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Facial Plastic Surgery & Aesthetic Medicine

Volume 22, Number 3, 2020


ª American Academy of Facial Plastic and Reconstructive Surgery, Inc.
DOI: 10.1089/fpsam.2020.0163

VIEWPOINT: COVID-19

Telemedicine in the Era of the COVID-19 Pandemic:


Implications in Facial Plastic Surgery
Tom Shokri, MD* and Jessyka G. Lighthall, MD, FACS

The global COVID-19 pandemic has placed unprece- communities or during public health emergencies.4
dented restraints on resource allocation and patient In response to the current pandemic, the Centers for
care. The rapidity with which the pandemic has spread Medicare & Medicaid Services, as well as most com-
has resulted in the depletion of hospital resources and mercial health plans, have amended policies including
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increased health expenditures.1 Additionally, the risk of waiving co-pays in order to encourage utilization of
occupational exposure for health care providers poses a telemedicine services. However, barriers to broad imple-
significant barrier to the delivery of timely and effective mentation of such services continue to exist, including
patient care. Otolaryngologists, including facial plastic equipment costs, provider training, and licensing as
surgeons, are particularly at risk given the increased well as payment and regulatory services. Additionally,
viral load within the upper aerodigestive tract and the ethical considerations such as Health Insurance Portabil-
aerosol-generating procedures performed.2 Many medi- ity and Accountability Act compliance must be taken
cal organizations have responded by deferring elective into account. Although establishing these programs in
cases and ceasing of nonessential services. Various an acute setting poses difficulties, many hospital-based
evidence-based guidelines have been published regarding health systems have leveraged already existing tele-
practice modifications during this time of pandemic, and medical platforms in their response to COVID-19.4
the literature is continually evolving.3 However, little is Community-based facial plastic surgeons lacking imme-
known regarding the length of time for which these pre- diate access to such programs may outsource telehealth
cautions may be implemented. Physicians are therefore services to providers such as American Well or Teladoc
faced with the difficulty of complying with new regula- Health. These platforms provide synchronous real-
tory restrictions while attempting to provide patient care. time audiovisual-enabled visits and are easy to use for
While it is important to mitigate risk of infection and patients, providers, and staff scheduling appointments,
further spread of this contagion, safe patient care must con- allow for patient connectivity via computer, tablet, or
tinue to be prioritized. This is difficult in the outpatient fa- smart phone, and abide by patient privacy laws.
cial plastic surgery setting in which in-person evaluation During the COVID-19 pandemic, additional profes-
and consultation is often instrumental in management. In sional evaluation and management codes have been ap-
light of this, alternative approaches toward care must be proved for telemedicine visits. Physicians must obtain
employed. Telemedicine, the provision of clinical services patient consent for the visit (often automated in existing
via the use of communication technology between patient platforms); document the type of visit (e.g., phone visit,
and provider, is one such resource that may be effectively synchronous face-to-face video visit, etc.); location of
implemented during this time. Telemedicine may refer to physician and patient; confirmation of identity; and com-
transfer of static images or video between patients and ponents of the evaluation and management service per-
physicians via mobile devices or the use of audiovisual formed. One key limitation is the ability to perform a
telecommunications software to facilitate correspondence comprehensive physical exam (palpation, intranasal or
in real time.4 Implementation of such services has become intraoral exam, scope evaluations, etc.). Due to this limita-
progressively feasible with the corresponding increase in tion, telemedicine visits are often billed based on the time
availability of smartphones, webcam-enabled personal spent with the patient, documenting the amount of time
computers, and high speed internet. spent on counseling and coordination of care.
The utility of telemedicine has previously been dem- Facial plastic surgeons are encouraged to familiarize
onstrated in addressing health-care inequities in rural themselves with the most effective means of integrating
Department of Otolaryngology–Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania, USA.

*Address correspondence to: Tom Shokri, Department of Otolaryngology–Head and Neck Surgery, Penn State Health Milton Hershey Medical Center, 500 University Drive,
Hershey, PA 17033, USA, Email: tshokri@pennstatehealth.psu.edu

155
156 SHOKRI AND LIGHTHALL

telemedical technology within their specific practice set- patients that require extensive postoperative care, such as
ting. For example, live teleconsultation requires coordi- those undergoing free tissue transfer, programs imple-
nation of patient and provider schedules, audiovisual menting electronic intensive care unit monitoring may
equipment with the capacity to stream in a seamless man- streamline patient care and facilitate the redistribution
ner, and access to high speed internet. This may be best of health care workers and resources to more deplete
utilized for initial consultations, in the postoperative set- areas.5 At this time of large-scale home quarantine, con-
tings to evaluate surgical site healing and patient con- cerns regarding workplace capacity and limitation of
cerns, or during more urgent issues to screen patients to subspeciality care may be addressed through application
determine whether they need an in-person evaluation. of telemedical protocols as well. These resources may
However, a more economical means of telecommunica- provide rapid access to a facial plastic surgeon for triage
tion, store-and-forward telemedicine, may be employed of patients with craniomaxillofacial trauma, postopera-
in nonurgent settings or when providers are not readily tive complications, or other potentially life-threatening
available.4 Store-and-forward telemedicine allows accu- conditions.
mulation of relevant patient data, such as patient com- In summary, telemedicine represents an invaluable tool
plaints or physical findings, through transfer of static for facilitating safe and timely patient communication and
images or stored video, which can be transmitted to the re- delivery of health care services for the facial plastic sur-
ceiving consultant to review at a later time. This type of geon. While limitations exist, specifically with respect to
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consultation may be most appropriate when implemented the capacity to perform comprehensive physical exams
in nonurgent scenarios or routine patient follow-up. or procedures, a generalized consultation with overview
In our practice, initially only postoperative and follow- of patient concerns, and postoperative findings may be rea-
up patients would send photos and videos attached to a sonably performed. This may allow for further triage in de-
description of how they feel they are recovering. After termining the acuity of concerns necessitating early
review, patients were messaged electronically or set up intervention as well as a decrease in overutilization of
for either a phone or urgent in-person visit based on the health care resources. Physicians are therefore encouraged
need. It was assumed that most facial plastic surgery pa- to familiarize themselves with telemedicine services,
tients would not be appropriate for telemedicine. How- available vendors, and reimbursement protocols as de-
ever, our system transitioned to live visits via Zoom tailed in the Centers for Medicare & Medicaid Services
and now the American Well platform. We have found Telehealth or Telemedicine Tool Kit.7
that many patients are happy with the experience and ap-
preciate the continuity of obtaining care without having Author Disclosure Statement
to risk their health by leaving the home during the pan- No competing financial interests exist.
demic. Currently, most patients are seen by synchronous
real time audiovisual visits, including initial consultations Funding Information
and follow ups for cosmetic surgery, rhinoplasty, trauma, The authors did not receive any specific grant from fund-
and cancer reconstructions. Through these platforms, ing agencies in the public, commercial, or not-for-profit
there is also the ability to provide multidisciplinary care. sectors.
For example, many patients in our facial nerve clinic
are being seen during the same session by both the physi- References
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This article has been cited by:

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