key: cord-316306-vfez5k02
authors: Bini, Stefano A.; Schilling, Peter L.; Patel, Shaun P.; Kalore, Niraj V.; Ast, Michael; Maratt, Joseph; Schuett, Dustin; Lawrie, Charles M.; Chung, Christopher; Steele, G. Daxton
title: Digital Orthopaedics. A Glimpse into the Future in The Midst of a Pandemic
date: 2020-04-22
journal: J Arthroplasty
DOI: 10.1016/j.arth.2020.04.048
sha: 
doc_id: 316306
cord_uid: vfez5k02

BACKGROUND: The response to COVID-19 catalyzed the adoption and integration of digital health tools into the healthcare delivery model for musculoskeletal patients. The change, suspension or relaxation of Medicare and federal guidelines enabled the rapid implementation of these technologies. The expansion of payment models for virtual care facilitated its rapid adoption. The authors aim to provide several examples of digital health solutions utilized to manage orthopaedic patients during the pandemic and discuss what features of these technologies are likely to continue to provide value to patients and clinicians following its resolution. CONCLUSION: The widespread adoption of new technologies enabling providers to care for patients remotely has the potential to permanently change the expectations of all stakeholders about the way care is provided in orthopaedics. The new era of Digital Orthopaedics will see a gradual and non-disruptive integration of technologies that support the patient’s journey through the successful management of their musculoskeletal disease.

The response to COVID-19 catalyzed the adoption and integration of digital health tools into the 8 healthcare delivery model for musculoskeletal patients. The change, suspension or relaxation of 9

Medicare and federal guidelines enabled the rapid implementation of these technologies. The 10 expansion of payment models for virtual care facilitated its rapid adoption. The authors aim to 11

provide several examples of digital health solutions utilized to manage orthopaedic patients 12 during the pandemic and discuss what features of these technologies are likely to continue to 13 provide value to patients and clinicians following its resolution. 14 Conclusion: 15 The widespread adoption of new technologies enabling providers to care for patients remotely 16 has the potential to permanently change the expectations of all stakeholders about the way care 17

is provided in orthopaedics. The new era of Digital Orthopaedics will see a gradual and non-18

disruptive integration of technologies that support the patient's journey through the successful 19 management of their musculoskeletal disease. The Covid-19 pandemic is placing a massive strain on the ability to deliver care to 27 patients with musculoskeletal complaints. In the world of hip and knee arthroplasty, which 28 generally cares for an older population with a number of co-morbidities, patients are being 29 asked to delay interventions until hospitals are safe for elective surgery. 30 31

Care delivery models based on the in-person visit are therefore not able to meet patient 32 needs in the context of "stay at home measures" and "social distancing". Conversely, digital 33 health tools have been particularly useful in the response to COVID-19 because they enable 34 care to be delivered at a distance. It is important to note therefore that the class of tools and 35 applications generally termed "Digital Health" may change the paradigm of how we deliver care 36 but does not change the care we deliver. For example, whether an exercise for knee 37 strengthening is proposed by a therapist or an avatar does not change the nature of the 38 exercise itself. This is an important distinction as these technologies are designed to enable and 39 simplify the delivery of care, not to change the actual treatments we provide patients. unfortunately, many perceive their adoption as threatening their livelihood or their inherent value 52

to the system. While such a point of view may be common, it is wide of the mark. In a recent 53 article in Harvard Business Review [1] , the authors made several salient points regarding the 54 topic of the perceived disruptive nature of digitalization. They point out that the adoption of new 55 technology does not require the wholesale disruption of the current value proposition of a 56 practice or hospital, but rather the implementation of digital tools enables the same institution to 57 better serve its patients; they emphasize that digital will not replace physical, but rather augment 58

it. They underscore that digitalization does not require a painful overhaul of legacy systems but 59 rather a focus on incremental bridging from one set of technologies to another. We 60 acknowledge at the outset that the wholesale transition to electronic health records (EHRs) was 61 painful and expensive. Portability and Accountability Act (HIPAA) rules were relaxed allowing televisits to be performed 74 via regular phones and commonly used social media applications. While these restrictions will 75 be relaxed only for the duration of the pandemic, it is likely that many will not be fully reinstated. with many practices going from 1-2% of all visits being online to nearly 100%. In person scribe 107 services were already common in clinics where the administrative burden of documentation was 108 perceived to be untenable. Many practices had to quickly pivot from the in-person scribe model 109

to utilizing virtual scribes on telehealth platforms. These virtual scribes, like their in-person 110 counterparts, can document visits in the EHR and free the provider to engage with the patient 111 on the online portal. The virtual scribes log into the visit and have access to everything the 112 clinician sees and hears. Digital scribes are joining the party as well. Virtual digital scribes are 113 software programs that take advantage of the rapid advances in the branch of artificial 114 intelligence (AI) devoted to voice recognition. Coupled to complex ontologies trained on 115 hundreds of thousands of medical articles, these algorithms can listen to a natural conversation 116 between the patient and the clinician and create the equivalent of a clinical note, place it in the 117 chart, and even provide an evaluation of the note for billing. Simpler programs can take and 118 transcribe a dictation. 119 120

As virtual digital scribes become further integrated into telehealth platforms, they will be 121 able to support clinicians working from home seeing patients without their support staff. While 122 randomized control trials have shown that access to scribes can decrease charting time and 123 increase physician satisfaction [2], little is known about the impact of digital scribes on patient or 124 decreasing physician burnout. Their increased adoption in busy clinics and Emergency 125

Departments has, however, been noted by companies in the space and while still in their 126 formative years, the potential of these companies should not be underestimated. 127 128 Chatbots 129 130

Chatbots can triage calls freeing staff to focus on more complex problems. What makes 131 chatbots different is that they use AI to not only understand the question being posed in 132 "natural" language, but also to select the corresponding answer from a selection of options. For 133 example, if a patient asks about a "headache", "pain between the ears", or "throbbing in the 134 head" the chatbot understands all three to be referring to a headache. It can then ask further 135 questions before providing an appropriate answer, recommend an appointment, or triage the 136 patient to a provider. During that window, the system can provide more and better data to optimize the models and 202 inform decisions to fight and manage the pandemic [8]. The elegance of the phrase, "flattening 203

the curve" is difficult to overstate. It has proven to be a life-saving concept that was born in data 204 and then successfully packaged into a simple phrase and infographic that concisely explained 205

what the problem was to decision makers and the general public alike. It lent credence and 206

context to the phrases that explained what to do about the problem (e.g., "social distancing" and 207 "shelter in place") and their impact. The story of this data-derived-insight turned public-health-208 meme is still unfolding but may truly go down as one of the great public health triumphs of our 209 day. One moral of the story is the importance of taking our data-derived insights across the 210 "finish line". Data, technology and a good analysis alone don't go far enough: we must make 211 the data do something by translating insights into effective policies that induce behavior change 212

if we are to achieve the desired outcome. This will be true as we apply data science to 213 orthopaedics in the future as well. 214

Third, there are faint glimmers of the potential impact of machine learning on basic 215 science in the efforts to find treatments and a vaccine for COVID-19. In general, machine 216 learning based approaches are helping scientists to target their efforts to those areas most likely 217

to meet with success as opposed to squandering time on experiments that are less likely to be 218 fruitful. For example, machine learning has helped scientists predict chemical properties of 219 drugs and proteins [9], predict vaccine immunogenicity [10], identify promising drug targets [11], 220 and even identify existing drugs that have the potential to be repurposed for use against other 221 pathogens [12] . It remains to be seen if these advancements will be successfully applied to the 222 discovery of treatments and a vaccine for SARS-CoV-2, the virus that causes COVID-19. The 223

exciting potential of machine learning is perhaps best exemplified by AlphaFold, a machine 224 Surgical scheduling platforms simplify the complexity of cancelling and rebooking 280

procedures. As the "curves begin to flatten" and surgeons are given the green light to proceed 281 with elective surgeries, they may be overwhelmed by the task of rescheduling these procedures. 282

This daunting task may be difficult to tackle with a notebook full of names, an EHR calendar not 283 designed for this purpose, fewer staff due to COVID-19 related requirements or staff reductions, 284

concerned patients, and the complexity of obtaining authorizations. Some surgeons may use 285 the current crisis as an opportunity to implement surgery scheduling platforms to streamline the 286 rescheduling process and modernize their practice with tools that can connect multiple 287 hospitals, implant representatives, pre-operative screening clinics and third party payers through 288 a single platform that can also provide analytics such as utilization metrics, backlog analysis and 289 cancellation mitigation tools 290

All interested parties are connected to the same scheduling-based platform and the 291 platform can connect to nearly all EHRs thanks to the wide and government required 292 implementation of Fast HealthCare Interoperability Resource (FHIR) standards to assist with 293 data sharing between EHRs and patients or providers. Some of these platforms can assist in 294 rescheduling by using artificial intelligence algorithms to identify which patients are available to 295 fill a cancellation or triage patients by level of care to surface the most urgent. All key players 296 are kept informed in real time of the schedule, most notably the patient. The goal is to keep 297 patients engaged in the process through direct communication while minimizing the work 298 burden placed on the surgeon and their support staff. 299

Integration can be accomplished in as little as a few days to a few weeks depending on 300 the complexity of the EHR integration. COVID-19 has challenged the health care system in ways that will reverberate for years 391 to come. The orthopaedic community has risen to the challenge of caring for patients sheltering 392

in place by exploring and adopting a set of digital health technologies that have extended the 393 community's ability to triage and deliver care in the most appropriate venue, whether that be at 394 home, the clinic or the hospital. We believe that many of the technologies presented in this 395

communication will prove to be useful at simplifying or addressing pain points that exist in 396 current care models. It can be argued that the pandemic has afforded us a glimpse into a future 397

where clinical orthopaedics partners with digital health solutions to create a hybrid: digital 398

orthopaedics. As we look forward to the end of the pandemic, it is likely that we will emerge to 399

find a care delivery model that is fundamentally and permanently changed. 400

Digital Doesn't Have to Be Disruptive. The best results come from adaptation 402 rather than reinvention

Impact of scribes on physician satisfaction, patient satisfaction, and 405 charting efficiency: a randomized controlled trial

Healthcare ex Machina: Are conversational agents ready for 407 prime time in oncology

Rehabilitation In-Home Therapy Compared with Traditional Care After Total Knee Arthroplasty: 411 VERITAS, a Randomized Controlled Trial

Telehealth Care Navigation for Arthroplasty Patients: A Retrospective Case Series

A fiasco in the making? As the coronavirus pandemic takes hold, we are 416 making decisions without reliable data

The lost 418 month: how a failure to test blinded the US to Covid-19

Flattening the curve for COVID-19:Expert Howard Markel Weighs in

Workshop report on basic research needs for scientific 424 machine learning: Core technologies for artificial intelligence

Methods for predicting vaccine immunogenicity and reactogenicity

Recent advances in the 430 machine learning-based drug-target interaction prediction

Using drug expression profiles and machine learning approach for 433 drug repurposing

Improved protein structure prediction using 437 potentials from deep learning

Computational 439 predictions of protein structures associated with COVID-19

Association of wearable activity monitors with 444 assessment of daily ambulation and length of stay among patients undergoing major surgery

Telemonitoring-supported exercise training, 448 metabolic syndrome severity, and work ability in company employees: a randomized controlled trial

Perception of Older Adults Toward Smartwatch Technology for 452

Assessing Pain and Related Patient-Reported Outcomes: Pilot Study. JMIR mHealth and uHealth

Gait Analysis Using Smartwatches

Wearable 458 inertial sensors and pressure MAT detect risk factors associated with ACL graft failure that are not 459 possible with traditional return to sport assessments

Virtual reality training improves trainee 462 performance in total hip arthroplasty: a randomized controlled trial

Virtual Reality for Total Hip Arthroplasty: Objective Measurement of Skills and Transfer of 466

Is virtual reality effective in orthopedic rehabilitation? A 468 systematic review and meta-analysis

Effects of early virtual reality-based rehabilitation in patients with total knee 471 arthroplasty: A randomized controlled trial

What the evidence shows about patient activation: better 473 health outcomes and care experiences; fewer data on costs

Why does patient activation matter? An examination of the 475 relationships between patient activation and health-related outcomes

Hospital admissions, emergency 478 department utilisation and patient activation for self-management among people with diabetes. 479 Diabetes research and clinical practice

College smoking-cessation using 481 cell phone text messaging

Diabetes management via mobile phones: a systematic review

Evaluation of a 485 mobile health system for supporting postoperative patients following day surgery

Improving patient health engagement with mobile texting: A pilot study in the 489 head and neck postoperative setting

Patient engagement and reported outcomes in surgical recovery: effectiveness 492 of an e-health platform

Patient adoption and utilization of a web-based and mobile-based portal for collecting outcomes after 495 elective orthopedic surgery

FAQs on Shortages of Surgical Masks and Gowns

NIH 3D Print Exchange

Fenton man producing COVID-19 protective gear amid supply shortage 502

3D Printing Community Responds to COVID-19 and Coronavirus Resources 505

Johns Hopkins Engineers Develop 3D-Printed Ventilator Splitters

Laser and electron beam powder bed 511 additive manufacturing of metallic implants: A review on processes, materials and designs

• COVID19 accelerated the adoption of digital technology in orthopaedics • Virtual musculoskeletal conditions will be managed using mobile technology • Digital Orthopaedics will not disrupt existing models but rather amplify them • Digital Orthopaedics includes telehealth, chatbots