What’s the role of telemedicine in primary care?

As part of trying to figure out where telehealth and video visits fit into the primary care setting, this week I got an amazing tour from the director of our emergency department, during which he showed me the program they’ve developed over the past year.

An incredible system, they take patients from triage who report to the emergency department with nonemergent issues, and move them to a consultation room off to the side of their urgent care space. There they are linked via video to an emergency provider who is located elsewhere in the hospital, who can go over their (hopefully) nonemergent issue and come to a quicker, safer, more efficient, and likely less expensive solution than a day in the ER.

They told me they get things like rashes that have been there for months, travelers who’ve arrived in New York City and have run out of their medications, simple musculoskeletal issues — the list goes on and on.

Through a video link-up, the provider can take a look at a rash, and look at various other things, pretty much anything that falls short of the laying on of hands or a diagnostic instrument. And certainly, nothing that involves any invasive tests like labs or imaging.

They are also providing a similar service from home, whereby patients can request a consultation with the doctor, and conduct the entire visit from the comfort of their couch. Apparently there have been very few instances where these video-from-home visits have resulted in serious diagnoses, although occasionally they have requested quite ill patients to present themselves to the emergency department for better evaluation and more intensive care.

Knowing that he knew that we were interested in developing a similar program, I promised not to poach patients from him, but in fact, he was more than willing to have us handle a lot of these simple issues. Turns out there are a lot of patients presenting to the emergency room for a lot of quite non-urgent visits, things that would certainly be amenable to an outpatient encounter with a primary care provider.

So as we rethink our paradigm for healthcare, for access, for quality, for getting our patients the best care they need when they need it, how does remote video access fit into a primary care model?

Do we envision the day when we will be conducting annual physicals remotely, via video link-up?

How much does my being in the room with the patient, or them being in the room with me, really matter?

There are certainly times where I probably don’t need to make a patient physically come in to the office. If you think about it we do this dozens of times a day, with the telephone care that we provide, interestingly currently free of charge.

The emergency department charges what seems like quite a reasonable fee through a swipe of your credit card for one of their home visits. We have to figure out how we can provide this care and add the value of the video connection, the actual seeing of the patient, to get our patients to willingly switch from free phone care to paid video care.

Multiple times a day, we get a phone call from a patient, with a clinical question, they’re not feeling well, and we do our best over the phone, but really wish they were here with us. If in fact I could see them, see how they look, I may be able to get some added information, decide that they look like they are teetering at the precipice of being quite ill, or that this set of severe symptoms they are describing is really not so bad.

As we move forward, I can foresee us figuring out new ways to provide care remotely, with the assistance of video. We can have patients go through physical maneuvers: think of having them do a Dix-Hallpike maneuver without you actually being there, and observing them for nystagmus. Have a patient ambulate in the hallway of their apartment, to observe their gait. Or shine a flashlight into the back of their throat to look for exudate on their tonsils. The opportunities are endless.

And smart hardware and software developers out there are working on algorithms, and new tech that will actually let us reach out and (almost) touch our patients. There are new apps that allow an otoscope attachment to be placed onto the camera of your cell phone, giving a remote pediatrician a view in a sick child’s ear.

Pee in a cup at home, pinprick of blood done right there?

And think how technology has allowed surgeons to operate remotely, removing a tumor from across the room, and theoretically at some point in the future from across the country. Maybe we can develop remote stethoscopes, remote reflex hammers, remote ophthalmoscopes, and, dare I say it, remote colonoscopes?

For now there certainly seems to be a lot of gee whiz factor to this stuff, but I was personally blown away by the setup they have in the ER, and the potential to get patients care in a better way. Having been to the emergency room for myself and family and friends, I know the physical and psychological exhaustion that comes from waiting hours and hours for care, when you really wish someone could just take care of this quickly in some better setting.

But as we change the paradigm, and offer the technology, I think that our ability to provide this care, and for our patients to be accepting of it, will be enhanced as it evolves and improves and delivers.

So since we have urologists removing prostates remotely, and psychiatrists providing counseling over Skype, we primary care doctors can’t be, won’t be, far behind, finding a niche, that sweet spot that gets our patients what they need without overly burdening us.

I still think that most of our care will remain face to face, the caring touch, the palpation of the abdomen, the chance to build the bond of patient-provider.

But just think, turn your head and cough may someday just be, well, cough.

Fred N. Pelzman is an associate professor of medicine, New York Presbyterian Hospital and associate director, Weill Cornell Internal Medicine Associates, New York City, NY. He blogs at MedPage Today’s Building the Patient-Centered Medical Home.

Image credit: Shutterstock.com

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