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COVID-19 and the resurgence of telehealth in otolaryngology

  • Christina H. Fang
    Correspondence
    Address reprint requests and correspondence: Christina H. Fang, MD, Department of Otorhinolaryngology, Head and Neck Surgery, Montefiore Medical Center, The University Hospital of Albert Einstein College of Medicine, 3400 Bainbridge Avenue, Medical Arts Pavilion, 3rd Floor, Bronx, NY 10467.
    Affiliations
    Department of Otorhinolaryngology, Head and Neck Surgery, Montefiore Medical Center, The University Hospital of Albert Einstein College of Medicine, Bronx, New York
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  • Richard V. Smith
    Affiliations
    Department of Otorhinolaryngology, Head and Neck Surgery, Montefiore Medical Center, The University Hospital of Albert Einstein College of Medicine, Bronx, New York
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Published:April 28, 2022DOI:https://doi.org/10.1016/j.otot.2022.04.012
      The objective of this review is to examine the impact of the ongoing Coronavirus disease 2019 (COVID-19) pandemic on the use of telehealth in Otolaryngology. The use of telemedicine rose dramatically during the pandemic to meet the need for continued patient care while allowing for physical separation of providers and patients. Telemedicine has been used to evaluate patients with a variety of pathologies including dysphonia, vertigo, and anosmia. Innovative use of at-home exams, such as video-otoscopy has aided providers in overcoming challenges associated with a highly specialized physical exam. The use of telemedicine in Otolaryngology will likely remain essential in the post-pandemic era and has promising results for improving clinical efficiency.

      Keywords

      Telehealth in the COVID-19 Pandemic

      Telemedicine, which includes telehealth and other virtual services, refers to the exchange of medical information remotely using virtual technology to improve a patient's health.

      Verma S. Early Impact of CMS Expansion of Medicare Telehealth During COVID-19. Accessed on January 21, 2022. Available at: https://www.healthaffairs.org/do/10.1377/forefront.20200715.454789/full.

      ,

      CMS. Medicare Telemedicine Health Care Provider Fact Sheet. Accessed on January 23, 2022. Available at: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.

      Telehealth can be performed in a synchronous or asynchronous form. Synchronous visits involve real-time audiovisual interaction. Asynchronous visits involve exchange of information that occurs when the provider and patient are not connected at the same time, such as e-mail exchanges or pre-visit completion of surveys by patients.
      • Waller M
      • Stotler C.
      Telemedicine: A primer.
      Telemedicine has existed for many decades and was originally used to increase access to care in rural communities by allowing providers to expand their geographic reach.
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      Medicare and telehealth: The impact of COVID-19 pandemic.
      Prior to the Coronavirus disease 2019 (COVID-19) pandemic, the use of telehealth was not widely implemented because of several limiting factors. First, there is an increased security risk with the exchange of protected health information across third party web-based platforms.
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      Continuation of telemedicine in otolaryngology post-COVID-19: Applications by subspecialty.
      Additionally, the inability to perform in-person physical examination limits the information available to a provider, which can potentially have medicolegal consequences.
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      Departmental experience and lessons learned with accelerated introduction of telemedicine during the COVID-19 crisis.
      Furthermore, the reimbursements of telemedicine did not provide financial incentives for providers to offer this service.
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      Embracing telemedicine into your otolaryngology practice amid the COVID-19 crisis: An invited commentary.
      Despite the implementation of the Interstate Medical Licensure Compact in 2017 to ease physician ability to practice across state lines, pre-pandemic licensure requirements limited the location of providers and patients during telehealth visits.
      • Adashi EY
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      The interstate medical licensure compact: Attending to the underserved.
      ,
      • Chaudhry HJ
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      The low utilization of telemedicine was a national phenomenon, as less than 1% of physicians used telehealth prior to the pandemic.

      Amwell. From Virtual Care to Hybrid Care: COVID-19 and the Future of Healthcare. Accessed January 27, 2022. Available at: https://business.amwell.com/resources/from-virtual-care-to-hybrid-care-covid-19-and-the-future-of-healthcare.

      The World Health Organization declared COVID-19 a global pandemic on March 11, 2020.

      Organization WH. Rolling updates on coronavirus disease (COVID-19). Accessed January 26, 2022. Available at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events-as-they-happen.

      This quickly led to drastic changes in the delivery of health care worldwide and an unprecedented rise in the use of telehealth due to public health concerns. Emphasis on ‘social distancing’ and ‘quarantining’ to decrease person-to-person contact and risk of virus transmission made patients reluctant to visit clinics and hospitals.
      • Lazzerini M
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      • Apicella A
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      Delayed access or provision of care in Italy resulting from fear of COVID-19.
      In addition, closure of outpatient clinics and postponement of elective care early in the pandemic prevented patients from being evaluated in-person. In April 2020, there was an estimated 75% decline in outpatient Otolaryngology visits.
      • Sclafani AP
      • Shomorony A
      • Stewart MG
      • et al.
      Telemedicine lessons learned during the COVID-19 pandemic: The augmented outpatient otolaryngology teleconsultation.
      As a result, the use of telehealth to perform virtual medical assessments was rapidly adopted by clinicians. Telehealth visits allowed vulnerable patients to remain in their homes while maintaining access to the care they needed.

      CMS. Medicare Telemedicine Health Care Provider Fact Sheet. Accessed on January 23, 2022. Available at: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.

      Expansion of Telehealth Coverage

      To meet the growing need for telehealth services during the COVID-19 pandemic, the Centers for Medicare and Medicaid Services (CMS) adopted major legislative and regulatory changes for reimbursements for such services.

      CMS. Medicare Telemedicine Health Care Provider Fact Sheet. Accessed on January 23, 2022. Available at: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.

      Prior to the COVID-19 pandemic, Medicare coverage of telehealth services was limited primarily to the management of chronic conditions.

      CMS. Medicare Telemedicine Health Care Provider Fact Sheet. Accessed on January 23, 2022. Available at: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.

      In addition, there were policy restrictions on where beneficiaries could receive these services and which providers would be reimbursed for such services.

      CMS. Medicare Telemedicine Health Care Provider Fact Sheet. Accessed on January 23, 2022. Available at: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet.

      In March 2020, after declaration of COVID-19 as a public health emergency, the CMS expanded the scope of Medicare telehealth by adding 144 telehealth services and allowing all beneficiaries to receive telehealth in any location.

      Verma S. Early Impact of CMS Expansion of Medicare Telehealth During COVID-19. Accessed on January 21, 2022. Available at: https://www.healthaffairs.org/do/10.1377/forefront.20200715.454789/full.

      The CMS further eliminated barriers by reimbursing evaluations performed over the telephone.

      Verma S. Early Impact of CMS Expansion of Medicare Telehealth During COVID-19. Accessed on January 21, 2022. Available at: https://www.healthaffairs.org/do/10.1377/forefront.20200715.454789/full.

      In addition, providers of certain services were covered by this expansion, including speech-language pathologists, occupational therapists, and behavioral health services.

      CMS. Summary of Policies in the Calendar Year (CY) 2020 Medicare Physician Fee Schedule (MPFS) Public Health Emergency (PHE) Interim Final Rules. Accessed January 27, 2022. Available at: https://www.cms.gov/files/document/mm11805.pdf

      Between March and October 2020, over 24.5 million of 63 million beneficiaries received a Medicare telehealth service.

      CMS. Trump Administration Finalizes Permanent Expansion of Medicare Telehealth Services and improved Payment for Time Doctors Spend with Patients. Accessed January 23, 2022. Available at: https://www.cms.gov/newsroom/press-releases/trump-administration-finalizes-permanent-expansion-medicare-telehealth-services-and-improved-payment.

      Commercial insurance companies, including Cigna and United Healthcare similarly adapted to adjust reimbursements for telehealth visits.

      Editors FPM. Cigna institutes new reimbursement policy for virtual care. Accessed January 23, 2022. Available at: https://www.aafp.org/journals/fpm/blogs/gettingpaid/entry/cigna_virtual_reimbursement.html.

      ,

      Editors FPM. UnitedHealthcare modifieds telehealth reimbursement policy for 2021. Accessed January 23, 2022. Available at: https://www.aafp.org/journals/fpm/blogs/gettingpaid/entry/uhc_telehealth.html.

      Many states also loosened regulation on licensure requirements to provide telemedicine across state lines, further expanding access for patients.

      Boards. FoSM. U.S. states and territories modifying requirements for telehealth in response to COVID-19. Accessed January 23, 2022. Available at: https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf.

      Telehealth in Otolaryngology

      The use of telemedicine in Otolaryngology has been described in the literature since the 1990s.
      • Stern J
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      Telemedicine applications in otolaryngology.
      • Blakeslee DB
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      Practice of otolaryngology via telemedicine.
      • Made C
      • Carle L
      • Soderberg O
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      Tele-otolaryngology consultations between two rural primary-care centres in southern Lapland and the University Hospital of Umea.
      • Heneghan C
      • Sclafani AP
      • Stern J
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      Telemedicine applications in otolaryngology.
      These early reports focused on its use in providing remote expert consultation. Given that telemedicine in the form of a synchronous 2 way video-based virtual visit was not widely used, the rise of telehealth in Otolaryngology was particularly dramatic during the COVID-19 pandemic.
      • Garritano FG
      • Goldenberg D.
      Successful telemedicine programs in otolaryngology.
      ,
      • McCool RR
      • Davies L.
      Where does telemedicine fit into otolaryngology? An assessment of telemedicine eligibility among otolaryngology diagnoses.
      Otolaryngologists are at relatively high risk for COVID-19 exposure due to a high viral load in the upper aerodigestive tract and the risk of aerosolization during routine in-office procedures, such as indirect laryngoscopy.
      • Kowalski LP
      • Sanabria A
      • Ridge JA
      • et al.
      COVID-19 pandemic: Effects and evidence-based recommendations for otolaryngology and head and neck surgery practice.
      Thus, the ability to perform virtual visits to reduce viral exposure for providers, staff members and patients and to preserve personal protective equipment (PPE) made telehealth a desirable alternative to in-office visits. To safely provide patient care and prevent transmission, providers don 1 time-use PPE when evaluating patients. Increased demand for PPE during the height of the pandemic led to intermittent supply shortages which placed providers at increased risk.
      • Kamerow D.
      Covid-19: The crisis of personal protective equipment in the US.
      ,
      • Ranney ML
      • Griffeth V
      • Jha AK.
      Critical supply shortages - The need for ventilators and personal protective equipment during the covid-19 pandemic.
      By offering virtual evaluations, offices were able to preserve scarce PPE resources and also divert patients away from emergency rooms and hospitals overwhelmed with COVID-19 patients.
      During the pandemic, otolaryngologists have utilized telehealth to evaluate a variety of pathologies, spanning all subspecialties. In facial plastic surgery, telehealth has been used for preoperative consultations and postoperative evaluations of surgical site healing.
      • Azizzadeh K
      • Kerolus JL
      • Nassif PS.
      The benefit of video visits in facial plastic surgery private practice.
      To overcome the challenges of obtaining high-quality photographs necessary for preoperative planning and documentation of outcomes, Tower et al. developed “screenshot photography,” during which the patient is coached through optimizing camera angles, distances, lighting and background.
      • Tower JI
      • Lee JY
      • Lee YH.
      Screenshot photography: optimizing photo-documentation while using telehealth video platforms.
      The authors describe the most ideal setting for patient positioning as a neutral background away from harsh direct light, with the camera at least 3 feet away from the patient's face. In rhinology, telemedicine has been used to evaluate patients with anosmia with the aid of at-home objective smell testing.
      • Klimek L
      • Hagemann J
      • Alali A
      • et al.
      Telemedicine allows quantitative measuring of olfactory dysfunction in COVID-19.
      Other effective telemedicine interventions have included evaluation of dysphonia,
      • Hseu AF
      • Spencer G
      • Jo S
      • et al.
      Telehealth for treatment of pediatric dysphonia.
      ,
      • Johnson DM
      • Hapner ER
      • Klein AM
      • et al.
      Validation of a telephone screening tool for spasmodic dysphonia and vocal fold tremor.
      vertigo,
      • Bertholon P
      • Thai-Van H
      • Bouccara D
      • et al.
      Guidelines of the French Society of Otorhinolaryngology (SFORL) for teleconsultation in patients with vertigo during the COVID-19 pandemic.
      ,
      • Shah MU
      • Lotterman S
      • Roberts D
      • et al.
      Smartphone telemedical emergency department consults for screening of nonacute dizziness.
      peritonsillar abscess,
      • Mallen JR
      • Shah MU
      • Drake R
      • et al.
      Utility of smartphone telemedical consultations for peritonsillar abscess diagnosis and triage.
      nasal bone fracture,
      • Barghouthi T
      • Glynn F
      • Speaker RB
      • et al.
      The use of a camera-enabled mobile phone to triage patients with nasal bone injuries.
      and home management of positive pressure ventilation in children.
      • Zhou J
      • Liu DB
      • Zhong JW
      • et al.
      Feasibility of a remote monitoring system for home-based non-invasive positive pressure ventilation of children and infants.
      Video and photo documentation appear useful in these clinical scenarios. In cases of peritonsillar abscess, patients were evaluated using 2 tongue blades and video documentation taken of the oropharynx.
      • Mallen JR
      • Shah MU
      • Drake R
      • et al.
      Utility of smartphone telemedical consultations for peritonsillar abscess diagnosis and triage.
      Patients with nasal bone fractures were evaluated using anteroposterior and overhead photographs.
      • Barghouthi T
      • Glynn F
      • Speaker RB
      • et al.
      The use of a camera-enabled mobile phone to triage patients with nasal bone injuries.
      Video recordings of eye movements during a Dix-Hallpike maneuver using a smartphone were utilized in evaluation of dizziness.
      • Shah MU
      • Lotterman S
      • Roberts D
      • et al.
      Smartphone telemedical emergency department consults for screening of nonacute dizziness.
      The use of telehealth in Otolaryngology has its unique challenges. A comprehensive otolaryngological evaluation involves high dependence on the physical examination, which often requires specialized equipment, such as otoscopy and laryngoscopy.
      • Moentmann MR
      • Miller RJ
      • Chung MT
      • et al.
      Using telemedicine to facilitate social distancing in otolaryngology: A systematic review.
      In addition, palpation of relevant anatomy, such as the neck, cannot be performed remotely, potentially delaying diagnosis of a mass.
      • Manning LA
      • Gillespie CM.
      E-Health and telemedicine in otolaryngology: Risks and rewards.
      Thus, patients should be counseled on the limitations of diagnosis and management provided purely based on a telehealth encounter. This also highlights the need to perform video-based telehealth, as opposed to telephonic telehealth, in the initial evaluation of a patient. There are cases however, where clinical reasoning based on a thoroughly obtained patient history and external exam findings can be adequate. Several studies have reported use of a basic smartphone camera and microphone in a telehealth visit to diagnose otolaryngologic disorders
      • Johnson DM
      • Hapner ER
      • Klein AM
      • et al.
      Validation of a telephone screening tool for spasmodic dysphonia and vocal fold tremor.
      ,
      • Shah MU
      • Lotterman S
      • Roberts D
      • et al.
      Smartphone telemedical emergency department consults for screening of nonacute dizziness.
      • Mallen JR
      • Shah MU
      • Drake R
      • et al.
      Utility of smartphone telemedical consultations for peritonsillar abscess diagnosis and triage.
      • Barghouthi T
      • Glynn F
      • Speaker RB
      • et al.
      The use of a camera-enabled mobile phone to triage patients with nasal bone injuries.
      ,
      • Shah M
      • Douglas J
      • Carey R
      • et al.
      Reducing ER visits and readmissions after head and neck surgery through a phone-based quality improvement program.
      and highly sensitive questionnaires to monitor for postoperative complications or disease recurrence.
      • Malik A
      • Nair S
      • Sonawane K
      • et al.
      Outcomes of a telephone-based questionnaire for follow-up of patients who have completed curative-intent treatment for oral cancers.
      ,
      • Shapiro SB
      • Lipschitz N
      • Kemper N
      • et al.
      Early experience with telemedicine in patients undergoing otologic/neurotologic procedures.
      To help overcome the challenges of a highly specialized otolaryngologic exam, innovative use of at-home exams can assist in patient evaluation and management (Table 1). In adult patients, the use of video-otoscopy, either using a smartphone-enabled otoscope or specialized video otoscope has been shown to be equal to in-person otoscopy based on a recent systematic review.
      • Moentmann MR
      • Miller RJ
      • Chung MT
      • et al.
      Using telemedicine to facilitate social distancing in otolaryngology: A systematic review.
      Several smartphone otoscope devices have been developed, including the Cellscope, Anykit, Tytlocare, and Teslong (Fig. 1). These devices can be used to relay real-time images during a clinical encounter. In pediatric patients, evidence to support parental use of smartphone-enabled otoscopy did not appear to be as strong because of decreased accuracy.
      • Moentmann MR
      • Miller RJ
      • Chung MT
      • et al.
      Using telemedicine to facilitate social distancing in otolaryngology: A systematic review.
      Instead, the use of at-home otoscopy by parents is thought to be better used for postoperative monitoring of tympanostomy tube placement in children.
      • Don DM
      • Koempel JA
      • Fisher LM
      • et al.
      Prospective evaluation of a smartphone otoscope for home tympanostomy tube surveillance: A pilot study.
      The use of smartphone applications can also provide helpful supplemental information. For patients with hearing loss, the use of a smartphone-based vibration test and application-based hearing test has been described with positive results.
      • Shilo S
      • Ungar OJ
      • Handzel O
      • et al.
      Telemedicine for patients with unilateral sudden hearing loss in the COVID-19 era.
      ,
      • Yang A
      • Lewis RJ
      • Watson N
      • et al.
      The cell phone vibration test: A telemedicine substitute for the tuning fork test.
      Portable diagnostic audiometers have also been utilized in the evaluation of hearing loss (Fig. 2).
      • Fletcher KT
      • Dicken FW
      • Adkins MM
      • et al.
      Audiology telemedicine evaluations: Potential expanded applications.
      For oropharyngeal examination, use of USB adaptable flexible endoscopes has been described (Fig. 3).
      • Cai Y
      • Zheng YJ
      • Gulati A
      • et al.
      Patient use of low-cost digital videoscopes and smartphones for remote ear and oropharyngeal examinations.
      Table 1Examples of telemedicine platforms and devices used in Otolaryngology.
      SubspecialtyDevice or Platform
      OtologySmartphone or tablet attachable otoscope
      • Dai Z
      • Wang Y
      • Hang C
      • et al.
      Telemedicine for ear diseases with the smartphone otoscopes via WeChat in the COVID-19 era.
      • Gupta N
      • Baghotia KS
      • Rabha M
      • et al.
      Comprehensive community screening of otological patients by trained technicians using a telemedicine device: An efficient and cost-effective way to triage patients with ear diseases.
      • Jayawardena ADL
      • Mankarious LA
      • Keamy DG
      • et al.
      Pediatric, Family-Centered, "At-Home" Otologic Physical Examination in the COVID-19 Era.
      • Meng X
      • Dai Z
      • Hang C
      • et al.
      Smartphone-enabled wireless otoscope-assisted online telemedicine during the COVID-19 outbreak.


      Self-recorded videos for vertigo evaluation
      • Fancello V
      • Bianchini C
      • Iannella G
      • et al.
      The evaluation of vertigo in children: Which role for parental-camera recording and telemedicine?.


      AudiologySmartphone enabled audiometry application
      • Shilo S
      • Ungar OJ
      • Handzel O
      • et al.
      Telemedicine for patients with unilateral sudden hearing loss in the COVID-19 era.
      ,
      • Yang A
      • Lewis RJ
      • Watson N
      • et al.
      The cell phone vibration test: A telemedicine substitute for the tuning fork test.
      ,
      • Gupta N
      • Baghotia KS
      • Rabha M
      • et al.
      Comprehensive community screening of otological patients by trained technicians using a telemedicine device: An efficient and cost-effective way to triage patients with ear diseases.
      ,
      • Irace AL
      • Sharma RK
      • Reed NS
      • et al.
      Smartphone-based applications to detect hearing loss: A review of current technology.
      ,
      • Chu YC
      • Cheng YF
      • Lai YH
      • et al.
      A mobile phone-based approach for hearing screening of school-age children: Cross-sectional validation study.


      Cochlear implant evaluation using Web application server and Bluetooth enabled audiometer
      • Fletcher KT
      • Dicken FW
      • Adkins MM
      • et al.
      Audiology telemedicine evaluations: Potential expanded applications.


      Head and Neck/GeneralFlexible digital endoscope for oropharyngeal examination
      • Cai Y
      • Zheng YJ
      • Gulati A
      • et al.
      Patient use of low-cost digital videoscopes and smartphones for remote ear and oropharyngeal examinations.


      Transmission of continuous positive airway pressure adherence data for evaluation of obstructive sleep apnea patients
      • Hu Y
      • Su Y
      • Hu S
      • et al.
      Effects of telemedicine interventions in improving continuous positive airway pressure adherence in patients with obstructive sleep apnoea: a meta-analysis of randomised controlled trials.


      LaryngologySmartphone based voice analyzer application
      • Munnings AJ.
      The Current State and Future Possibilities of Mobile Phone "Voice Analyser" Applications, in Relation to Otorhinolaryngology.
      ,
      • Payten CL
      • Nguyen DD
      • Novakovic D
      • et al.
      Telehealth voice assessment by speech language pathologists during a global pandemic using principles of a primary contact model: an observational cohort study protocol.


      Facial PlasticsLive video consultation for facial plastic surgery evaluation
      • Azizzadeh K
      • Kerolus JL
      • Nassif PS.
      The benefit of video visits in facial plastic surgery private practice.
      ,
      • Morisada MV
      • Tollefson TT
      • Shaye DA
      • et al.
      The digital doctor: telemedicine in facial plastic surgery.


      RhinologySmartphone based application for sinonasal symptom questionnaire

      Marcellino C, O'Brien EK, Choby G, et al. Distributed monitoring of sinonasal symptoms using a mobile device application-a pilot study. Int Forum Allergy Rhinol. 2021;11:1283-1286. doi:10.1002/alr.22795.



      Smartphone enabled digital otoscope attachment used for anterior rhinoscopy/nasal endoscopy
      • Sclafani AP
      • Shomorony A
      • Stewart MG
      • et al.
      Telemedicine lessons learned during the COVID-19 pandemic: The augmented outpatient otolaryngology teleconsultation.


      Fig. 1
      Figure 1Example of at-home otoscope (Teslong technology)
      Fig. 2
      Figure 2Portable diagnostic audiometer (OTOSphere, Otovation)
      Fig. 3
      Figure 3USB compatible flexible endoscope (Shenzhen Anykit Technology Co Ltd)
      The diagnostic accuracy and efficacy of treatment provided during telehealth visits is important to quantify. A retrospective review of patients who presented with laryngeal complaints found high concordance rates between their initial telemedicine visit and subsequent outpatient office visit.
      • Choi JS
      • Yin V
      • Wu F
      • et al.
      Utility of telemedicine for diagnosis and management of laryngology-related complaints during COVID-19.
      Specifically, they reported 86.0% and 93.6% concordance rates for diagnosis and management, respectively. This supports the use of telemedicine as a feasible initial option for patients with laryngology-related complaints.
      Physician and patient perceptions of telehealth appear to be generally positive. The American Otolaryngology – Head and Neck Society Telemedicine & Telehealth Working Group surveyed otolaryngologists on their telemedicine experience in 2021.

      Levi JYVCAOJHD. Tele-otolaryngology: through the pandemic, and beyond-interim findings on the study of telehealth in otolaryngology. Accessed January 21, 2022. Available at: https://bulletin.entnet.org/home/article/21403362/teleotolaryngology-through-the-pandemic-and-beyond-interim-findings-of-the-study-of-telehealth-in-otolaryngology.

      Of 282 otolaryngologists, 99% reported increased use of telemedicine during the pandemic and 85% intended to continue using telemedicine after the pandemic. 76% of providers felt that their patients responded favorably to the use of telemedicine as part of their care. The attitudes of Otolaryngology patients toward telemedicine are also favorable with a high satisfaction rate.
      • Layfield E
      • Triantafillou V
      • Prasad A
      • et al.
      Telemedicine for head and neck ambulatory visits during COVID-19: Evaluating usability and patient satisfaction.
      • Rimmer RA
      • Christopher V
      • Falck A
      • et al.
      Telemedicine in otolaryngology outpatient setting-single Center Head and Neck Surgery experience.
      • Hoi KK
      • Brazina SA
      • Kolar-Anderson R
      • et al.
      A longitudinal comparison of telemedicine versus in-person otolaryngology clinic efficiency and patient satisfaction during COVID-19.
      • Choi JS
      • Kim JH
      • Park S
      • et al.
      Telemedicine in otolaryngology during COVID-19: Patient and physician satisfaction.
      Perceived benefits of telehealth by patients include improved convenience and decreased costs associated with travel and parking.
      • Hoi KK
      • Brazina SA
      • Kolar-Anderson R
      • et al.
      A longitudinal comparison of telemedicine versus in-person otolaryngology clinic efficiency and patient satisfaction during COVID-19.
      ,
      • Triantafillou V
      • Layfield E
      • Prasad A
      • et al.
      Patient perceptions of head and neck ambulatory telemedicine visits: A qualitative study.
      Higher patient satisfaction has been associated with videoconference visits (vs telephone) and patients with English as a preferred language.
      • Choi JS
      • Kim JH
      • Park S
      • et al.
      Telemedicine in otolaryngology during COVID-19: Patient and physician satisfaction.
      There are barriers to telehealth to be aware of, however, which include patient access to technology, access to an interpreter, lack of trained staff, level of patient education, and patient comfort.
      • Hoi KK
      • Brazina SA
      • Kolar-Anderson R
      • et al.
      A longitudinal comparison of telemedicine versus in-person otolaryngology clinic efficiency and patient satisfaction during COVID-19.
      ,
      • Scott Kruse C
      • Karem P
      • Shifflett K
      • et al.
      Evaluating barriers to adopting telemedicine worldwide: A systematic review.
      ,
      • Jiang W
      • Magit AE
      • Carvalho D.
      Equal access to telemedicine during COVID-19 pandemic: A pediatric otolaryngology perspective.
      Based on an open-ended survey of Otolaryngology patients who had a video-based telehealth visit, the majority of reservations were centered around internet connection and accessing the user interface.
      • Triantafillou V
      • Layfield E
      • Prasad A
      • et al.
      Patient perceptions of head and neck ambulatory telemedicine visits: A qualitative study.
      It is plausible that as telehealth becomes more prevalent in medicine, the patient experience with a video encounter will improve with increased use. Some patients in this survey also noted there was a greater benefit to a telemedicine visit if there was already an established relationship with the provider.
      • Triantafillou V
      • Layfield E
      • Prasad A
      • et al.
      Patient perceptions of head and neck ambulatory telemedicine visits: A qualitative study.
      The use of a digital platform may potentially marginalize those with limited internet access or limited digital literacy, homeless patients, and undocumented immigrants.
      • Shehan JN
      • Agarwal P
      • Danis DO
      • et al.
      Effects of COVID-19 on telemedicine practice patterns in outpatient otolaryngology.
      Specific to Otolaryngology, we should be cognizant of patients who may not be able to communicate well in a virtual setting, such as those with hearing loss or with laryngectomies.
      • Bhutta MF
      • Swanepoel W
      • Fagan J.
      ENT from afar: Opportunities for remote patient assessment, clinical management, teaching and learning.
      Physicians therefore should conscientiously decide which patients are most appropriate for a telehealth evaluation.
      It is important to consider the patient's comfort level with telehealth as well. Although most providers agree with the implementation and continued use of telehealth, patients are not necessarily equally invested.
      • Fassas S
      • Cummings E
      • Sykes KJ
      • et al.
      Telemedicine for head and neck cancer surveillance in the COVID-19 era: Promise and pitfalls.
      The use of telehealth has declined as the pandemic has continued, as can be seen in Fig. 4, depicting the actual number and percentage of visits for telehealth and in-person. The change is notable in the early part of the pandemic, when New York City was greatly affected and many of our providers were reassigned to inpatient intensive care units. We saw a rapid return to in-person visits, when we reopened to the general population in early May, 2020, although we were seeing in-person visits throughout March and April, 2020 for acute conditions. As can be seen, despite offering telehealth to many of our patients, our telehealth volume has been consistently limited in number, with 1 temporary spike during a subsequent COVID-19 wave. This is in large part due to patient demands (for in person visits) and the need for specialized physical examination in Otolaryngology. Despite the accessibility of telehealth throughout the pandemic, many patients have waited to have any contact with their otolaryngologist and have only recently been returning to the office. We have found some success in having an experienced comprehensive otolaryngologist use telehealth as an expedited evaluation for comprehensive otolaryngology patients to facilitate transfer of care to the appropriate subspecialist, with arranging all necessary testing, to improve the timeliness of care. Overcoming reluctance in certain patients, however, will be required to make telehealth a universal platform.
      Fig. 4
      Figure 4(A) Monthly in-person and telehealth (video and telephone) visits from January 2020 through December 2021 in the Department of Otorhinolaryngology-Head and Neck Surgery at Montefiore Medical Center. (B) Visits noted in Figure A expressed as a percentage of total monthly visits.

      The Future of Telehealth

      As the use of telemedicine increases in our specialty, future studies are important to determine which patients and conditions are most appropriate and conducive for telehealth evaluation. A systematic review found that in-person follow-up appointments were required in 13%-72% of initial Otolaryngology telehealth consultations.
      • Gupta T
      • Gkiousias V
      • Bhutta MF.
      A systematic review of outcomes of remote consultation in ENT.
      This high conversion to in-person visits suggests that telehealth is best used for triaging patients with specific complaints.
      • Gupta T
      • Gkiousias V
      • Bhutta MF.
      A systematic review of outcomes of remote consultation in ENT.
      ,
      • Lechien JR
      • Radulesco T
      • Distinguin L
      • et al.
      Patient and otolaryngologist perceptions of telemedicine during COVID-19 pandemic.
      Virtual visits are also effective for evaluation of patients where a detailed physical examination is not critical (ie, preoperative discussion about surgery, interval follow-up visit after initiating medical management).
      • Sclafani AP
      • Shomorony A
      • Stewart MG
      • et al.
      Telemedicine lessons learned during the COVID-19 pandemic: The augmented outpatient otolaryngology teleconsultation.
      ,
      • Gupta T
      • Gkiousias V
      • Bhutta MF.
      A systematic review of outcomes of remote consultation in ENT.
      Patients with conditions that require detailed physical examination for accurate diagnosis, such as a neck mass, would instead be better suited for an in-office visit. Creating consensus guidelines to standardize which patients are most amenable to telemedicine consultation will aid in streamlining and optimizing healthcare resources.
      The marked increase in the use of telehealth during the pandemic has long term implications. With the ever growing pressure on hospital systems to reduce cost of care, telehealth may help improve clinical efficiency without compromising quality of care.
      • Arora P
      • Mehta D
      • Ha J.
      Impact of telehealth on health care resource utilization during the COVID-19 pandemic.
      In Otolaryngology as well as other specialties, telehealth visits have been shown to decrease office visit cycle time, defined as the time that a patient spends at a visit, when compared to in-person visits.
      • Hoi KK
      • Brazina SA
      • Kolar-Anderson R
      • et al.
      A longitudinal comparison of telemedicine versus in-person otolaryngology clinic efficiency and patient satisfaction during COVID-19.
      ,
      • Arora S
      • Rudnisky CJ
      • Damji KF.
      Improved access and cycle time with an "in-house" patient-centered teleglaucoma program versus traditional in-person assessment.
      ,
      • Andino JJ
      • Castaneda PR
      • Shah PK
      • et al.
      The impact of video visits on measures of clinical efficiency and reimbursement.
      Moving forward, incorporation of telemedicine into the workflow of healthcare systems is key to transitioning current practices into a sustainable patient care model.
      • Loeb AE
      • Rao SS
      • Ficke JR
      • et al.
      Departmental experience and lessons learned with accelerated introduction of telemedicine during the COVID-19 crisis.
      The key will be to incorporate remote physical assessment technology and to define which conditions, such as routine ultrasound monitoring of thyroid nodules, can be easily and safely performed using telehealth. Centralizing operations of services and employing dedicated qualified personnel can help solidify the role of telemedicine in the post-pandemic era.
      • Kreofsky BLH
      • Blegen RN
      • Lokken TG
      • et al.
      Sustainable telemedicine: Designing and building infrastructure to support a comprehensive telemedicine practice.

      Disclosures

      Christina H. Fang, MD – none, Richard V. Smith, MD, FACS – none.

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