USA Today: “The doctor will see you now — on the Internet – Patients like the convenience, and insurers save money. But diagnoses can go awry”

Dr Kevin Pho The Doctor Will See You Now

This USA Today article by Nashua NH based primary care physician Kevin Pho highlights for me the importance that we don’t just move conventional Doctor consultations online but that we follow best practice and ensure that consultations are fully supported by digital tools so that Patients and Carers can share all their important history, Doctors have access to all the relevant information and the entire consultation is documented.

Please watch Dr John Bachman MD, Prof of Primary Care at the Mayo Clinic introduce his Mayo Clinic Proceedings paper that outlines a process by which this can be achieved that saves time for both Doctors and Patients, greatly reduces the potential for a diagnosis to ‘go awry’ and ensures that patients are supported with information – so no one ever has to suffer this type of situation again.

My thoughts on the article:

Popularity of online video chats increasing. But something is lost through these Internet connections

I’m surprised that an article on this topic written by a Primary Care Doctor is so focused on what is being lost rather than what we all stand to gain. It reminds me of how back in the early days of the internet critics would discuss how much was being lost when we were communicating with people on the internet.

As the internet has matured and millions of people in business have posted personal and professional profiles online I think it’s incredible anyone cannot see that this opportunity is going to extend to the Healthcare profession whether we like it or not eg. the UK’s NHS already lets patients rate homeopathy providers.

Currently, only 13 states allow doctors to prescribe drugs and treat patients online

Living in a country like Ireland where we have a total population of less than 5 million I always find it fun when Americans say “only x states” eg. one of those states is California (with a land mass bigger than Japan and a population of 37M).

I’m surprised that a primary care Doctor isn’t calling for proper consistent legislation to be extended equally across the USA as there is no question that this variation is actually helping boost the illegal drug diversion and counterfeiting operations that are behind the illegal online supply of prescription pain medications etc.

Like many primary-care doctors, I’m seeing many patients this winter who are suffering from colds and/or the flu. Some patients think such ailments are so commonplace that a doctor should be able to prescribe an antibiotic after a conversation with them over the phone or Internet

I’m always miffed by this. When we have an epidemic – like the current influenza outbreak – why are healthcare providers so quick to post notices telling patients not to come into their clinics with flu symptoms but so slow to provide feasible alternatives for the patients who could benefit so greatly from them?

Boston Flu Burdens Hospitals as Warning Spurs Vaccine Demand

Why aren’t we looking to the preventative opportunities that remote consulting offers to reduce the need for clinic visits, reduce public exposure and protect the health of the other patients who need to visit clinics for a physical etc?

If health insurers had their way, more doctors would be performing online video chats with patients. However, I would be wary of this growing trend. Companies and insurers seem willing to change the physician/patient relationship to cut costs. More are offering services where patients can consult doctors through a webcam-enabled laptop, or smartphone or tablet. According to a survey by Mercer, a human resource consulting firm, 15% of very large employers use some form of telemedicine, and 39% are considering it. These so-called virtual office visits cost about $40, and patients with minor illnesses can quickly access a physician or nurse practitioner and be prescribed medication online. Patients rave about the convenience, but something is lost through these virtual connections

I think it’s important to note that there’s nothing “virtual” about video consulting with a registered Doctor. I also think it’s important that Doctors appreciate this demand is an opportunity for them to serve the preventative care needs of patients. In my opinion Family Doctors who grab this opportunity to make their services more convenient will only boost the value of the relationships they can form with their patients.

Dangers of errors. Accurate diagnoses can be missed without the face-to-face interaction. For example, I’ve seen a patient convinced he had a sinus infection only to find that he had a tumor inside his nose. Another complained of minor ear pain, but after examining her, I saw that an infection had spread to the point she needed to be hospitalized for intravenous antibiotics

It’s a shame when Doctors try and create fear about the prospect of their colleagues working dangerously online. There are also lots of health dangers that arise because many patients skip office consults because they feel they haven’t got time to go and get their symptoms (eg. something they are convinced is just a “sinus infection”) checked out – until it’s too late. Similarly there are lots of health dangers because of the time limitations in the working day for office visits and because most in-office consultations are poorly documented and most patients aren’t automatically provided with access to their electronic records and their Doctors notes.

Without the ability to examine patients, many doctors play it safe and prescribe drugs. A recent study from the Journal of the American Medical Association found that patients who were treated through virtual visits had higher antibiotic prescription rates for their sinus infections than patients who were seen in the office

Great point. I can imagine there might be a tendency to do this and that’s one of the reasons why we don’t provide prescriptions at 3G Doctor. Perhaps we should help balance the evidence base by publishing a study showing how low our referral rates are for patients who need a prescription?

Antibiotics overuse. Most sinus infections actually clear up themselves without antibiotics. A study published last year found that patients who had sinus infections felt the same after a few days, whether they received antibiotics or not. Worse, unnecessary drugs contribute to the growing problem of antibiotics resistance. Guidelines from the Infectious Diseases Society of America and Choosing Wisely, a consortium of medical societies that provide evidence-based guidelines, also recommend against knee-jerk antibiotic prescriptions for sinus infections

Great advice and I think it’s interesting to highlight that providing similar valuable information to a patient takes an “online Doctor” less than 2 seconds (eg. Crtl Alt Copy, Crtl Alt Paste).

More important, consider what would happen if something went wrong after the online-only consultation. For example, what if the patient had an allergic reaction to an antibiotic, or symptoms that got worse?

I think this merely highlights the importance of taking a good history and having access to a patients EHR whether you’re a Doctor working with patients online or in office (many patients who have suffered an allergic reaction to an antibiotic were not asked about their allergies and/or did not have their EHR checked by their prescribing Doctor).

I think it’s also clear that a patient who had any medication issue is going to be in a better place if they have an up to date EHR and anytime access to an informed Doctor.

And would a doctor face liability for missing something he or she could not see in a video visit?

I think we need to be clear about liability. A registered Doctor has exactly the same duty of care for a patient they are providing care to whether they are consulting with them in their office, on a home visit, over the telephone or indeed via a video consultation process that is supported with patient history taking tools and comprehensive documentation.

There is some room for virtual visits, with stricter conditions. For longtime patients, managing their hypertension and diabetes through a video chat is helpful

I’m a big advocate for defining these “stricter conditions” but it confuses me why (in light of the evidence) you would want to limit patient access to such important clinical tools to only those patients who are going to be seeing you remotely?

I’m confident that I could introduce Dr Kevin Pho to many patients who could convince him that there is a much wider need for remote consultations than he currently thinks exists eg. a CF patient who contracted an infection on her last routine visit to a hospital and now routinely uses Skype with her specialists, a disabled patient who lives hundreds of miles away from their specialist, etc.

But I would not feel comfortable treating new patients on the Web

I think it’s important to respect this decision and we should be careful to ensure no Doctor feels pressurised to provide care in a way that makes them uncertain or for which they feel incompetent.

I also think it’s great that Video Consulting is bringing diverse new working opprtunities for Doctors who feel they are suited to it. It’s great not only because it means skills can be transferred to where they’re needed when they’re needed (sparing patients a whole lot of unnecessary inconvenience) but also because it will support new flexible and remote working opportunities for very talented Doctors that I am certain will boost the appeal of family medicine as a career option for Doctors in the USA.

Currently, only 13 states allow doctors to prescribe drugs and treat patients online without actually meeting in person first. With the zeal to cut costs and maximize convenience to patients, there will be tremendous pressure to expand that number. Please remember, though, that what is cheapest for insurers, and easiest for patients, isn’t necessarily what is best

I think it’s fundamental that we accept that meeting with a registered named Doctor who has access to my EHR and will provide me with a fully documented consultation qualifies as “actually meeting in person” with a Doctor.

With acceptance of that I agree completely with this concern of Dr Pho’s and I think that’s one of the big advantages of providing patients with a set fee service that involves no subscriptions or uncertain commercial incentives.

About David Doherty
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