Becker's Spine Review

12 SPINE SURGEONS Expanding telemedicine for spinal care: 3 spine surgeons share insights By Alan Condon T elemedicine services are rapidly increasing across the country aer the Trump administration's March 13 declaration expanding Medicare coverage for the technology during the COVID-19 pandemic. ree spine surgeons discussed how they see telemedicine developing in spine. Note: Responses were lightly edited for style and clarity. Question: What are the biggest telemedicine trends in spinal care? Where do its obstacles and opportu- nities lie? Srdjan Mirkovic, MD. Northshore Ortho- paedic & Spine Institute (Chicago): ere is a current shi with telemedicine in spinal care due to the COVID-19 pandemic. e recent change in Medicare policy will enable spine surgeons to implement telemedicine in a greater way. Government reimbursements give specialists an opportunity to remote- ly screen, treat and monitor patients with chronic conditions. I anticipate a call from a person experiencing lower back pain will be handled over the phone by a nurse initially, making way for teleconferencing. But a spine specialist will still be able to talk to patients and authorize testing like an MRI. I expect more tele-diagnoses for straightfor- ward cases. ere will always be clinical care, but it will be more limited, and that's where I see some obstacles. ere will be few physical exams, which is a big part of what physicians do and how we make our diagnosis. Also, in- surance companies will authorize inpatient sur- geries, but I expect it will get tougher as trends point to more minimally invasive and outpa- tient care. e more telemedicine integrates into the healthcare system during this crisis, the more likely it will become permanent. Brian Gantwerker, MD. Craniospinal Cen- ter of Los Angeles: Telemedicine in spinal care was an inevitability. Its responsible appli- cation is crucial to its dawn and descent. Ob- stacles abound. Physician liability and duty to treat remain thorny, especially in states like California. Obtaining insurance cover- age for a treating physician is a deterrent if even downright prohibitive. Other issues are HIPAA compliance for telemedicine and hav- ing access to imaging. I am currently using a platform that allows HIPAA-compliant shar- ing of DICOM films. Online consults need to be compliant as well. Creative use of current- ly available technology and judicious use and discretion will allow it to expand its footprint. Gregory Schroeder, MD. Rothman Ortho- paedic Institute (Philadelphia): Telemed- icine in spine surgery is seeing a dramatic increase in usage in the COVID-19 era. At the Rothman Orthopaedic Institute, we have rapidly ramped up our telemedicine visits. Importantly, my patients have been extreme- ly satisfied with their telehealth visits. Many of the rules have been relaxed so that some previously non-HIPAA compliant platforms such as FaceTime can be utilized now. How- ever, it is not clear for how long this will be permitted. While there are many different platforms that are HIPAA compliant, some of these such platforms require patients to download an app on their phone. ese ap- plications have proven challenging to use in my practice, and I prefer applications such as doxy.me that do not require an app for the patient. Regardless of what application you find to be the best for you and your patients, the most challenging part of a telemedicine visit is the physical exam. It is helpful to understand what can and cannot easily be tested on tele- medicine visits. For instance, when evaluat- ing a patient for myelopathy, rapidly alternat- ing movements and tandem gait are easy to perform, whereas reflexes and a Hoffman's sign are not possible. Similarly testing motor strength for levels zero, one, two and three is easy, but it is challenging to judge strength between levels three, four and five. Last year at the Cervical Spine Research Society, we presented a pilot study validating a telehealth neurologic exam, but it requires the use of therabands. If telehealth becomes increas- ingly common, further studies are needed to determine the best way to perform a good virtual physical exam. n Appellate court slashes $10M verdict against Laser Spine Institute By Eric Oliver A Pennsylvania appellate court said a $10 million award to a family who sued Tampa, Fla.-based Laser Spine Institute alleging wrongful death was excessive in a 2-against-1 panel ruling, The Legal Intelligencer reports. The lawsuit alleged Laser Spine Institute discharged Sharon Kimble when she still had a significant amount of Dilaudid, an anesthetic, in her system. Ms. Kimble died hours later with postoperative instructions to take additional pain medicine. Ms. Kimble's lawyer alleged she had more than six times the amount of Dilaudid in her system than what was initially ordered. A jury initially awarded Ms. Kimble's estate $20 million — $10 million for wrongful death and $10 million under the Survival Act. A judge revoked the $10 million award under the Survival Act, and Laser Spine Institute appealed the wrongful death award. 3. The appellate court determined the $10 million award was excessive and vacated it. The court also recommended a new case take place in a lower court on damages. n

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