A Proposal for the Study of a Conceptual Framework to Inform Optimal Use of Telehealth for Postoperative Upper Extremity Care

Abstract

Telehealth is a familiar and widely available care-delivery model that is promoted as a solution for access-to-care issues and the rising costs of in-person health care services. Multiple studies report comparable clinical outcomes of telehealth care-delivery with traditional in-person care for many diagnostic conditions and patient groups, including postoperative orthopedic conditions such as knee and hip arthroplasty [1,3,4]. Despite the benefits, there was a slow widespread adoption and acceptance of telehealth across health care disciplines prior to the COVID-19 pandemic. Health care insurers did not routinely include telehealth services as reimbursable services in their plans [15]. For postoperative upper extremity musculoskeletal (UE-MSK) disorder care, telehealth services were rarely provided. The rapid adoption of telehealth services for postoperative UE-MSK care, born of necessity during the COVID-19 pandemic, suggested that telehealth is a possible, feasible, and safe alternative to traditional care-delivery for UE-MSK conditions, including for postoperative patients [6,8,9]. As we return to a normalized health care system, we are faced with new possibilities, challenges, and questions regarding optimal care-delivery models for our postoperative UE-MSK care patients. The factors affecting care-delivery outcomes for UE-MSK conditions are complex, multifactorial, and not well studied or understood. They span multiple perspectives and user groups. The pandemic provides a unique opportunity to study a cohort of patients who traditionally underused telehealth services, allowing for comparative analysis between care-delivery model groups. We propose a conceptual model to study and optimize clinical, patient, and health care organization outcomes that accounts for the complex interaction of multilevel factors: patient (demographics, co-morbidities), clinician (experience, specialty), clinical (diagnosis, surgery), and organization (resources) to drive the selection of optimal caredelivery for each patient (Fig. 1). Previous research in MSK telehealth focused on barriers to implementation from the patient and clinician perspectives. Common predictors of patient engagement were age, educational level, and computer literacy [5,10,11,14,15]. From the clinician perspective, common predictors of implementation included resistance to change, perceived depersonalization of care, and perceived patient privacy and safety [4,10,11]. Other studies have compared the cost of traditional care with telehealth services, indicating low reimbursement as a primary limiting factor of implementation [11,13]. Many of these studies focused on a single influencing factor such as costs, reimbursement rates, or clinician or patient perspective—ignoring the interactions of multiple factors on outcomes. Additional studies found no differences in clinical outcomes between telehealth and in-person MSK rehabilitation and postoperative care for other (non-upper extremity) orthopedic conditions such as spine, hip, and knee injuries [1,3,4]. The conceptual framework to inform optimal use of telehealth care accounts for multiple factors. Qualitative perspective studies and quantitative comparative outcome studies are necessary to increase understanding of the complex factors that contribute to the successful implementation and use of telehealth as an alternative care-delivery model. These quantitative and qualitative studies lay the groundwork and 976117 HSSXXX10.1177/1556331620976117HSS Journal: The Musculoskeletal Journal of Hospital for Special SurgeryWolff et al article-commentary2020