Could telemedicine prove to be a plastic surgery provider and patient pleaser after all? Dr. John F. Nigriny talks real-time continuity of care.
U.S. plastic surgeons who developed a telehealth workflow found telehealth encounters with reconstructive patients allowed for real-time clinical decision-making, saved patients and doctors time, resulted in satisfied patients and would likely significantly reduce costs, according to a study published August 2019 in Plastic and Reconstructive Surgery.
The model could be used in aesthetic medicine for consultations and other appointments, potentially offering the same benefits with patient and provider satisfaction, according to the study’s senior author John F. Nigriny, M.D., a plastic and reconstructive surgeon at Dartmouth-Hitchcock Medical Center, and assistant professor of surgery at the Geisel School of Medicine at Dartmouth, Lebanon, N.H.
“Our study was mostly on the post-operative end, but our goal is to advance this and start using it for consultative services. It’s much easier to do that in an aesthetic practice than a practice where you’re relying on insurance payment,” Dr. Nigriny says.
Dr. Nigriny and colleagues based the model they used on the Lean Six Sigma framework, a quality improvement and defect reduction process shown to be effective in business and manufacturing, and developed a testable workflow for telehealth visits. Their process optimized clinical efficiency for remote follow-up evaluations and included cellular phone network requirements of at least 2nd generation, or 2G, technology, and a secure, encrypted videoconferencing system.
They studied 72 reconstructive patients who had the telemedicine evaluations as part of their follow-ups post reconstructive surgery.
On the day of the telemedicine sessions, a visiting nurse with specialty certification in wound care traveled to each patient's home, using an iPad to enable visual examination and communication between the plastic surgeon and patient, according to an American Society of Plastic Surgeons’ press release.
The nurse performed hands-on tasks like changing dressings and removing sutures.
But Are Patients Satisfied?
One of the big take-home messages from the findings, according to Dr. Nigriny, is that most patients embraced telemedicine after they experienced it but not before.
While younger people were more likely than older patients to embrace the thought of having a telemedicine visit, nearly 75% of all the patients surveyed before their surgeries said they would prefer to have a traditional in-person visit for their follow-up appointments.
In a follow-up survey, nearly all patients said they were satisfied with their telemedicine visits. A total of 96% said all their questions were answered during the visit and they would use the telehealth option for future follow-up care.
Adopting telemedicine is an important topic in all of medicine, including aesthetic medicine, according to Dr. Nigriny.
“The advantage of telemedicine is that it can be a lot cheaper. You don’t have to set up an office. You don’t have to employ someone to seat patients, check patients in and do all of those kinds of things. It’s pretty much the same visit visually, other than the physical exam part, but a lot of skin-related and superficial surgical practices can benefit from this,” he says.
Telemedicine is good for patients because it increases access and decreases time.
“Ours is more of rural medical center, where patients travel on average 60 to 90 minutes each way to see us,” Dr. Nigriny says. “They don’t have to get in a car or take a big chunk of time out of work. Maybe they can do this on a break. If they’re not able to drive themselves, they don’t have to recruit someone or find transportation. It’s much more user friendly and cheaper because of that.”
Telemedicine also is possible because most providers and patients have the hand-held and other devices needed to make it work, Dr. Nigriny says.
Telemedicine already is changing access to care in the U.S. The University of Arizona, for example, has a telemedicine trauma service platform with which they consult with emergency department and other physicians in the region who might rarely see trauma patients or don’t have the expertise to treat them, according to Dr. Nigriny.
“If things like that are possible, certainly a consult regarding laser resurfacing, Botox, fillers or a facelift is doable,” he says.
Aesthetics as a Telemedicine Specialty
It’s much easier to implement telemedicine in aesthetic practices than in practices that rely on third-party reimbursement, according to Dr. Nigriny.
“The climate for reimbursement from a third-party payer of private or governmental insurance varies. There are some programs that Medicare has in certain states that can provide reimbursement for telehealth consultations, but it’s not across the board and is [only] in certain regions,” Dr. Nigriny says.
“For something like a cosmetic consultation, you don’t have to worry about the coverage side of things. You can make sure the visit gets paid upfront and proceed with the consultation.”
Furthermore, people who make appointments at cosmetic practices for consultations often don’t convert to actual surgery. The conversion rate can be as low as 10% to 15%, according to Dr. Nigriny.
That’s another reason telemedicine is attractive in for cosmetic practices. It’s more economically feasible and efficient for the patient and provider to do the consultation from a desktop, tablet or cell phone.
Dr. Nigriny and colleagues say using a model in which visiting nurses went to patients’ homes greatly enhanced the workflow for reconstructive patients.
“Most of the time when patients come back after a reconstructive procedure within a week or two of their surgery, they see one of our nurses, usually for things like drain removal, suture removal, inspection of wounds,” he says.
In the study, Dr. Nigriny or one of his practice’s nurse practitioners would conduct the telehealth visit with the visiting nurse involved.
“We could put these appointments in between office-scheduled appointments [because they] would take a very short amount of time. Sometimes five to 10 minutes,” he says. “The visiting nurse colleagues on the other end would act as our hands. They could take out drains and sutures and reassure the patient.”
The result, he says, was real-time continuity of care.
When visiting nurses see patients at their homes, they often don’t communicate directly with providers, and communication between visiting nurse and providers might be delayed days or more, according to Dr. Nigriny.
“In this case, the visiting nurse is getting real-time instructions,” he says. “The patient gets the same level of care with our supervision as they would get in our office, but they don’t have to get in the car and drive or worry about parking or getting a ride.”
Telemedicine, Technology & Tips
Plastic surgeons and other providers have long used a more basic form of telehealth called store and forward, where providers or patients might send pictures to consult with plastic surgeon experts.
“Essentially, we were just sending an image,” Dr. Nigriny says. “What we did in this study was more of a Skype or Facetime type of situation, where in real time we were interacting via that process over the internet to give the patient comments, hear what they had to say, give a whole visual exam and create a treatment plan.”
Technology continues to evolve, he says. Future innovation, like 5G networks, would offer more bandwidth to improve the quality of video. Things like haptic feedback, or the use of touch to communicate with users, could allow providers to virtually touch patients.
But barriers to telemedicine adoption remain, especially outside of fee-for-service medicine. Among those are acceptance by both insurers and government payers.
Aesthetic providers can, for the most part, start telemedicine services without having to worry about state and local coverage by third-party insurance, Dr. Nigriny says.
What they do have to worry about is patient privacy protection and HIPAA compliance.
“Whatever venue they choose to do [telemedicine] on, physicians have to make sure that things are HIPAA compliant and don’t violate any local or state laws around privacy,” he says. “That’s pretty doable.”
Providers who plan to charge for telemedicine consults and visits also need a venue and process for collecting payment.
“The other thing to consider is what kind of hardware you have. Image quality, audio quality - those types of things are important to the degree that the better the image quality and audio quality, the better able you are to communicate with patients,” he says.
Dr. Nigriny reports no relevant disclosures.