Adopting Telemedicine for the Preoperative and Postoperative Care of Colorectal Surgery Patients
July 19, 2024
Over the last several years, the UPMC Division of Colon and Rectal Surgery has implemented a total telemedicine pathway as a novel and high-quality option for preoperative patients. David Medich, MD, FACS, FASCRS, chief, and Andrew Watson, MD, MLitt, FACS, surgeon, explain the benefits of telemedicine, a natural evolution for health care in today’s world of comprehensive electronic health records (EHR) and widespread use of advanced consumer electronics.
Telemedicine allows UPMC physicians to provide high-quality care in a virtual setting using video-communication through a smart phone, computer, or tablet. During a video visit, the physician discusses the patient’s health issues and concerns and performs a telemedicine physical examination.
Similar to an in-person consultation, the physician also reviews test results, the patient’s medical history, and the findings of other specialists to develop a care plan tailored for each patient. The main difference is that the patient is at home or work and does not have to travel to access UPMC’s world-class care.
The Colorectal Surgery Total Telemedicine Pathway
The total telemedicine pathway established by the UPMC Division of Colon and Rectal Surgery promotes the use of video visits for consultations, preoperative patient evaluations, and postoperative follow up. Using the portal provided by the MyUPMC app, a new patient engages with the surgeon via video conferencing from a location of the patient’s choosing, typically home or work.
The surgeon can participate from any location with sufficient privacy and a secure internet connection, but typically works from a UPMC workstation with multiple monitors where they can interact with the patient and view the EHR simultaneously. This operational model for physician workflow makes the total telemedicine pathway seamless for the colorectal surgeons and gastroenterologists at UPMC.
Currently, multiple physicians use this infrastructure as part of their surgical toolkit in blended clinics — mixing telemedicine and face-to-face interactions each day.
Telemedicine Is a Safe and Effective Way to Establish the Surgeon’s Relationship With the Patient
When preoperative care is provided using the total telemedicine pathway, we are introduced to the patient in the video conference. Rapport and the patient’s condition are established quickly. In most cases, the physician interacts with them in person for the first time on the day of their procedure. The day of the scheduled surgical procedure is a continuation of the relationship first established on the screen, when the physician meets the patient face-to-face and interacts with family members or friends supporting the patient.
Importantly, telemedicine does not preclude in-person care when required or requested. Most of the time, the total telemedicine pathway allows the surgeon to accomplish everything needed to prepare for the day of surgery. Nonetheless, there will always be situations when an anesthesiologist or the colorectal surgeon need to see the patient in person to provide appropriate care. In these instances, or if a patient requests it, a preoperative clinic visit is scheduled.
Telemedicine is simply another tool for comprehensive, high-quality surgical care. The decision to employ the total telemedicine pathway is one of the surgical assessments that the UPMC colorectal surgeons make daily, with similar significance as decisions made routinely in the operating room.
Postoperative care is by far the easiest aspect of the total telemedicine pathway. Postoperative visits are typically short and involve inspection of incision healing, diet discussions, and postoperative expectations. Patients report great satisfaction with avoiding driving trips and extensive waiting room times. For most colorectal surgery patients, postoperative telemedicine is an appreciated convenience, and few have medical issues necessitating in-person evaluation and care.1,2
Telemedicine Benefits Patients
UPMC adopted the total telemedicine pathway because it is the patients’ best interest.3 When patients travel to our clinic for a straightforward surgical issue, the time, expense, and stress of travel are not ideal. Time and money are spent one each visit, and, for some patients, this presents significant hardship, especially if they have to take time off work. Patients routinely face challenges when they do not drive and need to find other transportation.
Because of colorectal issues, some patients have a very difficult time when they do not have easy access to a bathroom. The side effects of travel in this patient population are not inconsequential. A car trip might take twice as long as anticipated for a patient with a colorectal disorder because of the need for bathroom stops, or a patient may accept soiling themselves as the only way to make the trip.
When we can reach out to patients using telemedicine and see them in an easy and convenient location (e.g., at home or at work), receiving care is less burdensome and less stressful and saves both time and money. The vast majority of patients report that they are very satisfied after telemedicine visits.
The total telemedicine pathway is also appreciated by the UPMC medical team. The same preparation is required for telemedicine and in-person preoperative visits. With the evolution of the electronic health record (EHR), the surgeon can assess every detail of a patient’s medical record (e.g., laboratory tests, colonoscopy results, CT scans) from a single, stationary location. When patients are seen via telemedicine, they are significantly less likely to cancel or no-show to their appointments, especially in the winter.
We also know from our personal experiences that the surgeon may gain additional insight into the patient’s condition or lifestyle factors impacting the patient’s health by viewing their home or local environment.
Why Now?
Although some remote interactions became normalized during COVID-19, the total telemedicine pathway for colorectal surgery was not the result of the pandemic’s precautions. Its foundations were in place 10-15 years ago, since telemedicine is a natural evolution of health care in today’s digital world.4
The establishment and maintenance of the EHR have been integral to the development of telemedicine. UPMC was an early adopter of the EHR and has been recognized as one of the most wired health care systems in the United States for 25 consecutive years. More than a dozen UPMC hospitals are at the highest levels of EHR adoption.
Advancements in consumer electronics and the near-universal adoption of the smart phone have also been essential to the establishment of telemedicine. Americans have become accustomed to downloading applications for specific purposes, logging into these applications with unique identifiers, and communicating in real-time using video.
For most, the nuts and bolts of a telemedicine visit are not new. Moreover, by possessing, or even just having access to, a cell phone, our patient population has given us a cost-effective way to deliver high-quality medical care.
The Total Telemedicine Pathway Is Equivalent to In-person Care
Although UPMC believes that we are improving the patient experience and are not compromising care by implementing telemedicine preoperatively and postoperatively in our specialty, we recognize the need to verify the feasibility and quality of this approach as a tool for colorectal surgery and medicine in general. As telemedicine for preoperative visits was adopted, UPMC surgery successfully utilized telemedicine to evaluate 93 patients from 96 referrals. Three patients with planned telemedicine preoperative visits were converted to in-person preoperative care (~5%) — two due to medical issues and one due to an insurance issue.
Dr. Watson has conducted more than 950 telemedicine visits, with only three instances of in-person visit requests. Implementing a total telemedicine pathway for preoperative and postoperative care for patients undergoing colorectal surgery is clearly feasible, safe, and effective. To verify that care is not compromised using the total telemedicine pathway, key performance indicators (KPIs) were examined as a quality metric.
These KPIs (re-admissions, length of stay, length of surgery, cancelled cases, and morbidity and mortality) are routinely monitored by UPMC and the total telemedicine pathway team. No difference in safety, as indicated by KPIs, has been observed using the total telemedicine pathway as compared with in-person clinic visits.
There was also no significant difference in KPIs when comparing the first 70 patients cared for with a previous iteration of the total telemedicine pathway with the 70 patients treated immediately prior to its adoption. Thus, UPMC has documented that the quality of care is the same for patients evaluated with telemedicine and patients seen in person.5
Finally, patients rarely need to be rescheduled due to last minute issues discovered on the day of surgery. Telemedicine is an important advance in health care. It is more convenient for the patient, saving them both time and money. Exceptional health care can be delivered to most patients using telemedicine, with in-person appointments prioritized as needed. The availability of UPMC’s technology platforms, technological support, and its well-established and maintained EHR further elevate our application of telemedicine.
Twenty years ago, the total telemedicine pathway would have been unthinkable. Today, the evolution of consumer electronics and the EHR have made telemedicine easy, affordable, and an essential component of patient care. Care plans without the benefits of telemedicine would be a disservice to our patients. We are striving to develop evidence-based best practices for telemedicine in surgery and medicine and seek to pioneer new care delivery pathways.
The UPMC Division of Colon and Rectal Surgery offers surgical consultations for patients via telemedicine for conditions such as diverticulitis, ulcerative colitis, and Crohn’s disease. To learn more or refer a patient, call 412-647-1705.
References/ Recommended Reading
- Nicholson KJ, Rosengart MR, Watson AR. Telerounding Has Clinical Value and Enables the Busy Surgeon: A Colorectal Surgeon’s Ten-Year Experience. Am Surg. 2022 Dec;88(12):2923-7.
- Yao LY, Fleshner PR, Zaghiyan KN. Impact of Postoperative Telemedicine Visit Versus In-Person Visit on Patient Satisfaction: A Randomized Clinical Trial. Surgery. 2023 Feb;173(2):322-7.
- Watson AR. Why Surgeons Must Adopt and Leverage Telemedicine: This Journey Is Part of Our DNA. Surgery. 2021 Feb;169(2):225-6.
- Tyler KM, Baucom R. What Every Colorectal Surgeon Should Know About Telemedicine. Dis Colon Rectum. 2020 Apr;63(4):418-9.
- Hawkins AT, Ueland T, Aher C, et al. Shared Decision-Making in General Surgery: Prospective Comparison of Telemedicine vs In-Person Visits. J Am Coll Surg. 2023 Apr 1;236(4):762-71.
