The concept seems so strange, the idea of carrying out an “office visit” without the patient actually being in the office.
Right now we have it structured so that when a patient calls up requesting to see me on a day when I am already fully booked (or, as is usually the case, overbooked), our front desk staff is free to offer those patients a scheduled telemedicine visit over video.
They load the portal app, and “check-in” 15 minutes before the scheduled time. My phone buzzes and informs me they have “arrived,” then we make the video connection.
Many folks trying out this technology have commented how important it is to have a professional-looking background, and to remember not to stand up if you are doing these visits from home in your PJ’s (or worse, with no pants at all).
The visit then proceeds with the same back and forth we would do at a real office visit, but no vitals, and no obviously no physical since they are not actually where I can examine them.
Clearly, we don’t want to be doing these kinds of visits with really critically sick patients, we definitely don’t want to be evaluating people with new neurologic deficits who might be having a stroke, or crushing substernal chest pain radiating into their left arm and up to their jaw, or altered mental status, or sepsis at home.
But when a patient calls with a minor issue, something that up to now we’ve been handling through a patient portal message or telephone call, perhaps the added value of the video interaction may improve the quality of the care we provide, as well as increase the patient satisfaction and the provider satisfaction with handling healthcare in this resource-limited environment.
Now, clearly, there are plenty of situations where a quick email or text or patient portal message will suffice, and the patient getting to look at my ugly mug on their phone or laptop doesn’t really add any value.
But I can foresee a lot of times where laying eyes on a rash, or seeing how a patient looks with the flu, whether they appear sicker than they are billing themselves to be, or less so, might prove to be quite clinically valuable.
Also these type of visits add a lot of value for the patient, in that they don’t have to come in from their home far away, or take off time from work, or even get out of bed when they are knocked out from the flu, to have a significant clinical interaction with their primary care provider.
As video telemedicine evolves, we are going to be expanding these to multiple different types of care, into subspecialty medicine, and a lot of other types of practices.
We envision these types of visits working for all types of sick visits, mental health follow-up, medication management, smoking cessation, tele-dermatology, and more.
Right now, we’re going to be limited in our ability to do much in terms of vital signs and physical examination and lab testing.
Many of my patients have a blood pressure cuff at home, and they can do their own vitals for me.
The patient can show me their rash, open their mouth and say “ahh,” letting me see if they’ve got pus on their tonsils, and maybe even do some simple physical examination moves on themselves.
Imagine having a patient check themselves for rebound or guarding, or a Murphy’s sign!
We can walk them through the basic neurologic exam to distinguish between a Bell’s palsy and a central cranial nerve deficit.
I’m hoping that someday they’ll be able to hold their cellphone up to their lungs and let me hear their pneumonia or heart failure, or place the phone right over their heart and send an EKG right to me.
Of course, nothing will ever completely replace an in-person office visit. For most care, a physical examination and the actual laying-on of hands is definitely worth the trouble.
You get some of this through the video visits, you can get a sense of how a patient is doing, whether they’re depressed, whether they’re taking care of themselves.
But wouldn’t it be great if we get more information, from the comfort of our office, while the patient is in the comfort of their own homes?
Quite often, we have calls from patients who want us to evaluate significant clinical conditions, but say they are too sick to come in, or can’t arrange transportation, and have a significant enough constellation of symptoms that we think they definitely need to be “eyeballed” before a safe clinical plan can be created.
Often, this leads us to fall back on sending patients into local ERs.
One project we are working on with colleagues in our emergency department is to send paramedics out into the community for the express purpose of not bringing a patient in if they don’t need to be brought in, but having the EMT be the on-site eyes and hands and vitals and labs for the ER doctor and the primary care doctor, while the patient stays, for the moment, at home.
Working together, the ER doctor and the primary care doctor and the paramedic will be able to more completely assess the patient, and institute a comprehensive medical plan right on the spot, and even stay for a while and see how it goes.
We envision seeing patients who’ve just gone home from the hospital, or were sent home from the ER, who are still too sick to want to come back in, where the paramedics can go check on them in their home, check vitals, listen to their lungs, see how the wound is healing or if the cellulitis is improving, give a nebulizer treatment or a dose of diuretic, or even give the patient a liter of fluid and see whether they perk up.
And if things don’t go well, the paramedics are right there to bring them in to care where more extensive evaluations and treatments can be administered, either in our office or the ER.
Someday, as the technology advances, we’ll be able to get in-home vitals on almost every patient. Perhaps people will be able to walk to the corner drugstore and sit down in a kiosk or booth, have a video visit, and have labs drawn at the same time, and then a medication is magically delivered right to the pharmacist a few feet away from them.
For now, we’ll have to start slowly, and build up our experience with video televisits in primary care, and the partnership with our paramedic and emergency department colleagues.
The more we explore this as new models of care, the better we are going to be able to move ahead as the technology catches up with us, to provide our patients the right care at the right time, in the most patient-centered way possible.
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