These authors sought to compare the diagnostic effectiveness of a telehealth shoulder examination
against a standard clinical for rotator cuff tear (RCT), using magnetic resonance imaging (MRI) as a reference standard.
Two clinicians selected movement, strength, and special tests for the standard clinical exam that are associated with the diagnosis of RCT and identified similar tests to replicate for a simulated telehealth-based examination in 62 patients with shoulder pain.
They found that the overall diagnostic effectiveness of stand-alone tests was poor regardless of the group. They found no significant difference between the overall diagnostic effectiveness of the two exam formats.
Comment: This may not have been an ideal format to test the effectiveness of telehealth, in that the clinical tests were ineffective when administered in either format.
Travel from the patient's home to the doctors office can be costly, time-consuming, and risky (e.g.traffic accidents, contracting infectious disease). These barriers can interfere with needed patient-surgeon communication ("do I really want to take a two hour drive or a four hour flight for a 15 minute visit with my surgeon?")
Telehealth can be a cost-effective method for interacting with patients if used appropriately. In our practice we offer telehealth to patients who wish to avoid the cost, time and risk of travel. We use telehealth in several contexts:
(1) Getting to meet the patient, understand the chief complaint, document the history, medications, co-morbidities, social environment, and goals of management. During this exam, the surgeon can ask the patient to demonstrate the activities that cause discomfort as well as the active and passive ranges of motion. Baseline measures of patient-assessed comfort and function can be obtained (see this link). Based on this initial assessment, the surgeon can determine the need for additional diagnostic tests : plain films, MRI, CT, EMG, etc. Such tests can then be ordered and arrangements made to have the results and images sent for surgeon review. Unless they are contraindicated, simple flexibility and strengthening exercises can be initiated using diagrams and videos (see this link).
(2) Followup after initial evaluation to review progress and the results of diagnostic tests. At this time, the surgeon can share prepared material on some of the treatment alternatives (For example, The ream and run procedure (see this link).The total shoulder arthroplasty (see this link). The cuff tear arthropathy arthroplasty (see this link). The reverse total shoulder arthroplasty (see this link). The smooth and move procedure for irreparable rotator cuff tears (see this link)). Questions by the patient and family can be addressed in real time. Should surgery become an active consideration, arrangements are made for an in-person evaluation.
(3) Post treatment followup. Patients can be seen on telehealth for scheduled visits or unscheduled visits to address questions, problems, and concerns as well as to progress the rehabilitation program. Followup measures of patient-assessed comfort and function can be obtained (see this link).
The effective and efficient use of telehealth is facilitated by training the clinic staff in its use so that patients know how to connect to a secure server and are scheduled appropriately. As patients, staff and surgeons become more experienced it its use, telehealth becomes easier and more efficient.
