Perioperative Telehealth: Should Your Practice Make the Digital Leap?

Nirav Kamdar, MD, MPP, MBA
Department of Anesthesiology and Perioperative Medicine UCLA Health, David Geffen School of Medicine at UCLA, Los Angeles, CA

Is telehealth use among anesthesiologists something new? No. Anesthesiology has had over a decade of experience with telehealth in the perioperative environment and an even longer experience using the technology in the intensive care units. But as telecommunication technology has drastically improved in the last decade, and mobile phone adoption has reached near ubiquity in the United States, there has been a newfound interest with telehealth adoption among anesthesia practices. As anesthesiologists are compelled to practice more often in the perioperative space, this technological tool is ripe for adoption and use among anesthesiologists and other perioperative physicians.

The Economics Around Telehealth Adoption

Across the United States, we see heavy consolidation of healthcare practices— anesthesia is no exception. Larger corporate groups are purchasing anesthesia practices to reap the benefits of economies of scale. Healthcare systems are purchasing hospitals to increase their geographic footprint and maintain their reimbursement revenues in the face of consolidating payer entities. There is a phenomenon of regionalization and geographic specialization happening within these larger healthcare systems. Hence, patients will come to each healthcare location for consultation from farther distances.

The younger demographic of soon-to-be surgical patients (18-35) grew up with smartphone technology and universally own a mobile device. They are accustomed to ordering and receiving goods and services immediately from their phones: they order an Uber or Lyft for their immediate transportation, Doordash for their food delivery, Amazon for their market and grocery runs…they even order their medications for delivery over the internet and directly from their pharmacy. This demographic has the same expectations of “just-intime” delivery of goods and services for daily shopping as they do for healthcare. They are flocking to technology savvy healthcare startups for their primary care including One Medical and Forward. To attract and stay relevant to this demographic, who are currently the low-risk healthcare cohort, healthcare practices must understand that telehealth will be a staple digital interface for the modern patient.

The Startup Costs

Most practice managers may be reluctant to invest in telehealth due to sunk capital costs and daily operating costs. As conferencing technology advanced away from desktop computers to mobile phone technology, the sunk costs involved diminished and now are largely organizational. At UCLA, it was very practical and cost-permissive to pilot our telehealth endeavor using Zoom Telecommunications. This thirdparty software platform has longstanding experience with video digital conferencing and their end-to-end user interfaces are simple, logical and practical. Zoom’s platform is also HIPAA compliant when contracting with healthcare practices, which protects the practice from patient privacy concerns. Consumer and business telecommunication technologies have a downside in that they require administrative support to maintain the patient schedule and send out a Zoom-generated internet link by email to both provider and patient. Patients need to download a computer or cell phone app to launch the Zoom platform and there continues to be technical glitches on particular internet browsers for launching the platform. Overall, commercial telecommunication platforms can serve as a practical first step for smaller healthcare practices who want to pilot telehealth consults with patients.

After a year of our program, our UCLA Department migrated from Zoom to an electronic medical record (EMR) embedded telehealth portal provided by EPIC called MyChart Video in which the technological platform was designed and implemented by Vidyo. This simplified our administrative workflow as all the perioperative clinic scheduling for telehealth consultations were coordinated within the EMR, and both patients and providers could launch the telehealth portal from within the EPIC EMR or on their mobile device. This facilitated access to the patient’s chart during the patient interview and gave legitimacy of the interaction for the patient as they were accessing their patient-facing EMR portal to open the telehealth encounter. I am confident that in the future, the majority of commercial EMR platforms will offer a refined telehealth portal for their healthcare customers and bundle this feature into their product.

The Provider Benefit

Anesthesiologists face a clinician brand problem in modern healthcare. Often, our presence is elusive and we are apparitions behind the ether screen keeping our patients stable, safe and alive during major invasive procedures. Some clinicians argue that if we are doing our jobs right, patients shouldn’t remember us at all. However, I would argue that it is of prime importance for anesthesiologists to establish and maintain patient rapport prior to the day of surgery. Telehealth offers this digital interface venue between anesthesiologist and patient. The convenience of telehealth promotes on-time patient encounters since patients can link into the telehealth visit from virtually anywhere that has a cellular phone or internet connection. At UCLA, we have had patients enter an anesthesia consult from the passenger seat of a driving car, from their work office, from their living room, and even just out of bed while still wearing pajamas! Using telehealth encounters, we get a small glimpse into the patient’s home environment where we often see their partner, spouse, children or parents during the encounter and get a sense of their post-procedure support network. More specifically, we can evaluate their airway and even capture a still image of their airway and embed it into our chart or note to assist the airway assessment on behalf of an anesthesia colleague who will eventually care for the patient. The digital interview vastly improves a general phone-based assessment from the anesthesiologist to determine if this patient is “sick or not sick” far in advance of the surgical procedure date. In the literature, the telehealth consultations did not result in an increase of case cancellations or delays compared to those seen in-person. Overall, this digital interfacing opportunity for the anesthesiologist demystifies our role in the care process and ultimately advances the brand of our specialty as physicians.

The Patient Benefit

Patients derive the main benefits from telehealth encounters. The interaction with the anesthesiologist prior to their case is highly valued to many patients. Albert Schweitzer accurately said, “pain is a more terrible lord of mankind than even death itself.” Today, patients continue to have anxiety of the pain during surgery and even rare instances of awareness under surgery. They appreciate the opportunity to reveal those fears of anesthesia directly to a provider. At UCLA, we found that patients who have tried a telehealth encounter for preoperative evaluation prefer doing their consultation again using the platform and the majority of them are very satisfied with the experience, particularly for its time-saving benefit in urban Los Angeles traffic conditions. According to market research reports, the benefits that drive telehealth adoption are the convenience of the platform, the costs saved for the patient (both direct and time saved), and the reliability of avoiding an in-person visit. According to an Advisory Board survey, 40 percent of telehealth for a pre-surgery appointment. Of those surveyed, the platform, tends to attract users that are young, live in urban environments, have higher incomes, and are privately insured.

The Disadvantages

While digital patient interfaces are convenient and augment the patientanesthesiologist relationship, there are challenges to acknowledge. First, the demographics indicate that this platform is more consistent with a younger demographic and those who are comfortable adopting new technology. It may limit capturing the older, frailer population for which pre-operative evaluation is most important. If a healthcare practice has a patient population with a co-morbidity burden, telehealth may serve as a supplement rather than a replacement of a physical pre-operative evaluation clinic.

Financially, there are important considerations to evaluate the return on investment. Any clinical consult takes time away from general operating room activities. It requires a clinician or advanced practice nurse to spend non-OR time interfacing with the patient. This detracts from revenue generating activities. Unfortunately, current reimbursement for telehealth encounters from Medicaid and Medicare are poor or even non-existent. Medicaid reimbursement stipulations vary from state to state and must be investigated by each individual practice to establish reimbursement. Medicare gives limited telehealth reimbursement, except for rural locations, but recent announcements within CMS show that these stipulations could be changing in the future. Already, Medicare offers telehealth modifying codes for particular fee-for-service and remote monitoring billing codes (i.e., 99212- 99215 and 99091, respectively). Medicare also offers telehealth waivers for bundled payment programs such as complete joint replacement to aid telehealth adoption within bundled payment programs. I would argue that telehealth-based perioperative consultation is currently not revenue generating, but rather a brand building activity.

Who Should Adopt the Technology?

Perioperative telehealth programs are not advantageous for every healthcare practice. Large healthcare systems with patients with great geographic reach should invest in the technology, both to attract a younger, healthier, demographic into their system, as well as to add convenience to the surgical process for their patients who are accessing their system from more remote geographic locations. Telehealth visits make clinical sense in practices where patients have multiple co-morbidities where the practice would contemplate in-person pre-operative consultation. Since early literature shows no increase in case cancellations with ASA physical status I, II and III patients, telehealth offers an alternative to save on the sunk and operating costs involved in establishing a brick-and-mortar perioperative clinic. Finally, groups that wish to bundle more value into their surgical care package and experience should aim to invest into telehealth platforms to advance a competitive advantage and attract the tech-savvy, young, demographic that will be the future utilizers of modern healthcare and balance the financial risk pool for the healthcare system.

Areas of Growth

Within anesthesia, large areas of growth for telehealth use is predicted. I believe that anesthesiologists are the leaders of applied physiology in the hospital due to our mastery of monitoring real-time physiology with high-fidelity monitoring devices. In the future, I believe that reputation should transition to mastery of applied physiology outside the hospital using telehealth and remote monitoring technology. We already see large interest from private industry and big-technology companies around remote patient monitoring and wearables. Recently, Apple and Stanford University published their first study using Apple smartwatches to monitor and diagnose new onset atrial fibrillation using wearable sensors. Many expect the application of machine learning and deep learning methods to remote monitoring data will grow at a very high velocity in the next decade. Recently, the FDA cleared the first home remote monitoring wearable technology platform for patients and I expect we will see more remote monitoring devices to emerge in the digital health space. I would argue that this is a very ripe area where anesthesiologists should interact and codevelop with the industry to maintain our niche as applied physiology experts in a modern, cloud-computing, world.

Additionally, as patients adopt and use healthcare sensors within the home, we will see a growth in “patient-entered outcome data.” This is data that is pushed from a patient’s Bluetooth-enabled healthcare device to their phone, and eventually to the EMR for remote monitoring. I imagine such tools will help anesthesiologists redefine clinical assessment issues such as functional capacity and pre-operative optimization. Already at UCLA, we use Bluetooth-enabled weight scales to monitor our heart failure patients and track their dry weights so that we can schedule elective procedures when they are optimized. We can extend “patient-centered outcome data” to follow patients who aim to lose weight prior to surgery, or patients who need improved glucose control prior to elective cases, or even patients who have chronic pain and require an opioid reduction plan prior to coming back to the operating room. I picture a surgical future where rehabilitation has an active telehealth and remote monitoring component. Amazon already announced that they plan to deploy Alexa voice activation to decipher healthcare related information and push that information directly to clinicians via an electronic medical portal. In fact, telehealth opens up an entire new role where the anesthesiologist leads the 7-14 day transitions of care back to the outpatient world after an acute intervention—an activity that is highly valued by both CMS and healthcare systems to prevent unnecessary hospital readmissions.

Telehealth Implementation Tips:

For those anesthesiology practices that wish to make the digital leap by implementing a perioperative telehealth program, I offer the following advice:

1. Pilot the endeavor using commercially available video conferencing tools and survey the experience with both patients and clinicians early in the process.
2. Expect technical hiccups when you first launch the program. The learning curve is small, but it is still present for both patient and provider.
3. Start telehealth encounters ON TIME. Patients who conduct their business activities via their mobile phones expect on-demand services.
4. Explain the limitations of a telehealth visit during the consent process including the lack of a full physical exam or the need for a clinic visit to their primary care physician or specialist prior to their case if their history calls for a physical visit.
5. Set the expectations of the visit early in the conversation.
6. Look at the camera lens when speaking to your patient—not the window that displays the patient. Remember, the digital camera is above your computer or laptop screen.
7. Conduct your telehealth visit in a professional environment. Although these visits can technically be done from your own home, patients have a traditional expectation in their minds about visits with physicians.

Nirav V. Kamdar, MD, MPP, MBA is an is an assistant clinical professor and Director of Quality at the Department of Anesthesiology and Perioperative Medicine at UCLA. His research interests include applications of telemedicine and remote monitoring sensors for the perioperative period in surgical patients. He obtained his Doctor of Medicine degree from Stanford University School of Medicine and completed his anesthesia residency at Harvard University’s Massachusetts General Hospital in Boston, MA. Mr. Kamdar can be reached at NKamdar@mednet.ucla.edu.