Helpful Tips for Efficient Virtual Appointments

Post-COVID, telemedicine is here to stay, so how can spine specialists make the most of it? Get tips from our expert for more productive, efficient virtual appointments.

Peer Reviewed

With COVID 19 forcing the nationwide adoption of telemedicine, and patients loving the convenience and time saved, telehealth appointments are here to stay. Healthcare’s “new normal” is physicians  virtually and seamlessly consulting, diagnosing, and triaging patients online.

Telehealth visits surged to 154% in the last week of March 2020, compared to 2019, as reported by the CDC. A recent study by The American Journal of Managed Care found that patients much preferred virtual video visits to office visits for convenience and not having to travel to the appointment.

In this article, we’ll unpack telemedicine considerations for spine specialists and how to effectively prepare for and conduct virtual visits.

Spine specialist conducting telemedicine appointmentTelemedicine is here to stay, so here's how to make the most of your appointments.

Should You Still See Patients in the Office?

“Telemedicine is good for those follow-up post patients or for patients that are doing well. It’s particularly suited for patients that live out of town so they don’t have to travel in,” shares Isador H. Lieberman, MD, MBA, FRCSC, orthopedic spine surgeon at Texas Back Institute in Plano, TX.

When to see a patient in the office is determined by doing a triage history via phone to decide a face-to-face or virtual appointment is most appropriate. Dr. Lieberman notes that the main reason to see a patient in the office is to glean additional specific accurate information that wouldn’t be possible to obtain virtually.

Dr. Lieberman notes that neurologic deficit cases need to be seen as soon as possible in office. Conversely, patients that have had chronic pain symptoms for months or years typically don’t need to be seen immediately.

He continues that other reasons to see patients in office include those that you don’t know for certain that you can help via a virtual visit and those patients that may need to be referred to another specialist.

Research suggests the decision to initiate a face-to-face exam and/or surgery for higher acuity cases can be completed via telemedicine. Generally patients with signs of infections, acute ambulation loss, urinary retention, incontinence, and/or progressive neurological deficits are recommended to visit an Emergency Department for initial assessment.

Tests You Can Perform Virtually

There are numerous tests that can be performed virtually. Listed below are just a few of the evaluations that can be initiated with respect to gait analysis, cervical spine, lumbar spine, adult spinal deformity, and adolescent scoliosis.

Gait Analysis

In most instances, gait analysis can be done during telemedicine spine consult in a reasonable and safe manner.

Conditions that can be identified and assessed via telehealth include, but are not limited to:

  • Myelopathy
  • Lumbar stenosis
  • Neurogenic claudication
  • Ankle dorsiflexor weakness
  • Coronal deformity
  • Coronal imbalance
  • Leg length inequality

Cervical Spine Assessments

Telemedicine is well-suited for examining the ventral neck as well as the dorsal skin depending on patient history and related complaints. Surgical incisions can be monitored for infection and healing. It's recommended to assess posterior incisions for muscle atrophy and proper healing. Neck and head posture may be assessed passively, and while the patient is seated, active cervical range of motion (ROM) can be evaluated.

The cervical radiculopathy shoulder abduction test may easily be done virtually and is helpful in identifying cervical radiculopathy from shoulder dysfunction and peripheral nerve lesions. 93

Lumbar Spine Assessments

Multiple sacroiliac joint clinical pain provocation tests can be done virtually including the Fortin’s finger test. Active lumbar ROM can be easily assessed by having the patients perform movements that alleviate or produce pain such as flexion, extension, bending and rotation maneuvers. Lower extremity motor and sensory function may also be assessed.

Toe-walking, heel-walking, and squats can be implemented to  test calf/plantar flexors (S1) strength,  quadricep (L3/4),and  ankle dorsiflexor/tibialis anterior/extensor hallucis longus (L4/5).

A modified Trendelenburg test can be performed to evaluate the hip abductors (L5). Heel rises, toe rises, and single leg squats may be used to further differentiate a strength deficit relating to the contralateral limb.

Single leg squats, toe-rises, and heel rises can further distinguish a strength deficit relative to the contralateral limb. The hip abductors (L5) can be evaluated with a modified Trendelenburg test.

Adult Spinal Deformity (ASD) Exams

A telemedicine ASD exam may be performed beginning with a global posture assessment done standing to clearly discern sagittal and coronal deformities. The patient can be assessed for positive sagittal imbalance and associated compensatory mechanisms— knee flexion, pelvic retroversion, posterior head tilt, and hip extension.

Gait analysis may also be done via following the sagittal and coronal deformity evaluation.

Adolescent Scoliosis Exams

Aspects of the telemedicine patient exam that particularly apply to adolescent scoliosis patients include being alert to conditions that are significant to distinguish  from idiopathic scoliosis.  For example, cranial nerve dysfunction and facial asymmetry can signal brainstem and brain abnormalities.

If needed, hypermobility can be assessed using the Beighton-Horan criteria: little finger extension, knee extension, elbow extension, thumb to forearm, and forward bending.

Sagittal and coronal assessment is a key element of the adolescent spine examination. The Adams forward bend test can be used to evaluate the morphology and flexibility of the coronal curve.

Tips and Best Practices for Successful Telemedicine Sessions

Dr. Lieberman shares that it’s important to streamline, organize, and prepare the telemedicine  appointment workflow to ensure efficiency and provide an optimal patient experience.

Below are some specific tips to save time and ensure smooth, hassle-free patient exams.

Two to Three Days Prior to Appointment

Email the patient an exam checklist to optimize virtual visit efficiency: The list includes notes on body positioning, camera positioning, choosing the exam setting, and attire.

Have a staff member check the patient’s internet connection to make sure it works properly: Sometimes in remote areas the internet access isn’t good, so it’s very important to troubleshoot in advance of the appointment.

Get a backup cell phone number for the exam in case the original phone number fails on exam day.

Have a staff member virtually check the gait analysis runway to make sure there’s adequate room for the patient to walk back and forth.

Request the patient do the exam in a room that’s quiet and distraction free: What may happen is if you don’t address specifics about the exam location, you may call and have patients ready to do their exam from the inside of their car, in a busy parking lot, or some other ineffective exam venue shares Dr. Lieberman.

Suggest the patient enlist an assistant to position the device camera during the exam: Smartphones and tablets are a bit easier to operate to zoom in and out versus using a laptop or desktop computer.

Request fur and feathered “kids” be excluded from the patients’ exam: Disruptive dogs barking and jumping on patients during gait analyses, cats clambering over patients’ computer keyboards, and even a parakeet landing on a patient’s head - Dr. Lieberman has seen the gamut when it comes to pet shenanigans during virtual visits. He advises instituting a “no pets” policy for exams to save valuable time and provide effective patient evaluations.

15 Minutes Prior to Appointment

Enlist a staff member to call the patient, check the internet connection, and let the patient know the doctor will start the exam in about 10 minutes. The patient will then be waiting online for you prior to the exam, saving you valuable time.

Start of the Appointment

Similar to his face-to-face office visits, Dr. Lieberman underscores the importance of being cordial and keeping a sense of levity to put patients at ease. He likes to ask the patient to introduce any family members, friends, or caregivers attending the exam so they feel welcome to participate. He also recommends giving patients and people assisting them with the appointments the opportunity to ask questions during and at the end of the exam. For example, “Have I explained that to you well enough,” and “What questions do you have?”

HIPAA Considerations

“With consideration to HIPPA and confidentiality, be sure you’re in a separate private room where you can close the door and be free from interruptions. Ensure there’s no background noise so you’re able to concentrate on the telehealth visit,” advises Dr. Lieberman.

He also emphasizes being prepared with your telemedicine platform and equipment. “Be sure you’re familiar with your computer settings so you’re able to share your screen quickly and easily to virtually show the patient their X-rays,” he says. “It’s important to streamline that function so you’re not fumbling around. Patients will begin to wonder about your competency as a surgeon if you can’t figure out what button to push to operate your computer.”

“Telemedicine Is Here to Stay”

The national disruption of the COVID 19 pandemic blew in a telehealth sea change in the spine medical community. Fortunately doctors and patients alike are adapting, advocating, and appreciating virtual visits’ efficiency and convenience.

Dr. Lieberman’s practice is a sign of the current telehealth times, reflecting significant virtual visits. His daily caseload averages around 15 new patients and 15 follow up appointments. Of those 30 appointments, telehealth visits account for three to five new patient appointments and three to five follow-up appointments.

Dr. Lieberman reflects, “Telehealth is here to stay. It’s the first step to tele-treatment and tele-surgery. I envision a day where I’ll see patients via telehealth and do their surgical procedures remotely via robotics. What was science fiction 20 years ago is reality today.”    

Updated on: 04/07/21
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Peer Review: What Spine Specialists Need From a Telemedicine Platform
Isador H. Lieberman, MD, MBA, FRCSC

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