mHealth Research Digest with Anupam Kumar

Telemedicine has seen exponential growth in application in recent years.  This includes anything from consultations conducted by telephone to image transfers for the purposes of diagnosis at a distance.

The medical specialties perceived to benefit most from this expansion of communications technology applications are those that rely heavily on visual inspection for diagnosis and are in high demand for consultation such as plastic surgery, radiology, dermatology.

Plastic surgery, in particular, lends itself to initial patient assessment and management via 2D visual inspection.

While it has been accepted that telemedicine consultations in plastic surgery are indeed feasible with current communications technology, data on the potential benefit to the patient and protection of patient health information remains scant.

Gardiner et al. recently published a review in the Journal of Plastic, Reconstructive & Aesthetic Surgery in which they assessed existing studies on the use of telemedicine in plastic surgery and analyzed potential concerns that must be resolved prior to widespread application.

Methods

To locate published, original research on the subject, the authors of the study performed a literature search using permutations of relevant keywords. Twenty-nine articles were located that met inclusion criteria and concerned telemedicine applications in plastic surgery. These articles were grouped into common plastic surgery subfields:

  • 11 trauma and burns
  • 4 hand
  • 5 wound-care
  • 5 maxillofacial
  • 1 digital replantation
  • 2 free-flap monitoring
  • 1 technical application of telemedicine

Results

Twenty-eight of the manuscripts discussed benefits from the use of telemedicine systems, including improved access to expertise and costs saved through reduction of unnecessary transfers and conservation of hospital resources. Fifteen of the articles reported on complications associated with telemedicine. These complications were divided into six groups:

  • misdiagnosis (4)
  • time consumption (3)
  • training (4)
  • technical issues (3)
  • dissatisfied users (2)
  • cost (2)

Five studies successfully showed that “injury assessment was similar whether using transmitted digital images or visual examination with an accuracy of 90% or more.”

However, two studies concerning management of digital injuries and nasal fractures found that telemedicine consults were inferior to face-to-face consultation, suggesting a need for tactile or 3D imagery in effective evaluation. Only four articles touched upon ensuring protection of patient health information during data transfer for plastic surgery consultation.

Roe et al. found that burn experts were able to accurately diagnose patients based on digitally transferred imagery alone; visual inspection is the primary means for evaluation of burn patients, consistent with accuracy of over 97% reported by some studies. Additionally, Scerri et al. concluded that specialist advice through telemedicine would have prevented many unnecessary patient transfers that not only place unstable burn victims at risk for traumatic injury during travel but also incurs significant expense and errors in management. Hsieh and colleagues found that photographic assessment of traumatic amputation victims was highly sensitive and specific and similarly avoided inappropriate patient transfers.

On the issue of medico-legal implications of patient data transfer for telemedicine consultations, the authors report that risk evaluators and lawyers in the UK have concluded that only transmitting data relevant to the problem in question, using storing and transmission methods where confidentiality and security are guaranteed, and obtaining informed consent from the patient, are ways in which these problems can be minimized.

Additionally, the authors note that “the ideal modality for medical image transfer is via a secure online consultation website (https transmission and password protected).” Abou et al. and other authors of included studies utilized password protected secure networks, though further study is necessary to evaluate the strength of these information protection efforts. Although variable by institution, email can be secured when sent to others within the same protected network; guidelines on use of email for transfer of patient data continue to evolve and must be confirmed with legal departments at each institution.

Furthermore, benefits to patient outcomes and cost savings have yet to be demonstrated. Gardiner et al. have shown through their extensive literature review that patient information is currently being shared through digital communications technology by plastic surgeons. This communication occurs not only between plastic surgeons and referring physicians, but also between physicians and patients, nurses and physicians, and junior physicians and senior physicians for remote collaboration on diagnostically complex cases.

For medical fields that rely extensively on visual information for diagnostics, telemedicine represents a powerful avenue for patients and referring physicians to access specialty services without regard to physical distance. As noted by the authors, versatility and ease of telemedicine “means that it can be used between different healthcare professionals across different teams at different points in the care pathway of patients.”

Next Steps

However, cost savings and improved patient care outcomes, while theoretically likely, have yet to be proven in the literature. Accordingly, this promising field requires much research into the optimization of health communications technology for patient care as well as ensuring that such efforts are performed with utmost focus on patient health information security.

Authors: Sonya Gardiner, Tristan L. Hartzell

Institutions:  Addenbrooke’s Hospital, Cambridge, United Kingdom;  Department of Surgery, Massachusetts General Hospital, Boston, USA.

Original abstract: PubMed