Feasibility of telemedicine in maintaining follow-up of orthopaedic patients and their satisfaction: A preliminary study

Abstract

Background
The current COVID-19 pandemic has implications on the morbidities of orthopedic patients due to lack of routine follow-ups, and inpatient and outpatient-based interventions. Telemedicine has recently emerged as an alternative for healthcare delivery to the patients and providing them with important information about orthopedic self-care and medications that can be followed without a hospital visit. However, due to a lack of physical assessment, telemedicine is bound to have some limitations as well. The aim of this study is to analyze the effectiveness of proactive telemedicine in maintaining follow-up of orthopedic patients, and their satisfaction with telemedicine as an alternative mode of treatment delivery.

Methods
This one-month cross-sectional study enrolled the follow-up patients that visited the orthopedic outpatient-department in February 2020. The patients were sequentially called according to the order of their registration on a daily basis. Consenting patients were provided with telemedicine-based consultations, and those requiring physical evaluation were called for outpatient visits after documenting the valid reasons. The response-rates and the volume of patients requiring physical visits were measured for different diagnosis-based groups. Patients were asked to complete a questionnaire that included overall patient satisfaction with telemedicine, its effectiveness, and ease in following the telemedicine-based treatment.

Results
The response rate to telemedicine was 88.67%. Among the patients availing telemedicine, 71.43% were managed without needing physical visits to the outpatient-department. The need for physical examination and failed patient-doctor communication were the most common reasons for advising physical outpatient visits. The overall satisfaction-rate to telemedicine was 92% and only 7.2% of patients had difficulty in understanding or following telemedicine-based advice.

Conclusions
Telemedicine can effectively reduce the need for physical visits to outpatient-departments for follow up of orthopedic patients. The response-rate and overall patient-satisfaction rates to telemedicine are high. Further efforts in expanding the use of telemedicine and addressing its limitations, especially those related to the failed communications, are needed to develop it as an alternative to physical orthopedic consultations in the current situation.

Full text

Feasibility of telemedicine in maintaining follow-up of orthopaedic
patients and their satisfaction: A preliminary study
Sandeep Kumar
a
, Arvind Kumar
a
,
*
, Mukesh Kumar
a
, Ashok Kumar
b
, Rajesh Arora
a
,
Rakesh Sehrawat
a
a
Department of Orthopaedics, HIMSR, New Delhi, India
b
Gastroenterology, All India Institute of Medical Sciences (AIIMS), Rishikesh, Uttarakhand, India
article info
Article history:
Received 26 May 2020
Received in revised form
17 July 2020
Accepted 24 July 2020
Available online xxx
Keywords:
COVID-19
Orthopaedics
Patient care
Patient satisfaction
Telemedicine
abstract
Background: The current COVID-19 pandemic has implications on the morbidities of orthopedic patients
due to lack of routine follow-ups, and inpatient and outpatient-based interventions. Telemedicine has
recently emerged as an alternative for healthcare delivery to the patients and providing them with
important information about orthopedic self-care and medications that can be followed without a
hospital visit. However, due to lack of physical assessment, telemedicine is bound to have some limi-
tations as well. The aim of this study is to analyze the effectiveness of proactive telemedicine in main-
taining follow-up of orthopedic patients, and their satisfaction with telemedicine as an alternative mode
of treatment delivery.
Methods: This one-month cross-sectional study enrolled the follow-up patients that visited the ortho-
pedic outpatient-department in February 2020. The patients were sequentially called according to the
order of their registration, on a daily basis. Consenting patients were provided with telemedicine-based
consultations, and those requiring physical evaluation were called for outpatient visits after documenting
the valid reasons. The response-rates and the volume of patients requiring physical visits were measured
for different diagnosis-based groups. Patients were asked to complete a questionnaire that included
overall patient satisfaction with telemedicine, its effectiveness, and ease in following the telemedicine-
based treatment.
Results: The response rate to telemedicine was 88.67%. Among the patients availing telemedicine, 71.43%
were managed without needing physical visits to the outpatient-department. The need for physical
examination and failed patient-doctor communication were the most common reasons for advising
physical outpatient visits. The overall satisfaction-rate to telemedicine was 92%, and only 7.2% of patients
had difficulty in understanding or following telemedicine-based advice.
Conclusions: Telemedicine can effectively reduce the need for physical visits to outpatient-departments
for follow up of orthopedic patients. The response-rate and overall patient-satisfaction rates to tele-
medicine are high. Further efforts in expanding the use of telemedicine and addressing its limitations,
especially those related to the failed communications, are needed to develop it as an alternative to
physical orthopedic consultations in the current situation.
©2020 Delhi Orthopedic Association. All rights reserved.
Introduction
The current COVID-19 pandemic has disrupted the health care
services around the world.
1
The pandemic has disabled some of the
most advanced healthcare systems and will have long term
sequelae. The elective surgical procedures and the outpatient-
services have been deferred considering the high infectivity rate
and transmission of the SARS-Cov-2 virus. However, a longer delay
in these services carries an added risk of morbidity to the patients.
Moreover, a sudden resumption of these services can result in an
abrupt overburdening of the already compromised healthcare
services in the coming time foreseeable. As WHO suspects that the
*Corresponding author. Department of Orthopaedics, HIMSR, New Delhi, India.
E-mail addresses: drsandeepkumar20@gmail.com (S. Kumar), arvindmamc@
gmail.com (A. Kumar), drmukesh1.pmch@gmail.com (M. Kumar), drashok.
sgpgims@gmail.com (A. Kumar), rajeshmamc@gmail.com (R. Arora),
drrsehrawat@gmail.com (R. Sehrawat).
Contents lists available at ScienceDirect
Journal of Clinical Orthopaedics and Trauma
journal homepage: www.elsevier.com/locate/jcot
https://doi.org/10.1016/j.jcot.2020.07.026
0976-5662/©2020 Delhi Orthopedic Association. All rights reserved.
Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx
Please cite this article as: Kumar S et al., Feasibility of telemedicine in maintaining follow-up of orthopaedic patients and their satisfaction: A
preliminary study, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.07.026

COVID-19 risk may remain forever, it may be anticipated that
healthcare systems will now have to function with a calculated risk
of disease transmission. The crowded outpatient-departments
(OPDs) are usual in our country and pose a major challenge in the
regularization of the OPD services. A major proportion of the pa-
tients attending the outpatient services are follow-up patients,
those have been previously clinically evaluated or examined.
2
Alternative measures to maintain follow-up of such patients can
reduce the overcrowding in the OPDs and help in the maintenance
of physical distancing to prevent disease transmission.
3
Telemedi-
cine is a potential alternative that has already been used for health
care services delivery to rural and remote areas with a lack of
transport facilities, for those with socioeconomic limitations and
vulnerable patients for whom physical follow-up is inconvenient.
4
Telemedicine has been defined by the WHO as the remote delivery
of health care services by health care professionals using infor-
mation and communication technologies for the exchange of valid
information for the diagnosis, treatment, and prevention of disease
and injuries, research and evaluation, and for the continuing edu-
cation of health care providers, all in the interests of advancing the
health of individuals and their communities.
5
Telemedicine can be
facilitated by various modes of communication like telephone calls,
video conferencing, text messages, online chat services often sup-
plemented by internet-based exchange of records based informa-
tion. However, telemedicine has only been used focally in our
country and its effectiveness in maintaining the follow-up of or-
thopedic patients in India has not been previously analyzed.
6
The
Medical Council of India (MCI) has recently released the guidelines
for practicing telemedicine.
7
While it is important to know whether
the patients can adjust to the change in practice from physical
consultation to telemedicine-based consultations, patient satisfac-
tion is equally important.
The aim of this study is to analyze the effectiveness of proactive
telemedicine in maintaining follow-up of orthopedic patients, and
their satisfaction with telemedicine as an alternative mode of
treatment delivery.
Materials and methods
This cross-sectional observational study was conducted at a
tertiary care center after obtaining the clearance from the institu-
tional review board. The orthopedic department of this institute
has been providing telemedicine-based services since the
announcement of nationwide lockdown due to the current COVID-
19 pandemic. At least twenty follow-up patients were called on a
daily basis (excluding holidays) between 10:00 a.m. to 2:00 p.m. All
follow-up patients that attended orthopedic OPDs during the
month of February 2020 were called for telemedicine consultation
from April 1, 2020 to April 31, 2020 in the sequence of their
registration numbers. Patients not consenting for telemedicine that
included those who found the timing of the call or the call itself to
be inappropriate, those who were uncontactable, those without
internet access for the delivery of the telemedicine prescription,
and those who had recently visited or planned a visit to the hospital
were excluded. All telemedicine consultations were provided as per
national guidelines and were provided free of cost during the
aforestated period. All follow-up patients who underwent tele-
medicine consultations were encouraged to answer a
questionnaire-based survey, a week after their telemedicine
consultation. The telemedicine consultations and the feedback
survey questionnaire were provided to the patients in the language
of their choice. Further telemedicine consultations were provided
to the patients during the questionnaire-based survey, wherever
required.
The mode of communication for telemedicine consultations was
the telephonic conversations between the patient and the doctor
supplemented by the transfer of photographic-videographic data
and document records through internet-based services like email
and Whatsapp with a real-time interaction solely between the
patient and the doctor and only for the non-emergent purposes.
The consultations were provided to the guardians or parents when
the patients were minor. Audio consents were sought from all pa-
tients (guardians/parents for minor patients) prior to the tele-
medicine consultation. The doctors delivering telemedicine were
orthopedic senior residents and faculties with at least one year of
experience in orthopedic practice following completion of their
post-graduation. The patient’s presenting complaints and clinical
history were enquired and the data was supplemented with the
previous clinical records, investigations, and treatment that was
saved in electronic records of our hospital. Our institute has been
running electronic prescription services and outpatient manage-
ment information has been stored in the hospital server. Additional
records were sought over internet-based services whenever
required. Based on these, the patients’concerns were addressed
through health education, rehabilitation via pictorial or video
description over the internet, and pharmacological therapy, on an
individual basis. A picture of the telemedicine prescription was sent
to the patient through email or Whatsapp. In select cases where a
need for physical interaction was felt, after documenting the valid
reasons, the patients were advised to visit our hospital OPD or any
available orthopedic facility in their vicinity, for further evaluation
and management. We tried to limit the telephonic conversations to
up to 10 min duration for each patient. Based on their past man-
agement, the types of follow-up were recorded as: postoperative
follow-ups and non-operated follow-ups.
The diagnoses were broadly classified under following umbrella
terms based on the major symptoms for which the treatment was
sought: back pain and radicular symptoms, cervical disorders, large
joint degenerative disorders, treated fracture and dislocations, in-
flammatory arthropathies, instability, soft tissue injuries, non
traumatic soft tissue disorders, osteonecrosis, chronic infection,
musculoskeletal tumors, deformities, and others. The indications
for the physical presence in OPD were grouped as a) failed
communication between the patient and the doctor, where either
the doctor or the patient found it difficult to interpret the infor-
mation given b) need for a physical examination that was needed
for further treatment advice, c) insufficient records or those with
difficult interpretation, for example physically damaged reports,
unclear pictures of records and incomplete records, and d) alarming
symptoms where intervention or evaluation needs to be prioritized
considering the worsening of the symptoms. The proportions of the
patients required physical visits were measured for the reason for
the physical visit, for different diagnosis-based categories and for
the types of follow-up.
The questionnaire by Acharya et al.
8
was used to seek the
effectiveness of telemedicine consultations. This questionnaire has
been prevalidated and reliability-tested in the Indian population.
The questionnaire evaluated the patient’s perspective of the quality
of telemedicine service, patient satisfaction, and its shortcomings
(Table 1). The questionnaire was translated into the patient’s lan-
guage of understanding. Patients were given options of verbal
(telephonic) mode, email, and WhatsApp for answering the ques-
tions. The response rate to telemedicine was recorded as the per-
centage of patients consenting for telemedicine out of the total
patients contacted during the study. The frequency distribution of
the binary data of the questionnaire (in the form of ‘yes’or ‘no’) and
overall satisfaction rates of patients in different categories of di-
agnoses and type of follow-up were measured.
S. Kumar et al. / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx2
Please cite this article as: Kumar S et al., Feasibility of telemedicine in maintaining follow-up of orthopaedic patients and their satisfaction: A
preliminary study, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.07.026

Results
A total of 620 follow-up patients were called for telemedicine
consultation between April 1, 2020 and April 30, 2020. One hun-
dred and fourteen patients (18.38%) couldn’t be contacted due to
failed connections or non-availability of the patient for attending
the phone call. Twenty-nine patients (4.67%) had a lack of access to
the internet facility. Twenty-six patients (4.19%) had recently
visited or planned a visit to the hospital on their day of calling. One
patient has passed away during this follow-up.
The remaining 450 patients (72.58%) were considered for tele-
medicine consultation. There were 228 female patients and 222
male patients. The mean age was 38.03 ±16.23 (mean ±standard
deviation). Among these, 399 patients (88.67%) gave their consents
for telemedicine and 51 (11.33%) opted out of it. Three hundred and
ninety-one patients (86.89%) belonged to non-operated follow-up
patients. The proportion of patients that required a physical visit to
the hospital OPD or any orthopedic facility in their vicinity was
28.57%. The need for physical re-evaluation was least for patients
with back pain (10.57%) and cervical pain (9.7%) which together
formed diagnoses of 34% of all the patients receiving telemedicine
(Table 2). The follow-up patients of fracture and dislocations, large
joint degenerative disorders, inflammatory arthropathies, non
traumatic soft tissue disorders, chronic infections, and deformities
were the ones with a higher need for a physical visit to the OPDs
(Table 2). Among the patients requiring outpatient visits, a need for
physical examination (70.17%) was the most common indication
followed by the failed communication between the doctor and the
patients (15.78%) (Table 3). The worsening of the symptoms
(alarming symptoms) and difficulty in interpretation or availability
of records was observed in 12.28% and 1.7% of the patients receiving
the telemedicine consultations, respectively. The detailed results of
the telemedicine feedback survey are presented in Table 4. While all
those receiving the telemedicine consultation were satisfied with
the timing of calls, a major proportion of the patients (103 out of
399, 25.81%) felt that a detailed clinical history was not asked.
Thirty-two patients (8.64%) were not satisfied with the telemedi-
cine consultation they received and twenty-nine patients (7.83%)
found difficulty in following the same. The overall patient satis-
faction rates were high with exceptions in a few groups (Table 5).
Discussion
In the current pandemic situation, telemedicine has been
emerging as a viable mode of communication between doctors and
patients for the clinical assessment as well as for the treatment. The
MCI has only recently permitted telemedicine as an alternative
mode for treatment advice.
7
The basic requirement for the feasi-
bility of telemedicine is access to the telecommunication services
that can allow the information transfer between the patient and
doctor. While the limitations of telemedicine related to the lack of
physical examination and assessment of records are well justifiable
for newly presenting patients, the same may not be always appli-
cable to the follow-up patients. A simple knowledge of the pro-
gression of the symptoms and general condition of the patient can
guide further treatment. Further access to the patient’s previous
Table 1
Questionnaire for the patients’perception of the telemedicine.
8
S.No. Question Response
1. Was scheduling of the appointment appropriate? Yes/No
2. Was detailed medical history taken? Yes/No
3. Are you satisfied with treatment advice through telemedicine? Yes/No
4. Did you find telemedicine: a) Feasible
b) Convenient
c) Both
d) No response
Feasible/Convenient/Both/No response
5 Would you recommend this service to your friends? Yes/No
6. Did you find any difficulty in understanding the process of telemedicine? Yes/No
Table 2
Patients response rates and need for physical visit to outpatient departments based on their diagnoses.
Diagnosis Number of patients
contacted (n ¼450)
Patient that opted for
telemedicine consultation
(n ¼399)
Response rate (patients availing
telemedicine/patients contacted x 100
Proportion of the patients receiving telemedicine
that required a physical visit to OPD %(n)
Back pain and
radicular
symptoms
116 (25.7%) 104 (26.0%) 89.65% 10.57% (n ¼11, 1 with alarming symptoms)
Fracture and
dislocations
87 (19.3%) 77 (19.2%) 88.50% 36.36% (n ¼28)
Soft tissue injuries 67 (14.8%) 59 (14.7%) 88.05% 22.03% (n ¼13, 3 with alarming symptoms)
Large joint
degenerative
disorders
51 (11.3%) 48 (12.0%) 94.11% 39.58% (n ¼19, 7 with alarming symptoms)
Inflammatory
arthropathies
33 (7.3%) 32 (8.0%) 96.96% 40.06% (n ¼13, 1 with alarming symptoms)
Cervical disorders 31 (6.8%) 31 (7.7%) 100% 9.67% (n ¼3, 1 with alarming symptoms)
Non traumatic soft
tissue disorders
30 (6.6%) 24 (6.0%) 80% 54.16% (n ¼13, 1 with alarming symptoms)
Chronic infection 15 (3.3%) 13 (3.2%) 86.66% 53.84% (n ¼7)
Deformities 10 (2.2%) 7 (1.7%) 70% 71.42% (n ¼5)
Other conditions 5 (1.1%) 1 (0.2%) 20% 100% (n ¼1)
Tumors 3 (0.6%) 1 (0.2%) 33.33 None
Instability 2 (0.4%) 2 (0.5%) 100% 50% (n ¼1)
Total 450 (100%) 399 (100%) 88.66% 28.57% (n ¼114, 14 with alarming symptoms)
S. Kumar et al. / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx 3
Please cite this article as: Kumar S et al., Feasibility of telemedicine in maintaining follow-up of orthopaedic patients and their satisfaction: A
preliminary study, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.07.026

assessment records, investigations, and previous treatment, which
is often available in OPDs maintaining computerized records, can
help in an effective telemedicine practice (Fig. 1). This ultimately
reduces the physical patient burden in OPDs without affecting the
overall reach of patient care.
With the widespread use of smartphone and mobile-based
internet services, telecommunications have greatly advanced in
India.
9
While video conferencing applications and video call ser-
vices have been available, there are limitations due to network
coverage, the patients’unfamiliarity to video calls, and the suit-
ability of their mobile devices for the same.
Our results suggest that telephonic call-based telemedicine in
orthopedics can be effectively used as a medium for maintaining
the patient follow-up with patient satisfaction rates as high as 92%.
Patients with back pain and cervical symptoms which form more
than one-third of the follow-up patients can be satisfactorily
managed with telemedicine and with minimal need for physical
visits. Besides this major proportion of patients with degenerative
Table 3
Reasons for physical visit to the outpatient department or other orthopaedic facility.
Reason for advising physical visit to OPD Number of patients requiring physical visit (n ¼114)
Failed communications 15.78% (n ¼18)
Unclear records or difficult interpretation 1.7% (n ¼2)
Need for physical evaluation 70.17% (n ¼80)
Alarming symptoms 12.28% (n ¼14)
Table 4
Responses from the patients for the telemedicine feedback survey.
Question/Group Postoperative (n ¼48) Nonoperative (n ¼351) Total (Yes: No)
Was scheduling of the appointment appropriate? Yes 48 (100%) No 0 Yes 351 (100%) No 0 Yes 399 (100%) No 0
Was detailed medical history taken? Yes 45 (93.7%) No 3 Yes 251 (71.5%) No 100 Yes 296 (74.2%) No 103
Are you satisfied with treatment advice through
telemedicine?
Yes 45 (93.7%) No 3 Yes 322 (91.7%) No 29 Yes 367 (92%) No 32
Did you find telemedicine: Feasible, Convenient,
Both, Not responded
Feasible 13 (27.1%) Convenient 7
(14.6%) Both 28 (58.3)
Feasible 16 (4.6%) Convenient 82
(23.4%) Both 253 (72.0%)
Feasible 29 (7.3%) Convenient 89
(22.3%) Both 281 (70.4%)
Would you recommend this service to your
friends?
Yes 48 (100%) No 0 Yes 348 (99.1%) No 3 Yes 396 (99.2%) No 3
Did you find any difficulty in understanding the
process of telemedicine?
Yes 2 (4.2%) No 46 Yes 27 (7.7%) No 324 Yes 29 (7.3%) No 370
Table 5
Patient satisfaction rates to telemedicine under different diagnosis based categories.
Diagnosis Satisfaction rates to telemedicine
Back pain and radicular symptoms 92.30% (96 out of 104)
Cervical disorders 96.7 (30 out of 31)
Large joint degenerative disorders 87.50% (42 out of 48)
Fracture and dislocations 94.80% (73 out of 77)
Inflammatory arthropathies 87.50% (28 out of 32)
Instability None
Soft tissue injuries 94.91% (56 out of 59)
Chronic infection 100% (13 out of 13)
Non traumatic soft tissue disorders 87.50% (21 out of 24)
Tumors 100% (1 out of 1)
Deformities 71.42% (5 out of 7)
Fig. 1. A representative image of a template for the maintenance of electronic records of patients that can help in easy clinical assessment and consultations through telemedicine.
S. Kumar et al. / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx4
Please cite this article as: Kumar S et al., Feasibility of telemedicine in maintaining follow-up of orthopaedic patients and their satisfaction: A
preliminary study, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.07.026

disorders can also be managed with minimal physical follow-up
visits. The overall response rates were high (88.67%) suggesting
the interest of patients towards telemedicine. The highest rate of
patients requiring physical visits belonged to the patients with
deformities, chronic infections, large joint degenerative disorders,
and inflammatory arthropathies. The deformity assessment needs
physical evaluation to document the progression and correction. It
is better to increase the width of follow-up intervals as an effective
measure for the convenience of both the doctor and the patients.
The chronic infection patients often have chronic wounds that
require regular wound dressings and may have a pending surgical
intervention. Such patients should be given options for wound
management in their vicinity and should be educated regarding the
tell-tale signs of acute exacerbations to avoid delay in intervention.
The degenerative arthritis of large joints mainly affects the
vulnerable elderly patients and it may be difficult for them to un-
derstand the telemedicine advice, especially the rehabilitation part
and the access to physiotherapy. For these patients as well, the
width of follow-up intervals should be increased to reduce their
follow-up visits and their attendees should be explained regarding
home-based exercises and local therapies to reduce dependency on
hospital.
10
The probable issue with the inflammatory arthropathy
patients requiring physical OPD visits may also be related to a lack
of access to physiotherapy and overlapping treatment regimens
with rheumatologists. These patients should be advised to consult
their rheumatologists for appropriate long duration medical
regimen. Home-based exercises should be explained to them and
their attendees to reduce dependency on hospital for minor change
in symptoms.
11
The numbers of patients in other diagnosis based
categories were too less to make any inferences.
Inappropriate timing of the phone calls could be a potential
cause for lack of interest in telemedicine and could be a contrib-
uting factor in some patients opting out of telemedicine in the first
instance. It would be more convenient for them if a prior intimation
is sent through text, WhatsApp, or an email and they are asked to
respond with a convenient time slot. Secondly, around one-fourth
Table 6
Major studies analysing the feasibility of telemedicine in orthopaedic disorders and associated patient satisfaction rates.
Study and year Region Mode of telemedicine Sample size Patient satisfaction Diagnosis or symptoms of patients Need for
physical
visit
Couturier P
et al.
(1998)
15
France Videoconference 15 80% reported telemedicine as
excellent or good
Geriatric orthopaedic rehabilitation 13%
Aarnio P et al.
(1999)
16
Finland Videoconference with document
images
29 87% reported telemedicine as
good or very good
Mostly back symptoms and joint disorders NR
Wan AC et al.
(1999)
17
UK Videoconference 146 92% - score 8e10 (out of 10) Pain management, orthopedic disorders,
general surgery
NR
Haukipuro K
et al.
(2000)
18
Finland Videoconference 76 95% patients reported
telemedicine as good or very
good
Mostly knee and hip arthrosis NR
Williams M
et al.
(2008)
19
UK Telephone 598 93% patients were satisfied Carpal tunnel syndrome 6.8%
Sharareh B et al.
(2014)
20
USA Videoconference 34 Mean satisfaction of 9.44 out
of 10
Follow-up after total joint arthroplasty Nil
Sathiyakumar V
et al.
(2015)
21
USA Videoconference 12 89% patients satisfied Trauma follow up NR
Bini SA et al.
(2017)
22
USA Videoconference 14 Satisfaction was high and
comparable to physical visit
Physical therapy following total knee
arthroplasty
20%
Tsvyakh AI et al.
(2017)
23
Ukraine Smartphone application 48 83.1% patients were satisfied Orthopaedic rehabilitation in lower
extremity injuries
NR
Shem K et al.
(2017)
24
USA Videoconference 10 100% patients were satisfied Spinal Cord Injuries follow up NR
Waibel KH et al.
(2017)
25
Germany Smartphone application 5 Average satisfaction score of
4.7 out of 5
Frozen shoulder NR
Buvik A et al.
(2019)
26
Norway Videoconference 199 99% patients were satisfied Orthopaedic new referred, follow-up after
surgery, trauma or chronic disorders
NR
Sinha N et al.
(2019)
27
Pennsylvania Videoconference 101 Medial satisfaction rate 5 out
of 5
Pediatric fractures NR
Silva M et al.
(2019)
28
USA Videoconference 26 97.8% nondisplaced pediatric elbow fractures NR
Coronado RA
et al.
(2020)
29
USA Telephone 8 100% Cognitive-behavioral-based physical
therapy
NR
Kane LT et al.
(2020)
30
USA Videoconference 33 94.1% very satisfied or
satisfied
Post operative followup of rotator cuff
repair
NR
Cheng O et al.
(2020)
31
Canada Videoconference 32 100% patients rated excellent
or good
Musculoskeletal issues NR
Gilbert AW
et al.
(2020)
32
UK Telephone and video both 1359*-
telephone
133*-
videoconference
90% patients satisfied with
telephone
85% for video
Orthopedic patients with varying issues NR
Bailey JF et al.
(2020)
33
USA Digital program with an app,
videoconference and phone calls
6468 back pain
3796 knee pain
Final satisfaction score - 8.97
out of 10
Followup patients with knee and back
pain
NR
Current study India Telephone 450 92% patient satisfied with
telemedicine
Multiple orthopedic issues 28.57%
NR ¼not reported, *Final assessment.
S. Kumar et al. / Journal of Clinical Orthopaedics and Trauma xxx (xxxx) xxx 5
Please cite this article as: Kumar S et al., Feasibility of telemedicine in maintaining follow-up of orthopaedic patients and their satisfaction: A
preliminary study, Journal of Clinical Orthopaedics and Trauma, https://doi.org/10.1016/j.jcot.2020.07.026

of the patients felt that their detailed history was not taken. A
preset time-limit assigned for our calls could have probably resul-
ted in this incomplete history recording. Thus, it is important for
the treating doctor to anticipate the approximate time allotment
for various patients depending on their diagnosis and other avail-
able clinical information. Previously, several studies outside India
have found telemedicine to be an effective method of administering
healthcare services for orthopedic patients.
12e14
It reduces the
inconvenience of long travel distance, costs, and added discomfort
to the patient. In the current COVID-19 pandemic, telemedicine can
help in reducing the physical load on already overburdened or-
thopedic OPDs and reduce the risk of disease transmission to the
patient as well as the doctor. Currently, the estimated patient
satisfaction rate with teleconsultations is approximately 70%.
14
Both telephonic conversations and videoconference based ser-
vices have been used previously for delivering telemedicine.
14
However, with limited resources and easy access to telephone
calls compared to videoconferencing for the patients, the tele-
phonic conversation supplemented by internet-based transfer of
pictures and other records can be a cost-effective measure in an
Indian scenario. Our results compared well with the patient satis-
faction rates in previous studies that analyzed the feasibility of
telemedicine in maintaining follow up of orthopaedic patients
(Table 6). The need for physical visit was higher in our study which
could probably be explained by the diverse group of diagnoses
included in our study, telephonic conversations rather than video
conferencing, and regional differences in patient understanding
and interactions.
The automated mobile text response based tools can be helpful
in grading patient symptoms and administering the modified
treatment.
34
Patients can be asked to perform maneuvers based on
the pictorial information and the patient can “store and forward”
their performance in the form of pictures. This forms the basis of
virtual clinical examination.
35
Telemedicine may sound as promising, but it may be difficult to
solely rely upon telemedicine for patient care and the only purpose
of telemedicine should be to prioritize patient care when the
physical consultation is difficult or needs to be avoided, as in the
current pandemic situation. Besides this, patient age, intelligence,
lack of supporting devices, poor connectivity limit the applicability
of the telemedicine.
36
As evident in our results and advocated by
the previous studies, a major portion of patients avoided tele-
consultation. Privacy issues, trust factors, lack of awareness, diffi-
culty in comprehension can all be implicated and need to be further
investigated in the Indian scenario.
There had been some limitations of this study. Firstly, the study
is of preliminary nature representing a cross-sectional analysis of
patients in one tertiary care center during a month period. The
variability of response and the effectiveness of telemedicine can
vary from region to region and from time to time. Its effectiveness
and patient preferences may change once the current pandemic
situation is over. Further long term data is still needed. Secondly,
the study discusses the effectiveness and feasibility of one basic
mode of telemedicine delivery i.e, proactive telephonic calls sup-
plemented by internet based transfer of information. The other
modes may have different outcomes. Thirdly, the effectiveness of
telemedicine in new patients cannot be determined, as this study
included only follow-up patients. Fourth, since the patients were
not charged for the teleconsultations, the cost-effectiveness beyond
this study is difficult to determine. Also, the easy availability of
patient previous clinical records and investigations which were
stored in the hospital data server might have played a major role in
easing the telemedicine consultation. Without such a facility,it may
be really difficult to address the patient concerns. Lastly, the study
does not provide a comparative analysis due to the lack of a control
group. Nevertheless, the study provides an insight into the role of
telemedicine in the effective maintenance of orthopedic follow-up
in these times of unexpected necessity and which may further
evolve as a major mode of medical care.
The pattern of the orthopedic disorders and their response to
telemedicine can help the orthopedicians in prioritizing
outpatient-care. The basic minimum requirement of a phone and
internet can be used in the efficient delivery of telemedicine in
orthopedic patients.
Conclusion
The telemedicine-based consultations can effectively reduce the
need for physical visits to outpatient departmentsfor the follow-up of
orthopaedic patients, especially when patients’previous clinical in-
formation has been available to the treating doctor. The response rate
and overall patient satisfaction rates to telemedicine are high. Efforts
should be made to strengthen and facilitate telemedicine-based
medical care by spreading awareness, computerization of patient
records, and maximize the use of technology in patient care to reduce
the physical burden on outpatient departments,and to minimize the
risk of disease transmission in current COVID-19 pandemic.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
Declaration of competing interest
None of the authors have any conflicts to declare.
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