Virtual visits pose real issues for physicians

As smartphones, tablets, and other mobile computers proliferate, so does the opportunity for patients to try out a virtual doctor's visit, even with a physician they've never met before. Whether the technology promises to improve access to medical care or undercut the doctor-patient relationship remains a matter of substantial dispute.

Unlike the e-mail consults that some doctors already provide their patients, these virtual consults essentially offer a way to bypass the family doctor or any in-person interaction entirely. For a fee, frequently out of pocket, patients with a “live” video connection can run their symptoms by a doctor without leaving their home or office. The service can be driven by patient demand for convenience, lack of access to in-person care, and sometimes both, experts said.

In 2014, a projected 800,000 to 1 million virtual health consults via phone or video will be conducted, with double-digit growth anticipated for the following year, according to the American Telemedicine Association. As the technology becomes more sophisticated, so do the implications for doctors, patients, and state regulators alike. In an effort to encourage safe telemedicine practices, both the American Medical Association (AMA) and the Federation of State Medical Boards (FSMB) issued related guidelines this year.

Companies promote the virtual visits as an alternative for patients who can't get in to see their doctor. But ad hoc consults via video, when the doctor doesn't have any prior relationship with the patient, risk misdiagnosis even in seemingly straightforward circumstances, said Allan Goroll, MD, MACP, a general internist and professor of medicine at Harvard Medical School and Massachusetts General Hospital in Boston. A virtual doctor might not know enough details about the patient's history to ask pertinent questions, or the patient might not recall them, he said.

“One might argue that a rash is a rash is a rash, and it doesn't matter who sees it,” Dr. Goroll said. “But knowing the patient is critical to a successful virtual visit. Not knowing the patient makes a virtual visit susceptible to misdiagnosis and to the need for excessive testing.”

Expanding guidance

ACP's Ethics, Professionalism, and Human Rights Committee (EPHRC) will collaborate with ACP's Health and Public Policy Committee to develop guidance related to the practice of telemedicine, with the goal of finalizing it by late 2015, said Ana Maria López, MD, MPH, FACP, who chairs the EPHRC and also is medical director of the Arizona Telemedicine Program at the University of Arizona in Tucson. “I think there's tremendous interest,” said Dr. López.

Telemedicine approaches have proven to be a powerful diagnostic tool, and the University of Arizona's program has allowed patients within the statewide multi-institutional network to consult virtually with physician specialists or be monitored as their post-surgical wounds heal, she said. But the emergence of patient-initiated single-episode ad hoc virtual doctor visits is an example of a situation “where the technology has evolved faster than we've been able to develop policies,” she said.

The 1-time patient-initiated virtual interactions raise concerns regarding whether they will encourage disjointed medical care, Dr. López said. If the doctor-patient interaction is confined to “talking heads” via the video connection and the clinical interaction necessitates a physical exam, she said, “A key step in the clinical evaluation is missing.” Ways to address these gaps are being developed and marketed. Within a well-integrated health network, patient-initiated virtual visits can yield both clinical benefits and efficiencies, Dr. López said.

Doctors who ignore this latest competitive force do so at their peril, as it builds upon trends like pharmacy-based clinics that are providing increasing options for patients unable to fit their medical care into a 9-to-5 time frame, said Bob Doherty, ACP's senior vice president for governmental affairs and public policy.

In a recent blog post, Mr. Doherty detailed how easily he could have sought out a medical opinion at 5:05 p.m. on a random Thursday. After downloading a telehealth app to his phone, he submitted his ZIP code and located several board-certified doctors who were immediately available if he had chosen to go any further.

“I think it could be a threat to their [doctors'] business model if they lose a lot of their younger healthier patients, or the worried well patients, to these apps,” Mr. Doherty said. “To some extent, physicians rely on healthier patients to help cross-subsidize care for the sicker patients.”

Not surprisingly, a lot of the data about consumer interest have been generated by tech-related companies. One 2013 report by Cisco, based on feedback from 1,547 consumers in 10 countries, found that 74% were open to a virtual visit. Another survey, conducted in 2014 by the telehealth provider MDLIVE, found that 54% of Americans had postponed a doctor's visit because of inconvenience, according to 2,000 adults surveyed. The top reason, cited by 30%, was their inability to take a day off from work.

In their recent telemedicine guidance, leaders at the AMA and FSMB discuss virtual consults largely in the context of a previously established doctor-patient relationship. But both groups provided some flexibility regarding how that relationship could be established.

The AMA recommended that “a valid patient-physician relationship must be established, through at minimum a face-to-face examination, if a face-to-face encounter would otherwise be required in the provision of the same service not delivered via telemedicine. The face-to-face encounter could occur in person or virtually through real-time audio and video technology.”

The new FSMB policy, which was updated for the first time since 2002, provides similar guidance that “it may be possible to establish a physician-patient relationship through the use of technology without an in-person visit,” said Humayun Chaudhry, DO, MACP, president and CEO of FSMB.

The preference is still for the doctor and patient to meet first in person, Dr. Chaudhry said. But the state boards were sufficiently impressed with advances in real-time virtual technology to say that “an in-person visit may not be necessary in every physician-patient interaction,” he said. But virtual visits “shouldn't cut corners” on either time or thoroughness, maintaining the same privacy and other standards as an office visit, he said. “You should still ask about allergies,” he said. “You should still ask about the past medical history.”

Plus, no matter how astute the doctor on the other side of the camera, there's still a diagnostic risk in some circumstances, Dr. Chaudhry said. A virtual doctor, for example, might not see the pill-rolling tremor indicating Parkinson's disease “that would only be apparent if you looked at their thumb and their index finger,” he said. With another patient, poor lighting in their home might obscure precancerous signs of a skin lesion. “Had they been in your office, with the better lighting that you would normally have, perhaps you would pick up on it,” Dr. Chaudhry said.

Practicing virtually

Don't dismiss the diagnostic power, though, of a video connection and adept questioning, said Mia Finkelston, MD, a family medicine physician in Maryland, who is part of Online Care Group, a physician-owned group that provides online services using American Well's technology. Dr. Finkelston, who joined in 2012 and works 30 hours each week, has viewed images ranging from rashes to pinkeye to odd-looking moles. “I've had guys hold up their snot rags full of mucus to show me how green their mucus is,” she said.

When patients sign up for American Well online, they're asked to provide details about allergies, medications they are taking, and chronic medical conditions. The level of detail provided varies, and Dr. Finkelston said that she's quick to refer uncertain or complex cases to a doctor's office or an urgent care center.

In some cases, Dr. Finkelston will prescribe antibiotics without any lab results, such as when a patient reports burning urination and other classic UTI symptoms and no worrisome red flags, such as fever or vaginal discharge. But “If I don't have enough information, I'm not going to prescribe,” she said. “I'm very conservative. I was in my practice. I am maybe even more so now.”

American Well is one of numerous telehealth providers—examples include Doctor on Demand, MDLIVE, Teladoc, and others—that pop up with a quick online search. All American Well physicians must be licensed to practice in the state where the patient is located, according to spokeswoman Catherine Anderson. (As of September, Dr. Finkelston was licensed in 20 states.) The cost per visit is $49; the average wait time is under 2 minutes.

The medical symptoms most frequently treated via video consult involve acute respiratory infections, urinary tract infections, and skin problems, according to an analysis of 3,701 Teladoc visits for an 11-month period that was published in the February Health Affairs. Twenty-one percent of the users, whose virtual visits were covered through their health insurance, hadn't sought out any medical care (virtual or otherwise) the prior year.

Patients get criticized for unnecessary trips to the ED, but sometimes it's because they lack any other place to turn, said Judd Hollander, MD, associate dean for strategic health initiatives at Thomas Jefferson University's Sidney Kimmel Medical College in Philadelphia. “If you don't have a true emergency, but you do have something that warrants being seen now,” he said, “my hope is that we'll be able to take care of the great majority of those patients via telemedicine.”

Leaders at Thomas Jefferson University are in the process of creating what Dr. Hollander, an emergency medicine physician, dubs a “virtual emergency room.” They plan to contract with a telehealth provider—they were in discussions with American Well in early September—and would provide on-demand services first to their own employees beginning in 2015. Most virtual consults focus on “the simple stuff,” as Dr. Hollander dubs it, but “we believe that there may well be an opportunity to initiate care for moderately sick patients,” he said.

Take a possible case of appendicitis, Dr. Hollander said. In some instances, the patient might lose 8 to 10 hours in time and painful uncertainty, first calling their family doctor about acute stomach pain and waiting for a call back, then waiting in the emergency department and then waiting again, this time for the CT scan to be completed and then read, he said.

Instead, Dr. Hollander envisions a future not far off when that same patient could first call a telemedicine clinician at Thomas Jefferson who would conduct an exam via video. If the doctor remains concerned about appendicitis, the patient could be referred to an outpatient radiology center. Once the CT scan is reviewed, the patient could either return home if appendicitis has been ruled out or be sent to the hospital for surgery with clinicians able to prep the case in advance, Dr. Hollander said.

Revenue model?

Dr. Hollander describes his facility's virtual technology plans as a “Build it and they will come” scenario, with the hope that reimbursement will soon follow. That's one reason why Thomas Jefferson will offer the virtual on-demand care services to its own employees first, as any savings will be reaped by the university, he said.

To date, 21 states and the District of Columbia require that private insurers cover telehealth the same as they cover in-person services, according to the American Telemedicine Association. American Well already provides its telehealth services through some large health plans, including UnitedHealthCare and WellPoint, and is working to add more, Ms. Anderson said.

As telehealth develops, it might provide some doctors a revenue stream while building their practices or allow them to pick up extra income during off hours, Mr. Doherty said. For others, the virtual competition might convince them to expand off-hours coverage at their own practices, a strategy that Mr. Doherty acknowledged might be difficult, particularly for smaller practices.

Dr. Goroll, who has been approached by telehealth companies to sign up, said that he has no problem using e-mail and reviewing attached photos of rashes and injuries to care for his existing patients. He also agrees that primary care practices should provide expanded coverage. But reimbursement still typically requires a face-to-face visit, he said.

“One of the reasons why primary care has melted down in recent years is that payment has only been for face-to-face services, and yet the demand for services has been 24-7,” Dr. Goroll said. “Therefore these companies have recognized that people might even be willing to pay out of pocket. What they are doing is basically filling in a gap, and that gap occurs because payment has not been adequate to provide 24-7 coverage.”