Telemedicine in Follow-up Clinics: Safety, Satisfaction, and Strategy

Visual Element: A flow chart illustrating the "Telemedicine Triage Protocol," showing the decision pathway for routing patients to Face-to-Face vs. Virtual vs. Asynchronous review based on risk factors and clinical needs.

The Virtual Waiting Room: A New Paradigm

The COVID-19 pandemic acted as a forced catalyst for digital transformation in healthcare. What began as a crisis response has matured into a stable, efficient model of care. For orthopaedic surgeons, whose practice relies heavily on imaging and functional assessment, telemedicine offers a unique opportunity to decouple "clinical review" from "physical presence."

However, the transition is not without pitfalls. This article examines the safety, efficacy, and optimal implementation of telemedicine in orthopaedic follow-up clinics.

The "Wound Check" Fallacy

Traditional teaching dictates that a surgeon must "lay hands" on a patient to assess them. In the context of a routine 2-week post-operative check, this is often a fallacy.

• The Traditional Model: A patient travels (often hours), pays for parking, waits in a crowded waiting room for 60 minutes, sees the registrar for 4 minutes who says "wound looks dry," and then leaves.
• The Cost: Lost productivity for the patient, congestion in the clinic, and environmental cost of travel.
• The Virtual Model: The patient uploads a high-resolution photo of the wound. The surgeon reviews it between cases. "Wound looks dry. Remove sutures. Start physio."

Clinical Pearl: Patient selection is the single most important determinant of telemedicine success. It is not suitable for everyone.

Modes of Telemedicine

1. Synchronous (Real-Time Video)

This is the "Zoom" call. It mimics a face-to-face consult.

• Pros: Allows for real-time interaction, questioning, and guided examination ("Move your thumb like this"). Good for building rapport.
• Cons: Requires scheduling alignment. Tech failures (audio/video lag) can be frustrating. Not truly efficient for the surgeon.

2. Asynchronous (Store-and-Forward)

The patient submits data (photos, PROMs, videos of ROM) via a secure portal. The clinician reviews it at a later time.

• Pros: Maximum Efficiency. A surgeon can review 20 "virtual folder" patients in the time it takes to see 5 face-to-face. No scheduling conflicts.
• Cons: No immediate dialogue. Requires a robust platform.

Evidence Corner: Studies in The Journal of Bone & Joint Surgery have shown that asynchronous wound review has a 98% accuracy rate compared to in-person review for detecting surgical site infection (SSI), with significantly higher patient satisfaction scores.

What Works? The "Green Light" Conditions

Telemedicine is excellent for:

• MRI Results Review: "The scan shows a meniscal tear. Here are the options." (Screen sharing the MRI is often clearer for the patient than squinting at a monitor in a clinic room).
• Routine Post-Op Checks: ACL reconstruction at 6 weeks, TKA at 1 year (with X-ray).
• Fracture Clinic Triage: Reviewing ED X-rays to decide "Discharge," "Clinic," or "Surgery."

What Doesn't Work? The "Red Light" Conditions

Trap: Never use telemedicine for the "Unstable" patient.

Avoid virtual clinics for:

• New Patients with Undiagnosed Pain: Physical examination (palpation, stability testing, neurovascular status) is essential for diagnosis.
• Complex Pain/CRPS: These patients need holistic, face-to-face support.
• Breaking Bad News: Diagnosing sarcoma or informing a patient of a major complication requires the empathy and non-verbal communication that only in-person care provides.
• The "Technologically Challenged": Elderly patients with no smartphone support or poor connectivity.

The Virtual Examination: Tips and Tricks

If you are performing a video consult, you must adapt your technique.

1. Lighting: Ask the patient to face a window. Backlighting silhouettes them.
2. Camera Position: "Prop the phone up against a book on the floor" is better than holding it.
3. The "Comparison View": Always ask them to show the normal limb first, then the affected limb side-by-side if possible.
4. Gait: Ask them to walk away from the camera and back again.

Visual Element: A checklist graphic titled "The Virtual Exam Setup," showing ideal camera placement for shoulder, hip, and knee assessments.

Legal and Safety Considerations

Telemedicine is a medical consultation. All medico-legal standards apply.

• Consent: Document that the patient consented to a virtual consult and understands its limitations.
• Privacy: Ensure you are in a private room. Ensure the patient is too.
• Documentation: "Video consultation conducted. Limitations of virtual exam discussed. Red flags to watch out for explained: [List Red Flags]."
• The Safety Net: Always have a low threshold to convert to Face-to-Face. "I'm not 100% happy with how that looks on camera. Please come in tomorrow."

The Future: AI and Remote Monitoring

The next frontier is Remote Patient Monitoring (RPM).

• Wearables: Smart knee braces that track range of motion and step count daily (e.g., Canary Medical).
• Wound AI: Apps that use machine learning to analyse wound redness and swelling, flagging potential infections to the surgeon automatically.

Conclusion

Telemedicine is not a replacement for the art of surgery or physical examination, but it is a powerful adjunct. It respects the patient's time, optimizes the surgeon's workflow, and increases clinic capacity. The modern orthopaedic surgeon must be a "hybrid" practitioner, skilled in both the operating theatre and the virtual clinic.

Implementation Checklist

1. Platform: Use a dedicated, secure medical platform (not personal WhatsApp).
2. Protocol: Define exactly which appointments are "Default Virtual."
3. Admin Support: Ensure secretaries know how to troubleshoot patient tech issues before you join the call.
4. Billing: Understand the specific item numbers for telehealth in your jurisdiction.

References

1. Sathiyakumar V, et al. "Patient Satisfaction with Telehealth in Orthopaedics: A Systematic Review." JAAOS. 2022.
2. Buvik A, et al. "Cost-effectiveness of telemedicine in orthopaedics." BMC Health Services Research. 2019.
3. Australian Health Practitioner Regulation Agency (AHPRA). "Guidelines for Technology-Based Patient Consultations."
4. Sharareh B, et al. "Virtual Visits in Orthopedics: A rapid adoption protocol." Orthopedics Today. 2021.