How telemedicine can be a key lifeline after surgery

When Stephanie Brilla needed a follow-up appointment with her surgeon after having her appendix removed, she was able to do it during her lunch hour — and without leaving work.

The 25-year-old closed the office door and spent 10 minutes on a video call with Vahagn Nikolian, M.D., a general surgery resident at Michigan Medicine.

“It was just so convenient and efficient. I appreciate that I was offered this option,” says Brilla, who works as a leasing manager in Ann Arbor.

She’s among a growing number of Michigan Medicine patients participating in an innovative new approach: Surgery eClinics, which facilitate follow-up visits via video conferencing. Similar to the house calls of old, the virtual clinic approach underscores the importance of the doctor-patient relationship.

Patients are seen during a time that works best for their schedule by logging in to the Michigan Medicine Patient Portal with a mobile device and clicking on the Video Visit icon to start their clinic experience.

Much like Skype and FaceTime, the Surgery eClinic allow patients to engage in face-to-face conversations. Security and privacy protection measures allow discussion of personal health information. Patients are scheduled for a 15-minute appointment, and rather than being seen by multiple providers, they spend the entire appointment with their surgeon.

Introduced in March 2017, these eClinics are now being used in the hospital system’s gastroenterology, urology and general surgery divisions.

Less waiting, more value

IHPI member Larry An, M.D., medical director for the Telehealth Program at Michigan Medicine, says eClinics could play an important role in Michigan Medicine’s goal to increase the number of patients cared for locally and statewide, while also improving the value of care.

The concept of telemedicine and video medicine isn’t new. But its application in the field of surgery has been relatively limited.

Nikolian, the general surgery resident, has worked to make the Surgery eClinics a reality. He points out that the average length of a patient’s in-person office appointment after surgery, from check-in to checkout, is roughly 90 minutes.

“I wanted to find an easier way to see select patients,” he says.

Nikolian partnered with his mentor, Hasan B. Alam, MBBS, the Norman Thompson Professor of Surgery and section head of general surgery, to develop a pilot program for the Division of Acute Care Surgery, one of the surgery department’s busiest divisions.

“The impact can have downstream effects,” says Nikolian. “By seeing our uncomplicated patients in a more efficient manner, we can dedicate the limited in-person clinic time to more complex cases and new patient referrals.”

Michigan Medicine is at the cutting edge of using eClinics in a surgical setting, Alam says. More than 350 patients between the ages of 18 and 78 who have undergone operations such as gallbladder or appendix removal have used the Surgery eClinics during their recovery.

‘We’re just scratching the surface’

So far, the program has proven to be efficient and safe, with no patients demonstrating significant complications or requiring reoperation. Moreover, patient surveys indicate that the vast majority of participants would use the service again and recommend it to friends and family. Startup costs, Alam adds, have been minimal.

The benefits seem to support the investment, both for doctors and patients alike.

“They love it and so do I,” says surgery department chair Michael Mulholland, M.D. Patients who are more comfortable in their own home are also more forthcoming, he adds, noting that the efficiency allows him to see more patients and also provides more time to teach.

Across the system, 1,000 video visits have taken place.

And there’s room to grow: The eClinics easily could be expanded to include pre-operative workups and patients undergoing pre-habilitation before surgery, Mulholland says. But he cautions that not all patients are suitable candidates for eClinics; those who are sicker and have more complicated surgeries still need to be seen in person.

Alam and Nikolian envision Surgery eClinics filling a role for new patients as well, which could decrease the waiting time before surgical consultations. As technology has advanced, the use of laboratory data and imaging studies often defines the problem without requiring an in-person examination. In this context, patients have the opportunity to establish a robust relationship with their doctor through the video visits prior to the procedure.

“We’re just scratching the surface of how this can really benefit patients,” Nikolian says.

Objectives and challenges remain

Ryan Stidham, M.D., M.S., assistant professor of medicine, began experimenting with the eClinic concept three years ago. While Michigan has a rich telehealth history, offering videoconferencing as an alternative for in-person consultation was uncharted territory.

Stidham approached Michigan Medicine leadership about developing tools for video visits through the existing electronic health record and patient portal systems. It wasn’t unusual for his patients to drive eight to 10 hours for appointments that didn’t require physical exams. For his patients, who have Crohn’s disease and ulcerative colitis, many tests can be performed locally and results can be reviewed during the video visit.

Because most of Stidham’s meetings with patients focus on the discussion of appropriate medications and treatment plans and educating patients about often complex regimes, consultation often can be handled remotely.

“The acceptance has been excellent,” Stidham says. “Overwhelmingly, our patients really want this.”

There are still issues, however: Out-of-state patients and those on Medicare aren’t reimbursed for video visits. Medicare has covered live video consultations for decades, but the program places two big restrictions on coverage: The patient has to be located in an area with a shortage of health professionals and is required to be physically present in a local clinic for the video conferencing.

Chad Ellimoottil, M.D., M.S., an assistant professor of urology, says possible solutions are being investigated for coverage of eClinics. He notes that a telemedicine game-changer occurred last year when several commercial insurers changed their policies to allow video visits from home; proposed legislation might change Medicare’s policy as well.

Stidham, like many of his colleagues, is committed to removing whatever obstacles remain to make sure anyone needing virtual care can get it. “We’ll just keep moving forward,” he says, “because it’s best for our patients.”