Contributor: Minoti Parab, MD
To learn more about Minoti, click here.
An established patient calls the office for a same-day appointment and is told there are no openings in any provider’s schedule for the next week. He has not been in the office for over a year.
This 57-year-old male presents with intense pain in his right big toe that is 9/10. He has had similar pain previously in the same location approximately twice for which he has never been seen. He was out drinking with friends last night. He denies fever. ROS (Review of Systems) is otherwise negative.
Past Medical History: HTN (hypertension)
Medications: Lisinopril/Hctz 20/12.5mg 1 po qd
Allergies: No Known Drug Allergies
Vitals: Temp 97.10
Gen: Appears in distress due to pain
Skin: 1st MTP joint – red, swollen, warm and tender to palpation
What is different about this patient presenting with gout? The difference is this patient was seen via telemedicine instead of in an office or clinic.
Telemedicine provides cost-effective, convenient, and portable healthcare. A rising number of providers are considering adding telemedicine to their practice; however, for many physicians, adapting to this delivery system can seem daunting due to concerns which include quality assurance, time allocation, training requirements, and an online, limited physical exam. Furthermore, some providers feel telemedicine will fragment patient rapport and continuity of care, which could further fragment healthcare. Despite multiple published surveys showing patients are ready for telemedicine, these concerns raise the question, “Is medicine ready for telemedicine?”
These concerns, while valid, should not deter physicians from embracing innovation as healthcare advances into this new technology-driven frontier. Addressing these concerns can generate a more inviting view of telemedicine. Regarding quality assurance, telemedicine physicians are held to the standards for both brick and mortar and telemedicine practice. On top of this, many telemedicine providers practice in multiple states and are, thus, vetted by multiple state medical boards and payor-contracted credentialing organizations. They must demonstrate knowledge of federal and multiple states’ regulations about practice and prescribing.
Although medicine is essentially the same no matter how it is practiced, via office or telemedicine, specialized telemedicine training is essential. Organizations should make this protected training time to assuage providers’ fears of being overloaded with more work. Training should include basic technology, trouble-shooting issues, appropriate online care, and regulations pertinent to telemedicine. Formal training, as opposed to trial-and-error, ensures a smoother transition for patient and physician alike.
Another concern is the physical examination, or lack thereof, via telemedicine. This should be thought of not so much as a limitation, but a factor to help determine what is appropriately seen in a telemedicine setting. Some diagnoses are easily supported in telemedicine using evidence-based medicine from the office environment combined with office experience. A standard of care has already begun to take shape as more physicians and organizations have honed their telemedicine practices. Despite the progress, it takes a conscientious team to work through diagnoses and symptoms commonly seen to develop telemedicine standardization that can be disseminated to new providers and organizations.
Instead of thinking of telemedicine as fragmenting care, we should embrace telemedicine’s ability to strengthen continuity of care and build patient rapport by making healthcare more accessible and affordable, all the while maintaining quality of care. Often patients cannot be seen by their primary care provider for a variety of reasons, including provider unavailability, self-pay status, high deductibles, and co-pays. Sometimes the patient is in a location that is inaccessible to in-person care, such as those patients traveling or residing in rural locations.
Finally, a follow-up plan is essential. Documentation and communication with the primary care physician should be no different than would be expected in the brick-and-mortar practice. Also, due to unchartered waters for many patients utilizing this delivery system, it is important to take the time to educate and set patient expectations from the beginning.
As mentioned before, telemedicine can address the gaps in healthcare. It can improve patient care through compliance, access, continuity and outcomes, and help capture revenue that would otherwise be lost. In 2014, the telemedicine global market was valued at $14 billion, and the projected market for 2020 is $35 billion. North America dominated the market in 2014, but the Asia Pacific is expected to dominate by 2020.1 According to the Tractica report, telehealth video consultations sessions will increase from 19.7 million in 2014 to 158.4 million by 2020.2 In fact, the telemedicine provider REACH Health survey done in 2015 said 44% of organizations indicated telemedicine as high priority, and 22% as top priority.3
Looking back at this case, what does telemedicine offer our patient?
In 2013, less than half of U.S. adults reported being able to secure same or next-day appointments with their physicians, and less than 40% reported being able to obtain care after hours without going to the emergency department.4
Gout is one of the most poorly treated medical conditions. Gout is unlike other rheumatologic diseases in that a gold standard assessment is available, i.e., MSU crystal positivity. While this gold standard has high specificity, its feasibility and sensitivity may be inadequate.5 While it is ideal to send each patient for joint aspiration, it is not common practice. Gout is typically diagnosed using clinical criteria.6 The 2015 ACR/EULAR criteria for the classification of gout, a clinical-only version can be considered for use in settings in which synovial aspiration or tophus aspiration is not feasible.6 Many patients experience a delay in gout diagnosis due to office availability, but telemedicine offers easy access to healthcare so patients can be seen and diagnosed quickly. Treating gout flares as quickly as possible (< 24hrs) is ideal.
For most patients, a typical history, classic exam observed by webcam, and use of clinical criteria can support the diagnosis. Once these patients are seen via video-conferencing, counseled, and treated, a follow-up plan can help the patient enter the health system, or simply follow-up and continue appropriate long-term management. With time, we will be able to determine if adding this new type of visit will improve patient compliance and outcomes. Once followed up in the office, future acute gout exacerbations managed via telemedicine helps decrease overall patient overall cost while offices are free to see those medical conditions truly appropriate for an in-person visit. For initial diagnosis, when in doubt, it is important to explain to the patient, why, when, and where the patient should be seen in an office setting.
It is obvious that technology has changed people’s lives, and its use within medicine should be no different. By allowing access to care to anyone who has even the simplest technology (PCs, notebooks, and mobile devices), telemedicine can improve the quality of life of both physicians and patients. It is important to learn more about this topic, keep an open mind to its value, speak of its concerns, expect high standards of care, and develop standardized guidelines. Ongoing discussion and collaboration will help ensure best care practices in telemedicine and help to alleviate the concerns mentioned above while improving the current healthcare system.
Contact Minoti at: [email protected]
Reprinted with permission, The Maryland Family Doctor, Summer 2017
- Pallardy C. “Telemedicine market value to rocket to $35B value by 2020.”Becker’s Health IT and CIO Review. Scott Becker. 2016. https://www.beckershospitalreview.com/healthcare-information-technology/telemedicine-market-value-to-rocket-to-35b-value-by-2020.html Assessed April 13, 2016.
- Jayanthi A. “Telemedicine consult sessions to increase 700% by 2020. ”Becker’s Health IT and CIO Review. Scott Becker.2015. http://www.beckershospitalreview.com/healthcare-information-technology/telemedicine-consult-sessions-to-increase-700-by-2020.html Accessed April 13, 2016.
- Jayanthi A. “Comparing telemedicine objectives with success: 7 key findings.” Becker’s Health IT and CIO Review. Scott Becker. 2016. https://www.beckershospitalreview.com/healthcare-information-technology/comparing-telemedicine-objectives-with-success-7-key-findings.html Assessed April 13, 2016.
- Schoen C, Osborn R, Squires D, and Doty MM. Access, affordability, and insurance complexity are often worse in the United States compared to ten other countries. Health Aff (Millwood). 2013;32(12): 2205-2215.
- Tuhina N, et al. (2015) 2015 Gout Classification Criteria. Arthritis and Rhuematology, 67(10), 2557-2568.
- Am Fam Physician. 2014 Dec 15;90 (12): 831-836.