MedCity Influencers, Hospitals

What’s the future of the orthopedic patient experience?

A look at how telehealth can be harnessed for orthopedic patients and their families.

Every professional life is a book comprised of chapters. My first chapter in orthopedic surgery began in Boston as a resident. In 1973, Dr William Harris at Mass General Hospital introduced me to a very new procedure imported from England and Dr. John Charley. The procedure was total hip replacement. Dr. Harris was one of the first to adopt it in the United States.

Our incisions were huge, at least 8 to 12 inches long. Every trochanter was osteotomized requiring them to be wired back. Blood loss was so great we used hypotensive anesthesia. Everything was cemented. We were so concerned about cement embolization that we vented the femoral canal to avoid pressurizing the cement. Two cases per day was about the maximum a surgeon could do in a day.

Postoperatively patients stayed in bed for a few days. Hospital stays of for 10-14 days were normal. Most patient were sent to a rehab center for a couple of weeks. Every surgeon had his own special protocol. There were no preoperative education classes. Surgeon reimbursement was fee for service and averaged over $5,000 per case. Patient outcomes were not routinely measured by most surgeons, and therefore could not be shared with patients.

Forty years later, we see our most recent chapter in total joints. Incisions are four inches or less. Trochanters are left intact along with muscle attachments. Surgeons perform eight cases or more a day in two operating rooms. Blood loss is minimal due to TXA and less invasive surgery. Cement in hips is rarely used. Hospitals implement programs like “Joint Camp” that create a consistent delivery system that includes classes and written educational materials.

Patients stay in hospitals for two days with most patients going home. Surgeon reimbursement is still fee-for-service, but has dropped to an average of $1,500 per case. Unchanged is that transparency is still lacking as most surgeons still do not collect patient reported outcomes.

Now, the next question is what will the next chapter in total joint replacement look like? Newer drugs and new surgical techniques will most certainty emerge. Robotics and GPS measuring systems may reduce variability in positioning implants. However, these may not be the most important advances and changes.

The reimbursement system is transitioning to a value-based system. In this system, fees are bundled together amongst all the providers for up to 90 days postoperatively. Overall costs, patient experience and outcomes will matter as well to reimbursement. As a result, every hospital must find a way to improve quality, patient experience, collect outcomes while at the same time lowering overall costs. This includes managing costs after the patients leave the hospital.

In this new world, expect a very rapid transition for patients from the hospital to directly home. The will lead toward the inevitable trend to outpatient total joint replacements, whether in an ASC or hospital. This especially for younger patients and those in good health. This will create some important issues. With increasingly less patient and family face to face time it will be quite difficult to effectively educate patients and family and monitor their performance.

Another way to educate and monitor patient compliance and progress remotely both before and after surgery is necessary. It is said that most of us must read, hear or see things five times before we really own the knowledge. This must certainty be true for patients and family who are anxious about their health.

Patients and family must evolve from passive recipients of care to active participants. This will require the implementation of a “Pathway to Sustainable Excellence.” While there are many other components on a pathway to sustainable excellence, patient involvement sits squarely in the center. Our past efforts to make patients active participants in their care has been fraught with disappointment. Physicians have good reason to be pessimistic that we can accomplish this. And yet, they all agree that is a laudable goal. Using our traditional methods of education and monitoring will not work in this new environment.

There is a way that will work. It’s called telehealth and uses technology. Technology including smart phones, laptops and iPads have changed and scaled everything for us. Every other industry has taken advantage of technology. Healthcare can as well.

Telehealth companies are now using technology on a web based portal to engage, educate and monitor patients and families. The current system of patient and family education is dependent on a multitude of factors, including the location, knowledge and time pressure of the patient and provider. An information and monitoring technology system can be accessed from anywhere at anytime by anyone that has a password. In addition, the information, questions and instructions to the patient will always be consistent.

The real goal of using a technology system is not just for education but patient involvement and to monitor compliance. An educated and involved patient that understands “the Why” is not only compliant but takes corrective actions as instructed. To be effective to get patients involved, the following facts must be considered. People retain:

  • 5% of what they read
  • 10% of what they hear
  • 20% of what they see
  • 30% of what they are asked
  • 50% from group discussion
  • 75% of what they practice
  • 90% of what they teach

Even the greatest patient and family technology system won’t replace the personal interaction of patient and provider. However, the support of such a system helps the patients and families ask better questions. It actually gives the caregivers more time with patients. The patient’s progress, compliance and understanding of the information can be monitored by the system and reported to the caregivers. Both parties are much happier in this system.

Here is an example for total joint patients. When scheduled for surgery, patients are provided a link and passcode to a web based portal. They are walked through how to use it. One of the first things the patient does is select a coach and provide their contact information. Both the patient and the coach will now get the same written and video education along with questions to reinforce learning. Checklists are provided for timely completion of important tasks. Action steps are included for patients and families. Ongoing progress is monitored remotely by the system. A son or daughter three states away can now be intimately involved in their parent’s care prior to and after surgery. An alert system provides yellow (less serious) alerts that result in emails to the patients and coaches. Red (more serious) alerts go to a nurse navigator and perhaps to their surgeons when patient compliance and readiness for surgery is in question.

Information on the surgical and hospital experience is provided in order to establish expectations and reduce anxiety. It doesn’t end there. After going home, patients and families (coach) are provided post acute care information for 90 days postoperatively. Questions and responses by patients and coaches are recorded by the system and sent to a provider portal. To obtain a quicker and safer recovery for patients, yellow flags for concern and action steps to avoid complications are provided. More serious red flags for remote monitoring are managed by the navigator. Patient outcomes can be collected both pre- and post- operatively.

Everybody wins in this scenario. Physicians are assured the consistent information and monitoring is being provided every time to every patient. Nurses and staff care for patients who are better prepared for their surgery and recovery. They then have more time to be real caregivers and connect with patients. Patients and families are much less anxious, understand what to expect and most likely recover faster with fewer complications. They don’t feel abandoned and are much more likely to be happy going directly home. Hospitals win because patient satisfaction is extraordinary and overall costs especially post acute costs are lowered.

Creating a “Pathway to Sustainable Excellence” with the patient/ family involvement square in the center of that pathway will be a huge advance in healthcare. A recent article stated that “If patient engagement were a drug, it would be front-page news, and malpractice for doctors not to use it.” The use of technology to enhance patient and family involvement just makes sense. I look forward to this next chapter in total joints.

Throughout his career in orthopedics, Dr. Marshall Steele has helped build patient-centric service line delivery models through the implementation of best practices. Dr. Steele, a board certified orthopedic surgeon, is the founder of the Orthopedic and Sports Medicine Center in Annapolis, MD, and co-founder of Marshall Steele & Associates, a Stryker Corporation acquired company. He is the author of three books, frequent speaker and lecturer, and serves as advisor to VOX Telehealth, a provider of procedure specific, patient engagement solutions.

Photo: Flickr user Charlie

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