Telemedicine Update: A Family Physician Approach to Allergy and Care Coordination with the Allergist

Contributors: Minoti Parab, MD and Tania Elliott, MD, FAAAI, FACAAI 
To learn more about Minoti and Tania, click here.

 

password-222331_960_720.jpgCharles Babbage is considered the “father of the computer,” as he conceptualized and invented the first mechanical computer in the early 19th century. Intel launched the first microprocessor chip in 1971, and a computer took up an entire room. In 1972, Murphy and Bird conducted 500 patient consultations via interactive television, and Bird offered the first formal definition of telemedicine. He refined his definition of telehealth to include, “the practice of medicine via interactive audio-video communication system” in 1975. 

Fast-forward to 2017 where three billion people carry smartphones in their pockets, each more powerful than that room-sized computer. Telemedicine and telehealth are also more clearly defined. According to the AAFP, telemedicine is “the practice of medicine using technology to deliver care at a distance, over a telecommunications infrastructure, between a patient at an originating (spoke) site and a physician, or other practitioner licensed to practice medicine, at a distant (hub) site.”1 Telehealth refers to a broad collection of electronic and telecommunications technologies and services that support at-a-distance healthcare delivery and services. Telehealth technologies and tactics support virtual medical, health, and education services.1 mHealth, on the other hand, is known as mobile health and is form of telemedicine using wireless devices and cell phone technologies.2 

Why is there such a need to change how we practice medicine? According to projections by the Association of American Medical Colleges, the nation will be short more than 90,000 total physicians by 2020, and 130,000 physicians by 2025.3 The Annals of Family Medicine projects the United States will need 52,000 more primary care physicians by 2025.4 Access to specialist care can also prove challenging, as it is often limited to academic centers. Telemedicine can be leveraged to improve access to not only family physicians, but specialties, in particular, allergists. With approximately only 3000 active allergists nationwide,5 telemedicine offers the advantage to facilitate care coordination between specialties. This is already an integral component of family physician visits, and soon to become more valuable as we see a change in payment models. 

Today, 75 percent of health plans offer telemedicine service reimbursement, and according to the American Telemedicine Association, more than 15 million Americans received some form of medical care remotely in the last year. However, telemedicine is not as simple as “skyping” with a patient. Web-side manner, physical examination, clinical decision-making, documentation and care coordination need to be adapted for a video platform, in addition to supporting a HIPPA-compliant technology platform. 

The top 5 urgent care conditions currently treated through telemedicine services are allergies, cough, upper respiratory infections, sinusitis, and rashes. The prevention, diagnosis, and treatment of allergic and immunologic conditions are everyday occurrences for the practicing family physician, whether it be the management of more benign conditions (e.g., allergic rhinitis) or severe and potentially life-threatening conditions (e.g., anaphylaxis, status asthmaticus).6 Let’s discuss how telemedicine can be used to diagnose allergic rhinitis and improve care coordination with allergists. 

Allergic rhinitis is the fifth most common chronic disease in the United States, and affects about one in six Americans.7 Allergic rhinitis also accounts for as much as $2 to $4 billion in lost productivity annually, and an estimated 800,000 to 2 million lost school days.8 

Although few studies exist on how to differentiate among types of rhinitis, a thorough and comprehensive history usually suggests the correct diagnosis.9 A focused physical examination should follow the history. Acute illness with a viral infection will cause more generalized symptoms and occasional fevers pointing towards the most common type of nonallergic rhinitis. Whereas, patients with chronic allergic symptoms may have allergic shiners (i.e., blue-gray or purple discoloration under the lower eyelids), or they may breathe through their mouths, both of which signs can be seen with high quality webcams. Conjunctivitis, also seen via webcam, can be a component of allergic rhinitis or acute viral upper respiratory infection (URI). A careful examination of the nose is important to identify structural abnormalities, obvious polyps, mucosal swelling, and discharge. Examining the pharynx for enlarged tonsils or pharyngeal postnasal drip also can help identify viral causes or chronic drainage from chronic rhinitis.9 This can be addressed with the use of peripheral devices, that employ store and forward technology, typically from an originating site. Lymphadenopathy, which can be addressed by a physician directed physical exam, may suggest a viral or bacterial cause of rhinitis,9 whereas, wheezing or eczema suggesting an allergic cause, may be detected through webcam and peripheral devices. 

Aside from adapting for a telemedicine physical exam, the diagnosis of allergic rhinitis through history, as well as, initiation of treatment using over the counter/prescription medications, and counseling are similar to office based practice. Using real-time video consultations with a patient from their home can be tremendously valuable for allergy patients. Video enables the trained physician to see directly into the patient’s home to provide guidance on trigger avoidance, thereby helping to make a more accurate recommendation based on environmental context. It also enables a physician to interface directly with a patient during a time of need. 

Family physicians should send patients for an in-person office visit, or refer patients to an allergist when immunoglobulin E–specific skin or blood testing is recommended when first line treatment (e.g., environmental controls, allergen avoidance, medication) has been ineffective, a diagnosis of allergic rhinitis is uncertain, identification of a certain allergen could affect therapy, or to aid in titration of therapy.7 Other reasons to refer to an allergist include evaluation of primary immunodeficiency, and interpretation of Immunocap (formally RAST testing) results, as well as, difficult to treat asthmatics, initial workup for food allergy, management of urticaria and angioedema, and evaluation and management of atopic and contact dermatitis. Allergist referrals typically and historically take place in an office setting; however, average wait time to see an allergist in the office is approximately three weeks. Allergists can also utilize telemedicine for some visits. Not only does telemedicine promote longitudinal care coordination, but new technology such as three-way video conferencing, improves collaborative care allowing the patient visit to occur with the family physician and the specialist at the same time. 

Aside from allergic rhinitis, telemedicine for chronic disease management of other allergic diseases is promising. Allergic asthma or extrinsic asthma is the most common form of asthma and it is defined as asthma caused by an allergic reaction. A recent Cochrane review concluded current randomized evidence does not demonstrate important differences between face-to-face and remote asthma check-ups in terms of exacerbations, asthma control, or quality of life.10 A follow-up randomized, controlled trial demonstrated that telemedicine was as effective as in-person care for children with asthma.11 

Additional telemedicine applications for patients with asthma include real-time advice in a setting of perceived asthma exacerbation, proper inhaler technique, home environmental trigger assessment, medication management, and real-time video guidance with school nurses and teachers. Remote video visits will continue to expand in scope of practice as more store and forward technologies come on the horizon, from stethoscopes to interactive asthma pump device counters. Improved molecular diagnostics and interactive patient engagement apps will give physicians the additional tools they need to catch disease early and keep patients motivated and engaged in their healthcare. 

Telemedicine can improve patient outcomes, not only through initiating timely medical visits for minor urgent care complaints, but also by monitoring chronic conditions more closely, and allowing greater time for counseling. Telemedicine does not only improve patient access to care with family physicians, but it also improves access to specialists and help with care coordination. The time for virtual visits is no longer the future of medicine; it is now. 

Contact Minoti at: [email protected]
Contact Tania at: [email protected] 

Reprinted with permission, The Maryland Family Doctor, Summer 2017 

 

 

References 

  1. “Telehealth and Telemedicine.” AAFP. (1994) (July 2016 BOD). Retrieved from http://www.aafp.org/about/ policies/all/telemedicine.html on 4/6/17. 
  2. Americantelemed.org [Internet]. What is mHealth? Is it a type of telemedicine or something different? from americantelemed.org. [Updated 2015: 04-15]. Available from: http://www.americantelemed.org/about-telemedicine/faqs#.VaT5d53D9mM 
  3. Gordon D. “15 things to know about the physician shortage.” Becker’s Hospital Review. Scott Becker. July 24, 2014. http://www.beckershospitalreview.com/hospital-physician-relationships/15-things-to-know-about-the-physician-shortage.html Accessed April 4, 2017. 
  4. Ann Fam Med November/December 2012 vol. 10 no. 6, 503-509. 
  5. Adapted from 2012 A/I Workforce-Report.pdf . 
  6. American Academy of Family Physicians. Recommended Curriculum Guidelines for Family Medicine Residents Allergy and Immunology. AAFP Reprint No. 274. Revised 6/2015 by Allegiance Health Family Medicine Residency Program, Jackson, MI. 
  7. Am Fam Physician. 2015 Nov 15; 92(10):942-944. 
  8. Henderson D. (2015, February 3) New Guidelines for Allergic Rhinitis Released. Medscape. Retrieved 4/4/17 from http://www.medscape.com/viewarticle/839130 
  9. Am Fam Physician. 2006 May 1;73(9):1583-1590. 
  10. Cochrane Database Syst Rev. 2016 Apr 18. 
  11. Portnoy et. al. Ann Allergy Asthma Immunol 117 (2016) 241e245.