The Use Of Video Consultations To Support Orthopedic Patients' Treatment At The Interface Of A Clinic And General Practitioners

Katharina Estel Department for Traumatology and Orthopedics, Military Academic Hospital Berlin Luise Richter Department for Traumatology and Orthopedics, Military Academic Hospital Berlin Gordian Weber Department for Traumatology and Orthopedics, Military Academic Hospital Berlin Felix Fellmer Department for Traumatology and Orthopedics, Military Academic Hospital Berlin Sven Märdian Center for Musculoskeletal Surgery, Charité Universitätsmedizin Berlin Christian Willy Department for Traumatology and Orthopedics, Military Academic Hospital Berlin David Alexander Back (  david.back@charite.de ) Department for Traumatology and Orthopedics, Military Academic Hospital Berlin


Introduction
Telemedicine is a powerful tool in digitalization in the health sector. It offers the advantage of transferring the medical expertise of specialists over long distances with a reduction in both travel and waiting times for patients (1)(2)(3). As a part of telemedicine, the goal of video consultations is to enable medical contact between health professionals and patients-just as physical presentations in live consultations (LCs) (1,2). In recent years, su cient technology and legal foundations have been established, so video consultations are already being used in many countries' daily practices (4). Furthermore, the current SARS-CoV-2 (COVID- 19) pandemic has increased the need to offer noncontact treatment options and disseminate their acceptance among patients and physicians (5).
Recent studies have already demonstrated a high acceptance among patients for telemedical doctor visits (4). In addition, medical staff consider the results of orthopedic telemedical consultations (OTCs) to be equivalent to those of LCs (6). However, some studies have also stated that technical problems or a lack of knowledge regarding data exchange represent possible reservations of medical staff (7,8).
An additional bene t of OTCs may be seen in the enhancement of collaborations between specialists (e.g., at the clinic) and general practitioners (GPs) in the aftercare of patients (9). Since patients are often seen rst by their GPs and are only transferred to a specialist in cases of more complex pathologies or to seek other advice, digital means may be used to support these existing structures. For example, study data have shown that the number of LCs with specialists could be reduced when a primary care physician preselects orthopedic consultation requests and provides an OTC between a patient and a specialist (3). Different articles have been published reporting the clinical use of OTCs and the positive attitudes and experiences of orthopedic surgeons and patients (10,11). However, data describing the bene ts of a consultative presentation of patients to orthopedic specialists by various primary care physicians of a health region through OTCs and with subsequent treatment planning via OTCs are still lacking (3).
This work aimed to extend established OTCs in an orthopedic hospital department to the care of patients in general practice in the adjunct health region of the hospital. In particular, the feasibility, quality, bene ts and acceptance of OTCs at the interface between the clinic and general outpatient practice was analyzed.

Study design and setting
OTCs were introduced as a pilot project in the Bundeswehr Medical Service and the Bundeswehr Cyber Innovation Hub in Germany at the Department of Traumatology and Orthopedics of the Military Academic Hospital Berlin. Military physicians at regional medical facilities (comparable to civilian general practitioners, subsequently referred to as "GPs") were equipped with the necessary technology to present patients with orthopedic pathologies to a hospital specialist or an orthopedic specialist a liated with the hospital. These orthopedic specialists were the main point of contact for many soldiers in eastern Germany, so sometimes long distances had to be travelled for a standard live consultation (LC). In this project, the patients' GPs could choose between a digital consultation or the "traditional" LC.
Appointments were set by telephone, email or via the program used by the provider. Patients gave their informed consent with the option to withdraw from the study at any time without giving reasons and without consequences for their treatment before inclusion. The acquired data were pseudonymized. Data from the patients concerning their medical history, examination, diagnosis, and recommended procedure were documented using the standardized regular report forms of the hospital information system (HIS) during the consultation-analog to LCs. After the online appointment, the participating GPs and orthopedic specialists were asked to assess their examination experience using an evaluation sheet and the patients were asked to assess their consultation experience. The study period was April 2020 through October 2020, with prior IRB approval obtained (Ärztekammer Berlin, No.: Eth-12/19).

Technical procedure
Following the requirements of the national jurisdiction, only real-time videoconferencing was conducted with the participants. After a certi ed provider was selected (Deutsche Arzt AG, Essen, Germany), the provider established secure broadband connections between the patients and physicians. Before each OTC, a link and a password were sent via email or SMS to the GPs or patients. Herewith, they obtained access to a protected virtual waiting area. Once the physician was online, the OTC was started in a separate virtual room. The system used a browser-based approach; hence, the connection was not restricted to a speci c device (cell phone, tablet, etc.), operating system or manufacturer.

Participation criteria
All study participants were soldiers of the German Federal Armed Forces beyond 18 years of age and were versed in internet-based communication. Another prerequisite was a regular course of medical treatment. Exclusion criteria were, apart from the personal decision against participation, any circumstances in which-in the opinion of the treating doctors-continued involvement in the study would not have been in a patient's best interest.

Structure of the physicians' questionnaires
The questionnaire for the specialists contained 27 questions (

Results
A total of 89 OTCs were included in the study (77 rst presentations, nine second presentations, one patient with a third and fourth presentation, one between a specialist and GP).
The majority of the OTCs occurred with one patient, one specialist, and one GP present at the same time (n = 77). Twelve OTCs were performed between a patient and a specialist alone, but with the indication and consent of the responsible GP.
Most OTCs took place in the regional medical facility (n = 77). Only a small number were completed from patients' homes (n = 9) or other locations (n = 3). The different orthopedic pathologies are summarized in Figure 1. No patient who was offered the opportunity refused to participate.

Evaluation of specialists` perceptions
A total of 6 orthopedic specialists (m:f 4:2) participated. Their average age was 38.8 (± 1.6) years. All participating specialists described the atmosphere during the OTC as "very pleasant" (100%, n = 89). The detailed evaluation results of the specialists' OTC experiences are shown in Figure 2. In free text answers (not included in Fig. 2), time savings (n = 3) and an acceleration of further procedures for patients (n = 2) were indicated by the six specialists as the most important bene ts for their own practice.
In 71.9% (n = 64), the specialist did not experience any problems with the OTC. Registered general technical issues or problems with the OTC are described in more detail below.

Evaluation of the GPs' perceptions
Sixteen GPs (m:f 5:11) with an average age of 34.1 (± 6) years participated in the assessment. Concerning the OTCs, the GPs evaluated almost all consultations as "very pleasant" (n = 72; 92.3%). Figure 2 provides the detailed assessment results of this group. This occupational group emphasized the option for short notice contacts and further inquiries (n=3), fast decision-making (n=4), increased training (n=3) and no lack of information ow (n = 2). In 47.4% (n = 37) of this cohort, no problems occurred. A summary of the issues is shown in Figure 4.

Evaluation of patients' perceptions
The

OTC-based treatment recommendations for patients
Concerning assessment of the bene ts of OTCs, the specialists (n=85) indicated, in 95% of the cases, that it was the correct type of contact. In 4.5% (n = 4) of the cases, the specialists were unsure whether an OTC was indicated. In 23.6% (n = 21) of the cases, the patients also had to present to the outpatient clinic. These patients were signi cantly less satis ed with the OTC than the patients without outpatient clinic appointments (p = 0.005).
The procedural recommendations that emerged from the consultations are shown in Figure 3. For a total of twelve patients, there were "other" recommendations: orthopedic insoles (n = 7) and bandages (n = 2), as well as presentation to another specialist discipline (n = 1), referral to a civilian surgeon (n = 1) or workplace adjustment (n = 1).
OTC technical di culties Figure 4 provides an overview of the problems (n = 96) during the OTCs, which were primarily of a technical nature (n = 92).
Overall, the specialists and GPs saw a need for improvement in the organizational structure of the OTC (specialists: n = 8; GPs: n = 3), improved sound and image quality (specialists: n = 8; GPs: n = 3), a more stable internet connection (specialists: n = 7; GPs: n = 10), improved hardware with additional keyboards for the tablets and tablet holders with a better operability (specialists: n = 0; GPs: n = 5), better possibilities of transmitting radiological images, not only their ndings (specialists: n = 0; GPs: n = 3) and more OTC pretraining for GPs (specialists: n = 3; GPs: n = 1).

Discussion
In the current transformation of digital health care and the COVID-19 pandemic, digital options for adequate patient care over distances have become increasingly important (4,10,13), including in specialties with predominantly hands-on examinations, such as orthopedics (11,14,15). In this context, only a few studies have described patients' digital presentations by their GPs to specialists (9), especially in orthopedics (3).
The present study examined the bene ts of OTCs among orthopedic specialists, GPs and patients, covering technical feasibility, assessments of usefulness, quality and possible obstacles and challenges.
A unique feature of this study was the interaction and corporate treatment of patients by GPs and orthopedic specialists by digital OTCs, in most cases with the patients´ live participation.
The study demonstrated a high level of satisfaction among the participating groups with the consultative OTC. Additionally, close contact between the general practitioners and specialists was particularly valued. In addition, time savings by the elimination of travel and quick contact with orthopedic consultants were positive aspects of the OTC. In 64% of cases, recommendations could be made without the need for an LC.
The results demonstrate that the majority of the participants evaluated their OTC experience as positive.
In particular, the atmosphere of the OTC was perceived as "very pleasant" or "…pleasant in the following". The nding that more patients than physicians rated the experience as "…pleasant in the following" may be explained by a natural reaction when they were exposed to an initially unknown physician "on the screen" with a till then rather unknown digital technique. Another possible explanation might be the concern of the impairment of the doctor-patient relationship due to the lack of in-person contact that has already been described in previous studies, which is why patients approach the OTC experience somewhat cautiously (16).
The experience of the OTC was also mainly rated as very satisfactory by all participant groups, which is in concordance with results published elsewhere (17). However, although the group of patients rated the OTC experience very positively, slight deviations from the physicians were observed. In particular, the presentation of local ndings and functionality were evaluated slightly less favorably by the patient group than the two groups of physicians. It has already been published that the physical examination of patients with musculoskeletal disorders via telemedicine is limited (18, 19). However, with special tools and an adaptation of the examination techniques to the digital setting, quite a large number of functional joint assessments could also be performed su ciently via OTCs (20). Nevertheless, many published digital examination solutions lack evidence for their e cacy, which must be elaborated in future studies (18, 19, 21).
Particularly noteworthy is the crucial factor that an OTC could reduce travel distances for patients, which averaged 141 km in this study and could thus result in relevant time savings. Previous studies demonstrated that this aspect (2), combined with the elimination of long waiting times (3), is positively received by patients. In addition, the use of an OTC can be cost-minimizing by saving travel costs as well as preventing the absence of patients from their workplaces (22). Furthermore, it is known that patient compliance with follow-up routines is higher when travel distances are low (23). Hence, it might be assumed that OTC follow-up appointments are more likely to be attended (23).
LC follow-ups were required after approximately one-fth of the performed OTCs, consistent with the results of previous studies (3). In addition, most of the patients with LCs underwent a surgical procedure. Therefore, they had to present in person to review the surgical indication and/or preop preparation (legal consent, anesthesia, etc.). In summary, the subsequent LC was bene cial for these patient and helped to initiate a timely and satisfactory treatment course.
The GPs' questions about further imaging, physiotherapy or drug therapy were very often answered satisfactorily in the context of the OTC. They can therefore be considered relevant reasons for the presentation of orthopedic patients for OTCs. To the best of our knowledge, there are no data concerning this issue that are available to date.
In addition to the various positive aspects for the participants, our data show disruptive in uences (mainly technical issues) comparable to results published previously (2,24). While no problems occurred in approximately two-thirds of the OTCs, one-third of the OTCs had di culties with the image, sound, connection, camera settings, hardware or receipt of the invitation link, which should be avoided in the future to improve users´ acceptance (25).
With regard to the collaboration between GPs and specialists via OTCs, the results presented here show that the digital form of consultative patient presentation might positively impact the relationship between the different groups. The clear advantages were short-term contact and improved information ow through direct communication, which is not the case with the conventional process. In addition, there was the possibility of questions raised by the GPs being directly answering, which increases understanding and has a continuing educational role.
However, the study also has some limitations. For example, the young average age of the participants and the potentially associated general a nity for digitization topics might have led to positive selection biases in the survey. More participants with a broader age spectrum and a balanced sex distribution should be included in the future. In addition, the number of selected participants, especially physicians, was not comprehensive enough to make general statements about the suitability of OTCs with this interdisciplinary approach. The use of this form of consultative OTCs with the participation of doctors and patients should be evaluated for other medical disciplines.

Conclusion
Based on the results of this study with high satisfaction among the participating groups, it seems bene cial to perform consultative OTCs involving specialists, general practitioners and patients for orthopedic complaints. In addition to the already published positive aspects of OTCs, the presented data emphasized the close contact between GPs and specialists. Moreover, serving as digital support rather than as a replacement for live consultations, OTCs can be used to accelerate solutions for further diagnostics or treatment plans for more straightforward orthopedic case management. However, technical issues for practicable application in the daily work of physicians must be addressed, and further research on the use of this promising digital form of doctor-patient interactions should be performed in the future.

Declarations
Ethics approval and consent to participate The research project was approved by the responsible ethics committee (Ärztekammer Berlin, No.: Eth-12/19). We con rm that all methods were performed in accordance with the relevant guidelines and regulations of the ethics committee of Ärztekammer Berlin.

Consent to participate
Participation was voluntary and anonymous, and the study participants gave informed written consent.

Consent for publication
Not applicable.

Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Figure 1
Classi cation of patient cases (n = 72) into groups according to their pathologies.

Figure 2
Evaluation of the experience of the performed OTCs (n = 89) by GPs, patients and specialists (5-point Likert scale).

Figure 3
Presentation of the recommendations that the specialists reported for the patients in all OTCs (n = 89).

Figure 4
Accurate representation of technology problems (n = 92) considering all evaluations (n = 256) (IT problems = information technology problems, here: functional problems with the OTC provider software used).