key: cord-0807504-oll8g677
authors: Van Nest, Duncan S.; Ilyas, Asif M.; Rivlin, Michael
title: Telemedicine Evaluation and Techniques in Hand Surgery
date: 2020-06-02
journal: J Hand Surg Glob Online
DOI: 10.1016/j.jhsg.2020.05.006
sha: caecae3aeadcaa4dbd3e0e6ae41d7dc6ff0b60ac
doc_id: 807504
cord_uid: oll8g677

Abstract The demand for telemedicine has been increasing over the past several years with the growth of technology and digital connectivity in our daily lives. With the impact of the global COVID-19 pandemic, telemedicine implementation has become a necessity for many specialties as social distancing measures have greatly impacted access to routine medical care. This article presents a detailed and systematic approach to conducting a hand physical examination during a video telemedicine encounter. While the telemedicine physical examination presents its limitations, most components of the normal physical examination can be completed remotely with a systematic approach. We enumerate modifications to maximize examination remotely and present considerations for improved delivery of telemedicine care. These methods may be beneficial to providers incorporation telemedicine into their practice.

With the continued impact of the global COVID-19 pandemic, the application and expansion of 16 telemedicine modalities has come front and center. While telemedicine has been used successfully for 17 many years for a variety of purposes, the inability to physically touch our patients has resulted in limited 18 use of telemedicine for fields that rely heavily on physical examination. Thus, most of the data 19 presented to date on the efficacy of telehealth as an alternative to office visits has been largely focused 20 on telemental health, telerehabilitation, and teledermatology. 1 Because of the importance of the 21 physical exam within hand surgery, applications of telemedicine have been limited. Telemedicine 22 applications within hand surgery have largely focused on specific clinical situations, such as 23 postoperative care for select patients, smartphone photography to monitor range of motion for specific joints, or triage for tertiary referral. 2-6 A recent randomized controlled trial examining comprehensive 25 video-assisted orthopaedic consultations demonstrated that physicians rated their ability to examine 26 the patient as good or very good 98% of the time. 7 Of note, examination was completed with the help of 27 a nurse trained in physical examination maneuvers. It was also shown that these visits provided 28 adequate patient satisfaction and were cost-effective. 8, 9 While there have been successful applications 29 of telemedicine in specific settings, the ability to perform a comprehensive hand consultation and 30 examination has not been evaluated. Because of the current demand for telemedicine visits, the 31 purpose of this article is to characterize the components of the hand examination that could and could 32 not be performed remotely, and suggest adjustments to maximize the efficacy of the remote hand 33 consultation and examination. The comprehensive hand examination in a traditional office visit typically involves inspection 39 and palpation, vascular examination, sensory examination, and motor examination. The ideal position 40 for examination is with patient across from provider with the patient's hands resting on a table. 41

Complete inspection consists of observing how the patient holds their hands and assessing for any 42 visible signs of injury or trauma such as swelling, erythema, ecchymosis or laceration. Inspection should 43 also include having the patient demonstrate the digital cascade through flexion and extension, paying 44 close attention to any deficits in range of motion or malrotation. Palpation should assess for any areas of 45 localized tenderness, swelling, or masses. Any areas of localized swelling or erythema should also be 46 assessed for associated fluctuance and warmth. Vascular examination consists of peripheral pulse exam, temperature, color assessment, and capillary refill. A proper sensory examination should consist 48 of ability to discern light touch as well as two-point discrimination in the relevant sensory distributions. 49 A motor exam should begin with assessment for passive range of motion across all joints in the hand 50 and wrist. All extrinsic flexors, extrinsic extensors, and intrinsic muscles should be assessed with and 51 without resistance. Lastly, any specialty tests should be performed such as provocative test's for carpal 52 tunnel, cubital tunnel, or De Quervain's tenosynovitis, among others. 53

Using the normal, in-person hand exam as a framework, we can systematically go through and 54 assess each step or maneuver for feasibility during a remote, telemedicine encounter. Patient 55 positioning is very important during in-person examinations and is equally important when remote. 56

However, limitations in camera positioning poses challenges for both the patient and the provider. Ideal 57 positioning would have a camera looking down on the patient's hands, as if directly across from the 58 provider. However, this cannot be independently achieved with all personal computers or smart devices. 59

Additionally, this camera angle prohibits eye contact with the patient which could prove detrimental to 60 communication during the examination. The use of a smart phone poses additional limitations as one 61 hand may have to be used to hold the device. If a smart phone is the only option for a patient, the 62 assistance of a family member or friend may be warranted for videotaping. Alternatively, the patients 63 can be instructed to secure the handheld device in a vertical position across the patient for optimal 64 perspective. 65

During the physical examination, inspection can be accomplished with minimal limitation. 66

Adequate assessment for trauma and other signs of injury can be performed, as well as observation of 67 the digital cascade. Palpation cannot be performed remotely, and thus detailed assessment for 68 tenderness, as well as localization of any masses is limited by remote examination. The vascular 69 examination presents its limitations as well. Peripheral pulses and temperature cannot be properly 70 assessed whereas color and capillary refill can be reliable. Formal sensory examination with two-point discrimination is not possible to conduct remotely. Most aspects of the motor examination can be 72 accomplished remotely aside from strength against resistance. Passive range of motion can be 73 performed with the use of the patient's contralateral hand to demonstrate end range of motion. With 74 the use of graphical instruction or visual demonstration, motor function for each muscle group in the 75 hand and wrist can be evaluated with the assistance of the patients opposite hand. While these 76 maneuvers can be performed independently by the patient, the provider is unable to make a 77 quantitative strength assessment without providing resistance. Thus, distinguishing between 3/5, 4/5, 78 Cozen's can all be modified and performed independently in the remote setting. A summary of 84 limitations and reasonable alternatives for special hand tests can be found in Table 1 . In order to maximize the utility of any telemedicine visit, it is vital that any radiographic studies 160 or other advanced diagnostic testing such as EMG results are available for review. Special attention 161 should be made in the days leading up to a telemedicine visit to contact patients and provide them with 162 instructions on how to make imaging and test results available to their provider for timely review. 163

Additionally, if radiographic studies are necessary for a visit but have not been completed, these should 164 be ordered in advance. Because of the limitations of the remote patient encounter, having access to all 165 diagnostic studies is that much more important. Because of the limitations of the remote physical exam, it may be helpful and a more efficient use of time and resources to make preference for scheduling 167 patients with diagnostic studies ready for review for telemedicine visits. Thought should also be given to specific patient encounters that are not appropriate to conduct 185 via telemedicine. Clearly, any injuries that require manipulation such as displaced fractures or 186 dislocations, or other specialized care such as pin removal, cast removal or application, cannot be 187 conducted remotely. Additionally, patients for whom it is known with relative certainty that an injection 188 needs to be administered, such as recurrent trigger finger or CMC arthritis, would benefit little from a 189 telemedicine visit.

A more complicated issue to tackle is the surgical decision-making process and informed 191 consent. It has been shown that telemedicine encounters are non-inferior to in-person encounters for 192 patient comprehension during informed consent. 10 However, there is uncertainty whether reliable risk 193 and benefit assessment can be conveyed remotely. For patients with a previous in-person encounter 194 with documented appropriateness for surgical intervention, surgical decision-making and informed 195 consent can proceed without issue. We also feel that conditions with well-defined radiographic criteria 196 for surgery are appropriate for surgical decision-making and informed consent via a remote visit. In 197 these cases, the risks and benefits of intervention versus non-intervention, such as persistent deformity, 

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Cost-Effectiveness of 276

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US Department of Health and Human Services. Health Insurance Portability and Accountability Act 288 of 1996 (HIPAA)

Office for Civil Rights (OCR) UD of H and HS. Notification of Enforcement Discretion for Telehealth 291