Steven D. Losorelli, MS1, Varun Vendra, MD, MA2, Douglas M. Hildrew, MD, MMSc3, Erika A. Woodson, MD4, Michael J. Brenner, MD5, and Davud B. Sirjani, MD6
Abstract The meteoric rise of telemedicine early in the COVID-19 pandemic might easily be mistaken for an ephemeral trend—one reaching its zenith in a moment of crisis. To the contrary, momentum has been mounting for telehealth over decades. The recent increase in telecare reveals its potential to deliver efficient, patient-centered, high-quality care in an increasingly technology-dependent landscape. Prior to COVID- 19, surgeons lagged behind medical counterparts in embracing telemedicine; however, the pragmatic imperatives for remote care of patients and changes to Medicare removed key barriers to adoption. Otolaryngology–head and neck surgery has innovated across subspecialties, leading in COVID-19 scholarship and year-over-year publications on telemedicine. Yet, improved access to subspecialists is tempered by a digital divide that threatens to exacerbate disparities. Otolaryngology is poised to lead the transformation of procedural specialties while ensuring equitable care.
Telemedicine dates back to at least the early 1900s.Radio’s prominence ushered in the conception of telemedicine. As the medium gained traction in domains such as entertainment, politics, and commerce, its application to remote medical care was conceived. This vision was captured in the 1924 Radio News magazine headline ‘‘The Radio Doctor—Maybe!’’ as well as in conceptualized technologies for remote patient evaluation (Figure 1). Telemedicine has since expanded as telecommunication technologies have improved and insurance reimbursement practices evolved. However, adoption of telemedicine has not been uniform across medical specialties. For instance, radiology developed telemedicine platforms early, while progress in most surgical fields has historically been slow to nonexistent.
Telemedicine During the COVID-19 pandemic
As the COVID-19 pandemic erupted globally, it disrupted traditional modes of practice, creating space for innovation. The number of virtual health visits spiked across all specialties, followed by a decline as physical practice locations reopened (Figure 2). A striking finding from these data is the comparatively lower rates of telemedicine utilization by surgeons—even during the period of shutdown. These datamay reflect a lack of agility in surgical practices or heightened uncertainty about the fidelity of virtual physical examinations, procedures, and reimbursement. The lower rates may have stemmed from cancellation of elective surgery, finite capacity, or logistical barriers on the clinician or patient side.
Publication trends can provide a window into the integration of telemedicine into surgical practice. A bibliometric analysis demonstrated that 7 of 9 surgical specialties pub-
lished more telemedicine articles in the first 6 months of 2020 than in the entire 2019 calendar year (see Supplemental Methods, available online). Otolaryngologists published the highest percentage of articles mentioning COVID-19 during this period (Figure 3) and tripled the articles on telemedicine in the first 6 months of 2020 over the same period in 2019 (Figure 4). We found great differences across subspecialties, with most publications in general otolaryngology and audiology/otology.
Surmounting Barriers
The COVID-19 pandemic compelled many clinicians to make their first forays into telemedicine. As several otolaryngologic procedures may generate aerosolized viral particles, limiting patient intervention and encounters could decrease transmission. Recent changes to Medicare FFS billing (1135 Waiver), which provided equal reimbursement for virtual visits, supported telemedicine as a financially viable and prudent approach to the pandemic. The benefits of telemedicine include decreased travel time, flexibility of schedule, high patient satisfaction, cost savings for patients and health care systems, and increased access to high-quality subspecialty care. With many financial and logistical barriers removed, otolaryngology can lead among procedural specialties in telemedicine.
An important consideration in telemedicine is the digital divide, which may exacerbate disparities. Risk factors include limited access to computers or smartphones, low technological literacy, and inconsistent internet connection (Table 1). In a recent study of patients with head and neck cancer in Michigan, patients with lower socioeconomic status were less likely to complete audiovisual visits.Subspecialty care is concentrated in urban centers; therefore, rural Americans in remote regions who lack internet access may be unable to realize the benefits of virtual encounters (Supplemental Figure S1, available online). For patients without internet, store-andforward telemedicine might be considered, where a local clinician captures diagnostics with subsequent evaluation. Effective communication is of particular concern for Deaf and non– English-speaking patients; incorporating trained medical interpreters will play a critical role in providing equitable virtual care.
Cellular-Connected and Smartphone Devices
Best Practices in Specialty Referrals
Integration of telemedicine into a practice is most likely to prove successful with a streamlined referral system that ensures that key diagnostics (eg, imaging, audiogram, pathology) are available, using store-and-forward approaches. Ideally, the initial virtual encounter would be performed locally with the patient in the referring provider’s clinic. The local provider can perform crucial aspects of the examination under the guidance of the specialist (ie, telementoring). Audiovisual support would allow the specialist to review a baseline examination. If surgery is indicated on the basis of this evaluation, the patient could then travel for an in-person examination to fine-tune the operative plan, which could be executed during the same travel period. After surgery, followup visits can often be conducted virtually.
This approach is convenient for the patient and increases health care efficiency by ensuring an appropriate preoperative workup. Telementoring improves communication among doctors and patients. Unlike a phone call, visual collaboration with the referring provider fosters collegiality, similar to working side-by-side with another health professional. Implementation of this model at the Palo Alto Veterans Affairs Health Care System has markedly improved patient experience by reducing travel time, cost, and burden associated with preoperative patient visits. Furthermore, telehealth mitigates the risk of nosocomial infection, a key consideration as many head and neck patients have comorbidities that increase the risk of COVID19 sequelae.
Frontiers in Telemedicine
Many aspects of otolaryngology–head and neck surgery practice are conducive to telemedicine. COVID-19 has posed formidable challenges to patient care but has also unlocked unrecognized possibilities. Telemedicine can support the initial diagnostic evaluation of patients from areas without access to specialist care and sustain continual care of established patients. A variety of innovations are already enhancing telecare for the field by facilitating anatomic assessment, from smartphone attachments to facilitate otoscopy or rim flash for oropharyngeal photography to wearables for assessment of physiologic parameters. The standard virtual visit in otolaryngology is not only a tool for interactive care but a gateway to more sophisticated patient assessment and management. The demands of COVID-19 on clinical practice thus represent a critical opportunity for advancing otolaryngologic care.
Acknowledgment
We wish to thank Maura Farrell, senior director of advocacy at the American Academy of Otolaryngology–Head and Neck Surgery, for her assistance with policy expertise and data analytics on current telehealth usage, as well as facilitating data acquisition and usage.