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 benefits 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 finding 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 findings 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 sufficiently via OTCs (20). Nevertheless, many published digital examination solutions lack evidence for their efficacy, 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-fifth 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 beneficial 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 influences (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 difficulties 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 flow 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 affinity 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.