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EVIDENCE-TO-PRACTICE REVIEW  

 

67 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 

 
 

Clinical Implications of Telemedicine for Surgical Care: An Evidence-
to-Practice Review  
Adam M. Hollien, SCAT, ATC; Mary Catherine Avey, SCAT, ATC; Zachary K. Winkelmann, PhD, SCAT, ATC 
University of South Carolina, Columbia, SC 

  

 
ABSTRACT 
Telemedicine is a newer concept in medicine that utilizes 
technological devices to provide care to patients. In a society 
already greatly advanced with technology, telemedicine is 
the new frontier in healthcare. Implementing telemedicine into 
current practices will benefit both the patient and the 
provider. The technology utilized with telemedicine has 
demonstrated promise by decreasing patient travel time, 
decreasing lost time from work, increasing patient 
interactions, and increasing interprofessional collaboration. 
The cost of implementation is minimal compared to the cost 
savings that will be accrued from utilizing this technology. 
There are many specialty areas in healthcare where 
telemedicine can be implemented such as primary care, 
surgical, orthopedic, rehabilitation, and evidence-based 
research. An emerging setting for telemedicine is athletic 
training and sports medicine with potential to drastically 
change the profession for the better. Many of the skills 
athletic trainers perform on a regular basis can be completed 
via telemedicine. Regular use of telemedicine can provide 
benefits for the clinician, the patient, and the organization. 
Using telemedicine expedites the speed at which care can be 
provided to aid in patient recovery by limiting restrictions of 
distance or time away from work, life, and sport. Overall, 
telemedicine can advance the medical system by allowing a 
larger number of patients to have access to high quality 
health care similar to that of a face-to-face visit. 
 
Key Phrases 
Patient education, healthcare information technology, 
preceptor training and development 
 
Correspondence 
Dr. Zachary Winkelmann, 1300 Wheat Street, Columbia, 
SC 29208. 
E-mail: winkelz@mailbox.sc.edu   
Twitter: @zachwinkelmann 
 
Full Citation 
Hollien AM, Avey MC, Winkelmann ZK. Clinical 
implications of telemedicine for surgical care: An 
evidence-to-practice review. Clin Pract Athl Train. 
2022;5(1): 69-74. 
https://doi.org/10.31622/2022/0005.01.10.      
 
Submitted: May 2, 2020 Accepted: February 15, 2021. 

 
 
 
 
 
 

ORIGINAL REFERENCE 
Asiri A, AlBishi S, Madani W, El-Metwally A, 
Househ M. The use of telemedicine in surgical 
care: A systematic review. Acta Informatica 
Medica. 2018;26:201. 

SUMMARY 
 
CLINICAL PROBLEM AND QUESTION 
 
The use of electronic information and 
communication technologies to provide and 
support health care started as simple audio-only 
consultations following the invention of the 
telephone in 1876.1 Today, telemedicine has 
reflected the innovations of technology to provide 
health care utilizing a wide variety of virtual 
methods. Access to care is an essential aspect of 
patient-based health care, and providers must 
have the ability to make contact with the patient, 
especially when a distance separates them.2,3 It 
was reported that transportation issues such as 
distance, and not owning a vehicle delayed 
medical care for 5.8 million Americans in 2017.4 
Even when transportation is not an issue, the 
increasing costs of outpatient services inhibits 
access for about 1 in 10 adults.5 

Telemedicine allows many populations to benefit 
from health care interactions while maximizing 
time.6 For example, patients that have undergone 
surgery may experience functional impairments or 
may be prescribed opioids, both preventing them 
from operating motor vehicles which limits their 
ability to access providers.7 Medical professionals 
can perform pre-operative assessment, post-
operative care, and follow-up without the need 
for the patient to travel as they often include 
patient education, surgical wound checks, vital 
sign monitoring, or symptom assessments.7 Utilizing 

mailto:winkelz@mailbox.sc.edu
https://doi.org/10.31622/2022/0005.01.10


Clinical Implications of Telemedicine for Surgical Care: An Evidence-to-Practice Review 
 

 

68 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
  

telemedicine for health care limits patient travel 
while saving time and money and broadening 
provider reach limited by physical location. 7 
Telemedicine can be used with, but is not limited 
to, video and tele-conferencing, mobile-phone 
images, text messaging, and electronic monitoring 
devices.7 Many studies have investigated 
different aspects of telemedicine within specific 
subsets of surgical care, but none have looked at 
the use of this delivery method for surgical care 
from a larger perspective. Therefore, the purpose 
of this evidence-based review is to explore the 
broad range of telemedicine for surgical care 
with a specific reflection on how the athletic 
training profession may have a role in the use and 
deployment of telemedicine in operative 
management. For athletic trainers, understanding 
the role and benefits of telemedicine is necessary 
for the potential future growth of the profession. 
Specifically, telemedicine has the potential to 
impact the ease of communication with patients 
and the guidance of self-care initiatives for 
athletic trainers.  

SUMMARY OF LITERATURE 

This guiding systematic review included 24 articles 
that assessed telemedicine use before, during, or 
following any type of surgery guided by the 
Preferred Reporting Items for Systematic Reviews 
and Meta-Analyses.7 The articles included were 
mostly prospective observational studies, but also 
included retrospective studies, randomized control 
trials, and pilot studies. The studies reviewed the 
usage of various types of telemedicine technology 
including video and tele-conferencing, mobile 
phone, tablet applications such as Skype, digital 
images, and text messages.7  

Within this guiding systematic review, three types 
of surgical protocols utilized telemedicine, 
including: pre-operative assessment, post-
operative assessment, and conventional clinic 
replacement.7 Articles in the review analyzed the 
comparisons between usual care and 

telemedicine. Those that used some type of 
telemedicine pre-operatively utilized it for 
surgical referrals, diagnosis, review from other 
surgical teams, as well as at home consultation.7,8 
Comparisons between telemedicine and direct 
vision were analyzed for pre-operative means. 
Post-operative telemedicine was utilized by 
providers to assess wounds and medical 
equipment from vascular surgeries, 
appendectomies, total joint arthroplasties, 
ambulatory surgeries, and orthopedic trauma.7 
Post-operative telemedicine also included use of 
at-home medical technology such as surgical 
drains, blood pressure monitors, and electronic 
medication trays.7 Conventional clinic visits were 
replaced with telemedicine to address follow-up 
requirements for various surgeries, such as 
ileostomies, prostatectomies, and pediatric 
urology surgeries.7 Analysis of how telemedicine 
compared to usual in-person visits were assessed 
for both post-operative and conventional clinic 
care.  

SUMMARY OF OUTCOMES 

The outcomes from the guiding systematic review 
identified significant benefits of using 
telemedicine for both the providers and patients.7 
Overall, the experience of using telemedicine in 
surgical care for the providers yielded benefits 
with the ease of transmission of information to 
other hospitals regarding pre-operative details 
from the original patient interaction.6,7 
Additionally, pre-operative surgical care 
performed using telemedicine for diagnostic 
procedures, specifically such as analyzing organ 
structure and function, had the same level of 
provider accuracy as assessments performed 
within a conventional on-site clinic.7 The 
experience for providers using both synchronous 
and store-and-forward telemedicine was positive. 
Improved communications leading to reductions in 
unnecessary transfers and faster access to a 
specialist. Finally, the providers also noted 
improvements with overall surgical care provided, 



Clinical Implications of Telemedicine for Surgical Care: An Evidence-to-Practice Review 
 

 

69 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
  

based on fewer complications during surgery and 
a reduced mortality rate.7 

The ability for the patient to conduct pre- and 
post-operative appointments from home saved 
them a trip to the healthcare facility, while also 
enhancing at-home care plan adherence and 
long-term outcomes.7 During the at-home care, 
patients utilized synchronous telemedicine through 
live video and mobile phone communication to 
monitor surgical wounds. Moreover, patients used 
remote monitoring devices like an electronic blood 
pressure cuff and surgical drains for continuity of 
care with their providers.7 Patients also noted a 
strong patient-provider connection using 
telemedicine that resulted in a faster adjustment 
medications as needed.7  

FINDINGS AND CLINICAL IMPLICATIONS 

According to the guiding systematic review, 
telemedicine was found to be useful in surgical 
care. The majority of studies assessed the use of 
telemedicine between providers and patients, 
while one explored the inter-hospital use of 
telemedicine.7 We believe the findings 
highlighted in the summary of outcomes section 
identifies that telemedicine has a place in the care 
of surgical patients by allowing patient education 
and continuity of providers from pre-operative 
care to discharge. The findings also suggest that 
the benefits of telemedicine are two-fold, with 
patients and providers both noting improvements 
in their work and in their health outcomes. Based 
off the findings of this review, athletic trainers 
should continue to explore the implementation of 
telemedicine in various clinical settings.  

To get started with telemedicine in one’s clinical 
practice, technology and equipment must be 
obtained. Previous research exploring inter-
hospital use of telemedicine stated several 
limitations focused on the cost of telemedicine 
technology.7 In one study, the hospital systems 
believed implementing telemedicine would not 
save enough money to be significant for the 

overall cost of the system.7 However, the cost of 
technology to implement telemedicine has 
drastically decreased in the last decade, making 
it more affordable to health care providers and 
patients. For example, mobile phone applications 
and web browser platforms exists that are either 
no cost or low-cost alternatives to larger 
telemedicine systems, while telepresence robots 
are often seen in larger hospital systems. We 
recommend that athletic trainers attempting to 
introduce telemedicine explore these budget-
friendly options, such as Doxy.Me, for their daily 
use.  

It is important to note that as we explore cost-
effective options for telemedicine that we consider 
the privacy and security of the platforms. An 
aspect of care that differs from traditional face-
to-face appointments is the privacy of the 
patient.7 Previous research highlighted that 
athletic trainers, whether they were users or non-
users of telemedicine, were most concerned with 
the privacy of platforms when exploring 
telemedicine opportunities.9 Additional 
precautions and policies should be implemented 
to reduce the threat of patient confidentiality 
being breached.7 Encrypted servers and specific 
telemedicine rooms within the healthcare facility 
can be beneficial in providing private 
telemedicine patient encounters.7 Many of the 
low-cost applications are compliant with the 
Health Insurance Portability and Accountability 
Act (HIPAA) Rules, as well as the Health 
Information Technology for Economic and Clinical 
Health (HITECH) Act. Platforms that are HIPAA 
compliant such as Doxy.me, thera-LINK, VSee, or 
Zoom for Healthcare should be used rather than 
non-compliant platforms like FaceTime, Skype, 
and Facebook Live.  

After the initial cost for startup is considered, the 
guiding systematic review identified that long-
term benefits may involve cost savings from other 
aspects of patient care. Previous research 
analyzing costs of multidisciplinary healthcare 



Clinical Implications of Telemedicine for Surgical Care: An Evidence-to-Practice Review 
 

 

70 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
  

team meetings between face-to-face and 
telemedicine methods identified that the actual 
cost per patient was more expensive with the use 
of face-to-face evaluations and telemedicine may 
serve as an alternative.10 While most, but not all, 
athletic trainers do not bill for their athletic 
training services, the cost-savings from using 
telemedicine meetings may come from a reduction 
in missed time from work or additional expenses 
such as driving. For example, outpatient services 
that were conducted using telemedicine in 
comparison to traditional in-person visits saved 
each patient an average of 31.2 miles and 39 
minutes of travel time and $4.26 in travel costs.11 
We suggest that athletic trainers consider the 
long-term cost benefit of adopting telemedicine 
from multiple facets of their patient care, as well 
as the expenses from the patient perspective 
when choosing to adopt telemedicine. 

The findings from the guiding systematic review 
highlighted improvements in the communication 
and collaboration of the healthcare team, as well 
as the patient’s involvement in the process. The use 
of telemedicine has the potential to expand the 
access to specialty physician care and healthcare 
options that may not be directly accessible to 
physical location barriers. The access to specialty 
physician care has a direct influence on the shared 
decision making that shapes the patient-centered 
care approach that athletic trainers hope to 
achieve. Moreover, the connection of specialty 
care via telemedicine may allow the specialists to 
be more accessible. Previous research identified 
that specialists only attended 15% of face-to-
face meetings compared to 100% attendance at 
telemedicine meetings.10 While it is surprising, the 
decreased rate of those specialist physicians 
attending face-to-face meetings was undoubtedly 
due to the burden of travel through direct and 
indirect costs. We believe that telemedicine has 
the potential to improve the efficiency of the 
specialist providers, like orthopedic physicians 
and neurologists for sports medicine, when consults 
are needed on difficult or timely patient cases. 

Increasing the attendance of specialty care can 
improve the quality of the work-ups, as well as the 
overall patient satisfaction of the pre-operative 
education.10 Methods similar to this can be 
transitioned to the athletic training facility as 
collaborating physicians are typically not readily 
accessible, especially in the secondary school 
setting. The access to an orthopedic physician via 
telemedicine can provide student-athlete patients 
with access to a diverse and multifaceted 
healthcare system. The integration of telemedicine 
at the secondary school, college/university, and 
professional sport settings allows for ease of 
scheduling and scheduling preferences for the 
patient and the stakeholders involved in the 
patient’s care plan. We believe that in-person 
collaborations between physicians and athletic 
trainers for patient care can often seem rushed, 
limited in number or pushed to a specific time 
(example: waiting till game day). Time constraints 
for these physicians can be cut down by utilizing 
telemedicine visits to save travel time, as well as 
potentially increasing the number of appointments 
throughout the week.10,11 Athletic trainers that 
experience difficulties with physician 
collaboration should explore telemedicine as a 
creative solution to enhance interactions.   

For the providers, standardization is needed to 
ensure that each patient telemedicine encounter is 
similar in experience. This requires training for the 
providers to learn how to use the system and 
provide care through a different medium other 
than face-to-face.7 The length of the telemedicine 
visits also varied compared to face-to-face visits.7 
The initial telemedicine encounters were longer, 
but as the patient and clinician were more 
familiarized with the process, the appointment 
times decreased.7 State regulations should be 
reviewed prior to a telemedicine encounter to 
ensure the location of the meeting, and to ensure 
that procedures for informed consent and 
documentation are followed. Providers should 
also prepare for and conduct the meeting with a 
professional approach, establishing a webside 



Clinical Implications of Telemedicine for Surgical Care: An Evidence-to-Practice Review 
 

 

71 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
  

manner through empathy and eye contact with 
their camera. It is also essential that providers 
dedicate and organize a specific private area 
that is sufficient for telemedicine with adequate 
lighting and sound quality and a stable internet 
connection. We suggest that athletic trainers, 
regardless of athletic training facility size, 
dedicate a space such as their office to 
telemedicine encounters. 

CLINICAL BOTTOM LINE 

There are many options that make telemedicine 
possible for healthcare providers. In the current 
climate with an abundance of technology in our 
society, telemedicine is becoming a part of 
everyday practice. There are significant benefits 
of using technology to provide medical care 
including decreased travel time, decreased 
number of unnecessary visits, and ease of 
communication. Telemedicine can be used in a 
variety of settings and for a variety of clinical 
reasons including wound care, surgical follow-up, 
and initial evaluation, all of which skills athletic 
trainers are qualified to do. Specific to surgery, 
athletic trainers have a direct role in being there 
from time of injury to diagnosis and care planning, 
to pre-operative and post-operative care, and 
finally during return-to-activity and discharge of 
the patient. As athletic trainers are engaged in 
several practice settings, telemedicine for surgical 
care has the potential to improve the job duties 
and experiences for those in both traditional 
(secondary school and college/university) and 
non-traditional (physician practice and hospitals) 
settings. For example, follow-up appointments to 
monitor wounds post-surgery are common practice 
and can be provided via telemedicine.7 This 
method is respectful of the patient and provider’s 
time because these interactions are typically 
short.7  

It is also important to note that most clinicians are 
already using telemedicine without even realizing 
it. When patients send pictures of rashes or post-

surgical scars, the identification of the pathology 
and communication of next steps is technically 
telemedicine. Athletic trainers can use 
telemedicine to communicate with patients who 
may not be able to show up to the athletic training 
facilities for multiple reasons such as being 
bedridden following surgery, taking prescribed 
opioids, and conflicting class schedules. 
Telemedicine can also be utilized in many 
practical ways in the profession of athletic 
training, including wound checks and post-
operative evaluations, but also with initial 
evaluations and therapeutic rehabilitation. 
Additionally, the use of telemedicine allows for 
improved provider communication and 
collaboration with the patient or separately for 
general clinical advancement. Telemedicine 
allows these meetings to happen despite time and 
location constraints. As athletic trainers, we are 
encouraged to improve our patient-centered 
approach to healthcare delivery. Patient-
centered care can be achieved with many 
platforms including telemedicine as it prioritizes 
patient comfort, needs, and improves the ease of 
communication. Overall, the integration of 
telemedicine as a supplement to the practice of 
athletic training specifically for pre- and post-
surgical care, as well as other routine daily 
practices, has the ability to enhance patient 
outcomes and improve the patient-centeredness 
of our interactions. 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 5 – Issue 1 – April 2022 
  

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	ABSTRACT

