The role of telemedicine in postoperative care

Introduction

According to the Institute of Medicine, telemedicine is defined as “the use of electronic information and communication technologies to provide and support health care when distance separates participants” (1). With the proliferation and widespread adoption of technology, including the personal computer and smartphone, the electronic arsenal available to medical fields has exponentially risen. Since its implementation in the early 1950s, telemedicine has become a rapidly-expanding tool in medicine (1-6). The adoption of telemedicine has afforded improved access to care, ameliorated resource efficiency, and decreased costs associated with traditional office visits and has been applied in a wide array of fields in medicine (5,7-12). In addition to physicians’ offices, home health agencies, and skilled nursing facilities, over 50% of acute care hospitals are currently using telemedicine at some level (13). The telemedicine market is expected to reach the value of $30 billion dollars by 2019, which is anticipated to grow by 20–50% each year (14).

In recent years, telemedicine has been adopted in several domains of surgical care, including preoperative and postoperative care (15-17). The role of telemedicine in postoperative care is of significant interest and it has demonstrated excellent clinical outcomes, enhanced patient satisfaction, increased accessibility along with reduced wait times, and cost savings to patients and health care systems (15). The evolution of surgical care should focus on providing the highest quality of patient care with a special emphasis on patient and provider satisfaction, meanwhile maintaining optimal access to care. Thus, the benefits of telemedicine merit continuing consideration and utilization by all providers in the surgical field.

History of telemedicine

The National Aeronautics and Space Administration (NASA) has been at the forefront of telemedicine implementation and its application (18). Since the early days of sub-orbital flight, remote monitoring of crew members and environmental health have been integral parts of NASA’s space operations (19). When the Space program was initiated, telemetry of flight suit data allowed ground controllers to analyze and interpret a crew member’s basic physiologic parameters (19). Although data were collected and recorded during this time, it remained unlinked in real-time to crew members during these early missions (19). It wasn’t until the Apollo Project [1968–1972] that a biosensor harness, an integrated suite of equipment allowing for real-time transmission of health parameters to the ground control, was generated (20). Since the Space Shuttle program [1981], tracking and data relay have allowed constant real-time communication of biomedical information, which has served as a beacon for the integration and evolution of telemedicine. Overall, NASA’s ability to monitor and maintain crew health and telemedicine system performance in spaceflight has proved to be a well-coordinated effort, providing for the advancement and integration of telecommunication in the field of medicine (18).

Adoption of telemedicine and use in postoperative care

Although initially viewed as a futuristic concept through its early adoption and implementation by NASA, the telemedicine industry has rapidly grown and gained acceptance by both patients and providers. For the last two decades, the United States (U.S.) Department of Veterans Affairs (VA) has been at the forefront of telemedicine. In 2014, 1.2 million telemedicine visits were conducted for approximately 700,000 Veterans across 44 different medical specialties (21). Additionally, the VA system has prioritized telemedicine utilization in furthering care to its veterans and its use is now even a healthcare performance goal for the 2014 to 2020 fiscal years with $1.2 billion allotted for telemedicine efforts in the 2016 VA budget (21,22).

Although telemedicine in surgery gained interest in the late 2000s, the VA health care system, with its robust and long-running video visit program, has played an integral role in adoption of telemedicine in the field of surgery (23). In 2013, the VA health care system conducted one of the first and largest pilot programs examining whether a telephone visit could safely substitute a traditional office visit for elective general surgery cases, including elective laparoscopic cholecystectomy and open hernia repair (24). During this 10-month study period, excellent clinical outcomes and high patient satisfaction were achieved (24). Several follow-up studies confirmed these findings in the VA healthcare system and also in a wide variety of surgical fields including subspecialties of general surgery, urology, plastic surgery, neurosurgery, and obstetrics and gynecology (15,21,25-30).

Telemedicine modalities

Evolution in technology has effectuated a systemic change in the ways health care is delivered to patients. A robust and reliable broadband connection is preemptive to provision of efficient care over long distances. A comprehensive broadband signal transmission system, or the “pipe,” comprises elaborate infrastructure that enables flow of data at modest speeds. Recent improvements in these infrastructure facilities globally have given way to cost-effective access to wider bandwidths that allow higher data transmission rates. This has stemmed the emergence of renewed interest in telemedicine (31).

In recent years, telemedicine in postoperative care has been implemented via a multitude of modalities. Short message service (SMS) text messaging, smart-phone applications, automated calls and wearable devices have become some of the most widely used modalities (21). SMS-based communications have been widely adopted over the years, and are used twice as frequently compared to application-based interventions (32). Generally, any cellphone or computer can send and receive SMS texts, providing a very basic and easy-to-use modality for patient communication. Despite SMS messaging being used for over a decade, mobile health (m-health) applications and fitness trackers are considered to be the fastest growing segment fueling the growth of telemedicine today. These applications have the potential for a superior interface between patients and providers with numerous modalities of communication including pictures and videosJeny (32). Despite these benefits, some clinicians feel that application-based modalities can be a potential barrier to delivery of health care to patients over a distance, since not all patients have access to smartphones and computers, which are required to use these applications (32).

Although there are some concerns regarding the underuse of mobile phones and m-Health applications in certain populations, including the elderly and the lower socio-economic class, numerous studies indicate that both young and old patients are able to utilize these modalities and can greatly benefit from them (33,34). Overall, both SMS messaging and m-Health applications have emerged as a great avenue to shorten length of hospital stay and improve quality of care delivered to patients by potentially identifying complications earlier, and therefore decreasing 30-day readmission, improving recovery, and reducing health care costs in post-operative patients (34,35).

Utilization of telemedicine in the postoperative period

Although telemedicine has been richly adopted in various aspects of surgical care, its utilization in postoperative care has become of great interest (15). Telemedicine during the postoperative period has been used predominantly in three manners (15), which include (I) scheduled follow-up (24,36-44), (II) routine monitoring (44-48), and (III) management of arising issues as needed (49,50). Recently, the replacement of traditional clinic visits with telemedicine has become highly popular. Numerous studies have demonstrated the potential for replacing traditional follow-up clinic visits with either a telephone call (24,25,39), automated messaging (51), or an online videoconference chat, which can occur from either an affiliated institution (37,38,42) or the patient’s home (40,41,43). Some interest in picture-focused smart phone-based services for surgical wound care evaluation has also emerged (52-54).

Routine monitoring of patients has also gained interest. In some settings, clinicians have used this method to assist in patients’ reporting of postoperative symptoms through either an automated telephone survey (45) or via a videophone (47). Other clinicians, however, demonstrate routine monitoring of specific objective clinical data including ileostomy output (55), blood pressure and medication adherence (47), surgical drain output (48), and home spirometry results (46,56). Although not as commonly utilized, there are reports of patients conveying specific postoperative concerns as they arose through automated messaging systems (49,57) and communications based on smartphone digital photography (50). Overall, there is a tremendous potential for providers to communicate remotely and deliver excellent care to patients in the postoperative setting through a variety of means.

Clinical outcomes of telemedicine in postoperative care

Telemedicine has shown promise in improving outcomes for patients in the postoperative setting. It is imperative to say that in the absence of excellent clinical outcomes, all the secondary benefits of any healthcare intervention become of limited use. Recent literature contains growing evidence for excellent clinical outcomes following the introduction of telemedicine in the postoperative setting. Studies report that clinical outcomes are comparable to the outcomes in the setting of traditional clinic follow-up (15). As an example, in elective low-risk procedures like laparoscopic and open inguinal hernia repair, laparoscopic cholecystectomy, parathyroidectomy, arthroplasty and pediatric urological procedures, complication rates generally range from 0 to 4.8% which are not statistically different from the complication rates following traditional clinical follow-ups postoperatively (24,37,39,41,42). High-risk non-elective procedures, including those involving orthopedic trauma have known higher rates of complication. The complications reported following these procedures are similar in settings of traditional clinic follow-ups and telemedicine (40). It is worth noting that no studies have reported statistically higher complication rates with telemedicine visits when compared to complication rates in traditional clinic follow-ups (15).

The potential shown by telemedicine in the postoperative setting has led some authors to question the need for routine traditional office visits for low-risk procedures. Chen et al. found that for elective appendectomy and cholecystectomy, providers would spend an average of 7.8 hours in traditional office visits for every intervention that needed to be performed, which included staple removal, suture removal, drain removal, medication changes, additional imaging, and future follow-ups (58). Such findings have left some clinicians to propose that for low-risk elective procedures, follow-ups via telemedicine can be a better option (15). However, select patients may require traditional office visits for follow-up, while others may not require any follow-up at all. Regardless, it appears that telemedicine use in the postoperative setting affords excellent clinical outcomes comparable to those following up in traditional clinic visits across a wide array of surgical specialties. Further work is ongoing to determine the optimal patient populations and surgical specialties that are best suited for telemedicine adoption.

Patient satisfaction of telemedicine

Patient satisfaction is an integral component of good surgical care. The use of telemedicine in postoperative care should therefore entail high patient satisfaction and willingness for participation. In general, patient willingness towards telemedicine use in the postoperative setting is high. For example, in the fields of transplant, general, and vascular surgery, a sizable proportion of patients (90%, 77%, and 90% respectively) reported willingness and confidence in provider ability to conduct remote postoperative care including blood pressure monitoring, medication adherence guidance, and evaluation of postoperative wounds (47,54,59,60).

Furthermore, patients who participate in postoperative care involving telemedicine report both high patient satisfaction and ease of use. Finkelstein et al. demonstrated that 90% of patients were satisfied with home spirometry monitoring following lung transplant (46), while Segura-Sampedro et al. reported high levels of satisfaction with surgical wound remote follow-up by smart phone after appendectomy (52). Some studies in the fields of urology and orthopedic surgery actually report higher patient satisfaction rates for telemedicine care than traditional office visits (41,43). Others, however, report mixed views with about 50% patients preferring some form of telemedicine as the means to deliver postoperative care (61). Overall, across the literature, patient satisfaction and ease of use are high for telemedicine in the setting of post-operative care. Nevertheless, future studies focusing on larger patient populations testing a more rigorous cascade of clinical outcomes will help determine which patient populations will best suit utilization of telemedicine for post-operative care following various types of surgery.

Provider satisfaction of telemedicine

Since the early days of implementation of telemedicine for post-operative care, patient satisfaction has received precedence over provider satisfaction. However, this does not negate the fact that in addition to a high degree of patient satisfaction, providers also express satisfaction towards various telemedicine modalities for delivery of post-operative care. Following radical prostatectomy, urologists reported a high level of provider satisfaction for video visits (88%) versus office visits (90%) (36). Urologists also reported high levels of provider-perceived quality of medical history (82% vs. 72%), therapeutic management (85% vs. 86%), and patient satisfaction (97% vs. 86%) for video visits when compared to traditional office follow-up (43). For monitoring burn patients postoperatively, providers reported being “very satisfied” in over 90% of telemedicine encounters (44). In general, surgical providers appear to have a high degree of satisfaction similar to patients. Some providers, however, express concerns regarding the effectivity of use of telemedicine in their current clinical workflow of traditional office visits (43). As telemedicine in postoperative care is still in its infancy, continued implementation and repeated revisions of clinical workflow may help to alleviate these concerns in the near future.

Time and cost savings for patients

Both time and cost savings contribute majorly toward high patient satisfaction. In their systematic review of 21 studies evaluating telemedicine use in the postoperative setting, Gunter et al. reported both significant patient time and cost savings (15). As opposed to driving from their residence, patients saved between 79.6 to 367.2 round-trip miles and 77.5 to 317 minutes of total travel time (24,37-40,42,43,61). These round-trip miles and travel time saved directly translate into monetary savings for families, ranging from $36 to $357 dollars saved on travel (24,37-40,42,43,61). In addition, several studies report that patients and their families can potentially avoid taking time off from work and other responsibilities and prevent spending one or more nights in a hotel by utilizing telemedicine for postoperative care (15,40,43). Canon et al. determined that for every 23 miles away from their clinic, patients are 111% more likely to prefer telemedicine for postoperative follow-up (37). Since many university hospitals provide care to wide geographic regions and have subsets of patients with significant traveling distances, patients are more likely to prefer remote follow-ups through the use of telemedicine. This should encourage the health care systems to adapt to this growing need of the patients.

In addition to patients saving both travel time and travel distance, some studies report that telemedicine can afford significantly decreased “cycle time,” which is the total time spent from the beginning to the end of a clinical encounter (23). This eliminates time spent on non-clinical activities like waiting at the start and end of appointments and being moved to the examination room (23). Following minor procedures such as total joint arthroplasty, an average Skype call per patient as short as 2.71 minutes has been reported (41). For elective general surgery procedures, significant differences in patient-reported visit times with online postoperative care (patient time, median; 103 min. versus 15 min.; P<0.01) have been reported (25). The degree of change in “cycle time” however, is dependent largely on the procedure performed. Following radical prostatectomy, similar wait times (18.4 vs. 13 min.; P=0.20) and total time devoted to clinical care (17.9 vs. 17.8 min.; P=0.97) between video visits and office visits have been reported (43). However, this has not altered the high patient and provider satisfaction rates. As telemedicine provides a significant time and cost saving advantage to the majority of patients, its application should be considered in all postoperative patients who are eligible.

Telemedicine for rural settings and patients with transportation barriers

Academic and non-academic centers throughout the country provide surgical care to distinct patient populations in diverse geographic regions. Telemedicine use in postoperative care can directly impact the clinical care provided, especially to patients in rural communities and urban areas with poor access to transportation (23). Approximately 52% percent of patients living in rural communities have access to smartphones and can participate in postoperative telemedicine care (62). Also, there are numerous patients in urban areas where mobility and transportation issues are prevalent. Telemedicine has been applied to these patient populations in under-developed countries, with rudimentary transport systems, with success. If surgeons continue to adopt these practices for providing postoperative care, profoundly more patients will be able to follow up and receive excellent care.

Healthcare system savings and revenue generation

The use of telemedicine in delivering postoperative care is still in its infancy and its implications on healthcare system cost savings and revenue generation are largely to be determined. However, early reports and projections are promising. Daily telephone calls to postoperative ileostomy patients facilitated decreased readmission rates and a savings of $63,821 for the total hospital cost of a dehydration-specific readmission (63). Other countries have shown promise by demonstrating that telemedicine may save as much as $600,000 over a 5-year period for regional hospitals in Queensland, Australia (64). Furthermore, in the U.S. several studies report that telemedicine for postoperative care can generate a substantial number of additional clinic slots for new patient evaluation at the VA health system (24,25). Not only does this play an important role in improving access to surgical care and decreasing wait times, but this is also projected to increase the number of elective operative cases secondary to increased new patient evaluations. Currently, there are several studies underway to determine the full financial implications of utilization of telemedicine in the postoperative setting (65). Overall, it appears that the post-operative use of telemedicine should not only generate cost savings for healthcare system, but it also should spawn a substantial amount of additional revenue if the added elective surgeries are conducted secondary to additional new patient evaluations.

Ethical considerations of telemedicine

Reports on breaches in critical data have been on the rise in the past decade (66). In the U.S. alone, data breaches were reported for 29 million patient health information (PHI) records by HIPAA-covered entities between 2010 and 2013 (67). With the expeditious growth in electronic health deployment since 2012, the frequency and magnitude of electronic health care data breaches are likely to increase (68,69).

The soaring susceptibility to data breaches makes it challenging to establish a practical health care delivery system, which involves the exchange of confidential information between the participants. It is imperative to say that concern over privacy is legitimate and gaining patient confidence requires a robust privacy and security plan. Current standards for all m-health applications are that encounters be secured to the “greatest practical extent through… Integrated Services Digital Network (ISDN), Advanced Encryption Standard 5 (AE5) encryption, or virtual private network for Internet transmissions” (70). Although some HIPAA-compliant messaging applications exist, most applications are lacking on grounds of security and privacy, which poses concerns for patients (71). In addition, standard SMS texting cannot be encrypted, causing additional concerns. As not all patients have access to smartphones in which HIPAA-compliant applications may be downloaded and used, patient privacy and confidentially remains a serious issue (71). As telemedicine applications continue to evolve, the current focus on protecting and maintaining PHI on secure systems with minimal data leakage remains crucial to both providers and patients (71).

Current barriers to further adoption of telemedicine use

Excellent clinical outcomes, high patient satisfaction, time and cost savings, healthcare cost savings and revenue generation, and improved access to care are among the numerous benefits of telemedicine application in the postoperative setting. However, there are several barriers, both at federal and state level, that hinder its adoption (21). First, current licensure and practice laws for health professionals require health care providers to practice on a state-by-state basis. As telemedicine has proven to be safe to be applied across state borders, the requirement to duplicate licensure and adherence to different practice rules may prevent underserved populations from receiving care by many providers who are unable to fulfill these pre-requisites. There are some states, however, which allow licensure reciprocity across state borders. Only a handful of states, however, are currently extending conditional licensure to physicians across borders for establishing telemedicine practices. In addition, failure of provider reimbursement poses hurdles in inter-state healthcare delivery. As of 2017, there are 29 states which require state-regulated health plans to reimburse telemedicine visits (23). Other barriers that keep the patients from benefiting from telemedicine include, but are not limited to, select states having requirements of being accompanied by a healthcare professional during the visit, being physically present in a medical facility or in a physician’s office during evaluation, and providing a written consent to the provider before receiving care (23).

At a national level, the Centers for Medicaid and Medicare Services have been incorporating telemedicine technologies in recent years. Although five years ago the Medicaid and Medicare reimbursement was problematic to an extent, several efforts have been made to wave these barriers. In May 2017, the bipartisan Congressional Telehealth Caucus reintroduced several bills aimed at addressing the current Medicare barriers for telemedicine efforts, which include expansion of the scope of reimbursed services along with redefining rural qualifications (23). Some major commercial payers, including United Healthcare and Blue Cross Blue Shield, have recently waived their origination site requirement and now allow for reimbursement of in-home video visits (23). Overall, such interventions will help introduce change and make telemedicine a much more feasible option to provide and receive healthcare. Given such efforts and enthusiasm for the Medicare program, many anticipate that surgeons will greatly adopt telemedicine for postoperative care for patients located at home within the next five years (23).

Conclusions

Telemedicine has become one of the most rapidly-expanding components of the health care system. In recent years, the role of telemedicine in postoperative care has received significance as it has demonstrated excellent clinical outcomes, a high degree of patient satisfaction, decreased driving distance and wait times, and cost savings to both the patient and health care systems. The evolution of surgical care should continue to focus on providing the highest quality patient care with a high degree of patient and provider satisfaction, meanwhile allowing the greatest access to surgical care. Telemedicine in postoperative care appears to attain these goals and should be considered as a viable option for healthcare centers. Future work focusing on patient confidentiality and widespread dissemination and implementation of telemedicine in surgery is on the go.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

References

1. Institute of Medicine (US) Committee on Evaluating Clinical Applications of Telemedicine; Field MJ, editor. Telemedicine: A Guide to Assessing Telecommunications in Health Care. Washington (DC): National Academies Press (US), 1996. Available online: https://www.ncbi.nlm.nih.gov/books/NBK45448/, doi: 10.17226/5296 [Crossref]
2. Armstrong DG, Giovinco N, Mills JL, et al. FaceTime for Physicians: Using Real Time Mobile Phone-Based Videoconferencing to Augment Diagnosis and Care in Telemedicine. Eplasty 2011;11:e23. [PubMed]
3. Collins J, Dasgupta P, Kirby R, et al. Globalization of surgical expertise without losing the human touch: utilising the network, old and new. BJU Int 2012;109:1129-31. [Crossref] [PubMed]
4. Khurana KK, Rong R, Wang D, et al. Dynamic telecytopathology for on-site preliminary diagnosis of endoscopic ultrasound-guided fine needle aspiration of pancreatic masses. J Telemed Telecare 2012;18:253-9. [Crossref] [PubMed]
5. Platts-Mills TF, Hendey GW, Ferguson B. Teleradiology interpretations of emergency department computed tomography scans. J Emerg Med 2010;38:188-95. [Crossref] [PubMed]
6. Zennaro F, Grosso D, Fascetta R, et al. Teleradiology for remote consultation using iPad improves the use of health system human resources for paediatric fractures: prospective controlled study in a tertiary care hospital in Italy. BMC Health Serv Res 2014;14:327. [Crossref] [PubMed]
7. LaMonte MP, Bahouth MN, Hu P, et al. Telemedicine for acute stroke: triumphs and pitfalls. Stroke 2003;34:725-8. [Crossref] [PubMed]
8. Clinical Update: Telepsychiatry With Children and Adolescents. J Am Acad Child Adolesc Psychiatry 2017;56:875-93. [Crossref] [PubMed]
9. Kaliyadan F, Ramsey ML. Teledermatology. StatPearls. Treasure Island (FL): StatPearls Publishing StatPearls Publishing LLC., 2017.
10. Moller DS, Dideriksen A, Sorensen S, et al. Tele-monitoring of home blood pressure in treated hypertensive patients. Blood Press 2003;12:56-62. [Crossref] [PubMed]
11. Scalvini S, Capomolla S, Zanelli E, et al. Effect of home-based telecardiology on chronic heart failure: costs and outcomes. J Telemed Telecare 2005;11 Suppl 1:16-8. [Crossref] [PubMed]
12. Thrall JH, Boland G. Telemedicine in practice. Semin Nucl Med 1998;28:145-57. [Crossref] [PubMed]
13. Adler-Milstein J, Kvedar J, Bates DW. Telehealth among US hospitals: several factors, including state reimbursement and licensure policies, influence adoption. Health Aff (Millwood) 2014;33:207-15. [Crossref] [PubMed]
14. Intelligence M. Global Telemedicine Market—Growth, Trends and Forecasts (2015-2019). 2015. Available online: http://www.mordorintelligence.com/industry-reports/global-telemedicine-marketindustry
15. Gunter RL, Chouinard S, Fernandes-Taylor S, et al. Current Use of Telemedicine for Post-Discharge Surgical Care: A Systematic Review. J Am Coll Surg 2016;222:915-27. [Crossref] [PubMed]
16. Park ES, Boedeker BH, Hemstreet JL, et al. The initiation of a preoperative and postoperative telemedicine urology clinic. Stud Health Technol Inform 2011;163:425-7. [PubMed]
17. Latifi R, Mora F, Bekteshi F, et al. Preoperative telemedicine evaluation of surgical mission patients: should we use it routinely? Bull Am Coll Surg 2014;99:17-23. [PubMed]
18. Burg G. editor. Telemedicine and Teledermatology. Curr Probl Dermatol. Basel K, 2003;32: 6-11.
19. Nicogossian AE, Pober DF, Roy SA. Evolution of telemedicine in the space program and earth applications. Telemed J E Health 2001;7:1-15. [Crossref] [PubMed]
20. Doarn CR, Nicogossian AE, Merrell RC. Applications of telemedicine in the United States space program. Telemed J 1998;4:19-30. [Crossref] [PubMed]
21. Ellimoottil C, Skolarus T, Gettman M, et al. Telemedicine in Urology: State of the Art. Urology 2016;94:10-6. [Crossref] [PubMed]
22. Department of Veterans Affairs FY 2014-2020 Strategic Plan. Available online: http://www.va.gov/op3/docs/strategicplanning/va2014-2020strategicplan.pdf. Accessed December 1st.
23. Ellimoottil C, Boxer RJ. Bringing Surgical Care to the Home Through Video Visits. JAMA Surg 2018;153:177-8. [Crossref] [PubMed]
24. Hwa K, Wren SM. Telehealth follow-up in lieu of postoperative clinic visit for ambulatory surgery: results of a pilot program. JAMA Surg 2013;148:823-7. [Crossref] [PubMed]
25. Kummerow Broman K, Roumie CL, Stewart MK, et al. Implementation of a Telephone Postoperative Clinic in an Integrated Health System. J Am Coll Surg 2016;223:644-51. [Crossref] [PubMed]
26. Greiner AL. Telemedicine Applications in Obstetrics and Gynecology. Clin Obstet Gynecol 2017;60:853-66. [Crossref] [PubMed]
27. Kahn EN, La Marca F, Mazzola CA. Neurosurgery and Telemedicine in the United States: Assessment of the Risks and Opportunities. World Neurosurg 2016;89:133-8. [Crossref] [PubMed]
28. Vyas KS, Hambrick HR, Shakir A, et al. A Systematic Review of the Use of Telemedicine in Plastic and Reconstructive Surgery and Dermatology. Ann Plast Surg 2017;78:736-68. [Crossref] [PubMed]
29. Robaldo A, Rousas N, Pane B, et al. Telemedicine in vascular surgery: clinical experience in a single centre. J Telemed Telecare 2010;16:374-7. [Crossref] [PubMed]
30. Sudan R, Salter M, Lynch T, et al. Bariatric surgery using a network and teleconferencing to serve remote patients in the Veterans Administration Health Care System: feasibility and results. Am J Surg 2011;202:71-6. [Crossref] [PubMed]
31. Shaw DK. Overview of telehealth and its application to cardiopulmonary physical therapy. Cardiopulm Phys Ther J 2009;20:13-8. [PubMed]
32. Lu K, Marino NE, Russell D, et al. Use of Short Message Service and Smartphone Applications in the Management of Surgical Patients: A Systematic Review. Telemed J E Health 2017. [Epub ahead of print]. [Crossref] [PubMed]
33. Miloh T, Annunziato R, Arnon R, et al. Improved adherence and outcomes for pediatric liver transplant recipients by using text messaging. Pediatrics 2009;124:e844-50. [Crossref] [PubMed]
34. Martinez-Ramos C, Cerdan MT, Lopez RS. Mobile phone-based telemedicine system for the home follow-up of patients undergoing ambulatory surgery. Telemed J E Health 2009;15:531-7. [Crossref] [PubMed]
35. Semple JL, Sharpe S, Murnaghan ML, et al. Using a mobile app for monitoring post-operative quality of recovery of patients at home: a feasibility study. JMIR Mhealth Uhealth 2015;3:e18. [Crossref] [PubMed]
36. Albert MV, McCarthy C, Valentin J, et al. Monitoring functional capability of individuals with lower limb amputations using mobile phones. PLoS One 2013;8:e65340. [Crossref] [PubMed]
37. Canon S, Shera A, Patel A, et al. A pilot study of telemedicine for post-operative urological care in children. J Telemed Telecare 2014;20:427-30. [Crossref] [PubMed]
38. Costa MA, Yao CA, Gillenwater TJ, et al. Telemedicine in Cleft Care: Reliability and Predictability in Regional and International Practice Settings. J Craniofac Surg 2015;26:1116-20. [Crossref] [PubMed]
39. Eisenberg D, Hwa K, Wren SM. Telephone follow-up by a midlevel provider after laparoscopic inguinal hernia repair instead of face-to-face clinic visit. JSLS 2015;19:e2014.00205.
40. Sathiyakumar V, Apfeld JC, Obremskey WT, et al. Prospective randomized controlled trial using telemedicine for follow-ups in an orthopedic trauma population: a pilot study. J Orthop Trauma 2015;29:e139-45. [Crossref] [PubMed]
41. Sharareh B, Schwarzkopf R. Effectiveness of telemedical applications in postoperative follow-up after total joint arthroplasty. J Arthroplasty 2014;29:918-22.e1. [Crossref] [PubMed]
42. Urquhart AC, Antoniotti NM, Berg RL. Telemedicine--an efficient and cost-effective approach in parathyroid surgery. Laryngoscope 2011;121:1422-5. [Crossref] [PubMed]
43. Viers BR, Lightner DJ, Rivera ME, et al. Efficiency, satisfaction, and costs for remote video visits following radical prostatectomy: a randomized controlled trial. Eur Urol 2015;68:729-35. [Crossref] [PubMed]
44. Yoder LH, McFall DC, Cancio LC. Use of the videophone to collect quality of life data from burn patients. Int J Burns Trauma 2012;2:135-44. [PubMed]
45. Cleeland CS, Wang XS, Shi Q, et al. Automated symptom alerts reduce postoperative symptom severity after cancer surgery: a randomized controlled clinical trial. J Clin Oncol 2011;29:994-1000. [Crossref] [PubMed]
46. Finkelstein SM, MacMahon K, Lindgren BR, et al. Development of a remote monitoring satisfaction survey and its use in a clinical trial with lung transplant recipients. J Telemed Telecare 2012;18:42-6. [Crossref] [PubMed]
47. McGillicuddy JW, Gregoski MJ, Weiland AK, et al. Mobile Health Medication Adherence and Blood Pressure Control in Renal Transplant Recipients: A Proof-of-Concept Randomized Controlled Trial. JMIR Res Protoc 2013;2:e32. [Crossref] [PubMed]
48. Rao R, Shukla BM, Saint-Cyr M, et al. Take two and text me in the morning: optimizing clinical time with a short messaging system. Plast Reconstr Surg 2012;130:44-9. [Crossref] [PubMed]
49. Pirris SM, Monaco EA 3rd, Tyler-Kabara EC. Telemedicine through the use of digital cell phone technology in pediatric neurosurgery: a case series. Neurosurgery 2010;66:999-1004. [Crossref] [PubMed]
50. Sidana A, Noori S, Patil N. Utility of smartphone camera in patient management in urology. Can J Urol 2014;21:7449-53. [PubMed]
51. Anthony CA, Lawler EA, Ward CM, et al. Use of an Automated Mobile Phone Messaging Robot in Postoperative Patient Monitoring. Telemed J E Health 2018;24:61-6. [Crossref] [PubMed]
52. Segura-Sampedro JJ, Rivero-Belenchon I, Pino-Diaz V, et al. Feasibility and safety of surgical wound remote follow-up by smart phone in appendectomy: A pilot study. Ann Med Surg (Lond) 2017;21:58-62. [Crossref] [PubMed]
53. Pozza ED, D'Souza GF, DeLeonibus A, et al. Patient Satisfaction With an Early Smartphone-Based Cosmetic Surgery Postoperative Follow-Up. Aesthet Surg J 2017;38:101-9. [Crossref] [PubMed]
54. Gunter R, Fernandes-Taylor S, Mahnke A, et al. Evaluating Patient Usability of an Image-Based Mobile Health Platform for Postoperative Wound Monitoring. JMIR Mhealth Uhealth 2016;4:e113. [Crossref] [PubMed]
55. Bednarski BK, Slack RS, Katz M, et al. Assessment of Ileostomy Output Using Telemedicine: A Feasibility Trial. Dis Colon Rectum 2018;61:77-83. [PubMed]
56. Fadaizadeh L, Najafizadeh K, Shajareh E, et al. Home spirometry: Assessment of patient compliance and satisfaction and its impact on early diagnosis of pulmonary symptoms in post-lung transplantation patients. J Telemed Telecare 2016;22:127-31. [Crossref] [PubMed]
57. Carrier G, Cotte E, Beyer-Berjot L, et al. Post-discharge follow-up using text messaging within an enhanced recovery program after colorectal surgery. J Visc Surg 2016;153:249-52. [Crossref] [PubMed]
58. Chen DW, Davis RW, Balentine CJ, et al. Utility of routine postoperative visit after appendectomy and cholecystectomy with evaluation of mobile technology access in an urban safety net population. J Surg Res 2014;190:478-83. [Crossref] [PubMed]
59. Sanger PC, Hartzler A, Han SM, et al. Patient perspectives on post-discharge surgical site infections: towards a patient-centered mobile health solution. PLoS One 2014;9:e114016. [Crossref] [PubMed]
60. Wiseman JT, Fernandes-Taylor S, Barnes ML, et al. Conceptualizing smartphone use in outpatient wound assessment: patients' and caregivers' willingness to use technology. J Surg Res 2015;198:245-51. [Crossref] [PubMed]
61. Stypulkowski K, Uppaluri S, Waisbren S. Telemedicine for postoperative visits at the Minneapolis VA Medical Center. Results of a needs assessment study. Minn Med 2015;98:34-6. [PubMed]
62. Smith A. U.S. Smartphone Use in 2015. Available online: http://www.pewinternet.org/2015/04/01/us, accessed February 13th.
63. Iqbal A, Raza A, Huang E, et al. Cost Effectiveness of a Novel Attempt to Reduce Readmission after Ileostomy Creation. JSLS 2017;21(1).
64. Smith AC, Scuffham P, Wootton R. The costs and potential savings of a novel telepaediatric service in Queensland. BMC Health Serv Res 2007;7:35. [Crossref] [PubMed]
65. Armstrong K, Coyte P, Semple J. The Effect of Mobile App Follow-up Care on the Number of In-person Visits Following Ambulatory Surgery: A Randomized Control Trial. Stud Health Technol Inform 2015;216:894. [PubMed]
66. Blumenthal D. Wiring the health system--origins and provisions of a new federal program. N Engl J Med 2011;365:2323-9. [Crossref] [PubMed]
67. Liu V, Musen MA, Chou T. Data breaches of protected health information in the United States. JAMA 2015;313:1471-3. [Crossref] [PubMed]
68. Kaggal VC, Elayavilli RK, Mehrabi S, et al. Toward a Learning Health-care System - Knowledge Delivery at the Point of Care Empowered by Big Data and NLP. Biomed Inform Insights 2016;8:13-22. [PubMed]
69. Adler-Milstein J, Jha AK. Sharing clinical data electronically: a critical challenge for fixing the health care system. JAMA 2012;307:1695-6. [Crossref] [PubMed]
70. Luxton DD, Kayl RA, Mishkind MC. mHealth data security: the need for HIPAA-compliant standardization. Telemed J E Health 2012;18:284-8. [Crossref] [PubMed]
71. Przybylo JA, Wang A, Loftus P, et al. Smarter hospital communication: secure smartphone text messaging improves provider satisfaction and perception of efficacy, workflow. J Hosp Med 2014;9:573-8. [Crossref] [PubMed]