for those who live farther away from their physicians.
“As we begin to resume in-person visits, most places are starting at a reduced capacity. Therefore, having some sort of screening visit to determine if [patients] need any advanced imaging before they come in for their visit may be helpful,” Tanaka said.
Virtual care may also be helpful with follow-ups from a research standpoint, which Tanaka said does not currently have a good mechanism of access.
“For researchers who are reporting on longer term follow-ups after a procedure, bringing the patient back in after their care has ended leads to issues related to how the visit would be covered,” she said. “It can be difficult and costly to have patients come back into the office to have an examination for research purposes. As our capabilities continue to improve, possibly being able to do these as virtual visits, where the costs and the travel may not be as much of a barrier, might be another way that we can explore the utility of this going forward.” – by Casey Tingle
Disclosure: Tanaka reports no relevant financial disclosures.
Collapse
Read more about
Click Here to Manage Email Alerts