I just had a conversation with a buddy who will start doing telemedicine. He has plenty of experience dealing with patients in the urgent care but telemedicine is different. It requires a unique workflow which is unlike anything you do in the urgent care setting.
I recommend focusing on triaging in telemedicine and turning away from the diagnosis mentality. Provide and impression and close the loop. You will see more patients, have less risk of practicing telemedicine, and have happier patients.
The Urgent Care Visit
In the traditional urgent care visit we have nurses who perform the intake and obtain vitals. Most of the chief complaint information has already been obtained. The patient has gone through an extensive waiting period and data collection just to see a clinician. Their expectations are high.
As clinicians, we need to perform a little warm-up session before we can go digging into the patient’s orifices or perform any intervention. Therefore we spend an inordinate amount of time breaking the ice.
We ask open-ended questions. We nod and say things like “tell me more” and “so you were saying about that neck pain”. We do the fake empathy stuff.
Then we do the exam, most of which is for show – appeasing the patient and protecting against legal consequences. Though, I did, finally, one time, hear an abdominal bruit in a relatively younger dude. It didn’t change the outcome of the visit.
I’ll break this topic down into more details and I’ll do it from the patient’s perspective in order to help the medical professional understand the mindset of a patient.
Have you ever had a telemedicine visit yourself? It’s very interesting being the patient in a telemedicine visit. It’s so different from a traditional urgent care or clinic visit – it catches you off-guard.
Patients are looking more for an expert opinion from a clinician rather than an intervention – whether medications or further testing.
It’s generally quite easy for a patient to schedule a telemedicine visit. They can do it online. They get placed in the queue immediately and often will speak to a clinician in <5 minutes.
Patients have a bit of healthy skepticism when it comes to a telemedicine visit. “What the hell can a doctor do for me over the telephone?!”
The patient usually wants to know one of the follow, in descending order:
- whether they need to get seen right away (ER, UC)
- what they can do for their symptoms at home
- whether they need antibiotics for a particular condition
- post-op, post-hospital questions
- requesting a medication refill
- requesting a particular antibiotics
Patients don’t expect you to stay on the phone with them for 15 minutes. In fact, they are a bit frustrated if that happens.
They have turned to telemedicine in order to optimize their time. Their expectations are low and they don’t care to spend forever on the phone, barraged with questions.
I want to say a word about acuity. Clinicians worry that they are going to get chest pain patients and parents calling about their septic infants. ?
This is almost never the case. Again, have faith in how smart patients are. Though we encounter poor judgement commonly in the urgent care, that’s only because of how accessible and urgent care is.
Telemedicine is more selective. It’s not ubiquitous and so it attracts the more savvy individuals, those with realistic expectations.
The Triage Approach
I would recommend that the clinician adopt a triaging approach to a telemedicine visit. Lemme ‘splain with the following few steps:
- assess acuity
- minimize questioning
- request a self-exam
- offer impressions – not diagnoses
- close the loop
1. Assess Acuity
The main task is assessing the acuity of the visit – triaging. You are trying to determine if the UTI symptoms might coincide with pyelonephritis or PID, needing immediate, in-person assessment.
- Does the headache patient have symptoms which can be monitored at home for a few more days?
- Does the child with diarrhea have any symptoms of dehydration which require an urgent visit?
- Can the hypertensive who has run out of medications wait until they are seen by their PCP?
- Does their persistent cough after an inpatient PNA management pose a concern?
- Is the knee pain after a TKR normal or out of proportion to the history?
Once you have a good idea, don’t torture the patient any further.
Let them know that they need to be seen. Let them know where, how acutely, and go a step further and google a location if they don’t have a clue where to go. Superstar. ?
2. Minimize Questioning
Don’t pull a medical student on these telemedicine patients. Keep it simple. Don’t ask open-ended questions, that’s the wrong approach for telemedicine.
“Tell me more about your vague abdominal pains.” No! Do not tell me more about your vague abdominal pains. That gives me vague headaches.
Instead, be specific. “Is the headache worse with exertion, cough, or position?”
Talk less. I know you’re used to talking a ton in the urgent care – squeezing every last bit of information from the patient. But patients who turn to telemedicine are more self-motivated. They’ll tell you what’s pertinent.
In fact, should you encounter a patient from whom you have to milk every last bit of information, send them into the clinic. A poor historian is not a good candidate for a telemedicine visit.
The less you ask, the more professional and trustworthy you appear. It’s like picking up on a woman in a bar. Talk a lot and you’re out. Minimize your word usage, but make them potent, and you’re golden.
Most of the questions we ask patients in the urgent care are meant to help us determine the exams and tests which we’ll need to order next. Well, ya ain’t going to be doing any of that. That’s not what telemedicine patients are turning to a telemedicine doctors for.
Telemedicine isn’t meant to replace the in-person visit. It’s meant to offload easily triagable patients from busy clinicians.
Having patients do a brief self-exam makes you appear thorough and it’ll offer you valuable information. Have the patient press on a few spots. Have them look in the mirror at their tonsils. Have them look at a rash and describe it to you with your guidance.
How reliable is a self-exam? Well, you’re not about to remove someone’s appendix over the phone because of RLQ tenderness. It doesn’t need to be perfect.
4. Impressions – not diagnoses
“I’m not able to diagnose you over the phone but I can give you a fairly accurate assessment of what’s going on and what you can do next.”
Remember, you’re not going to be diagnosing people over the phone or on a video visit. The point is for you to triage, to guide them in the right direction, and to let them know what to do next.
Sure, you can use the UTI code but I prefer using the Dysuria code in the ICD-10 section. Then I’ll explain my MDM in the assessment/plan section. It’s rare for your telemedicine company to give you pushback.
Occasionally, I can determine that someone’s dysuria is likely UTI related. I can offer them some home remedy options or, if they have the most classic of UTI symptoms, I can order a course of antibiotics.
- Abdominal pain and not biliary colic
- Nausea/vomiting + diarrhea and not viral gastroenteritis
- Headache and not migraine or tension headache
5. Close the Loop
- Ask the patient about why they are calling.
- Then gather a little more information.
- Then have them do a brief self-exam.
- Then offer your impression and direct them to the next steps.
You now closed the loop, instead of leaving it open for the patient to make requests for antibiotics or a 7-month off-work note. Keep it simple and you won’t confuse the patient.
Sure, a patient might follow up with a request of Augmentin for their 5 days of sinus tingling and nose tickle. Don’t dismiss the patient but don’t reopen the visit.
Keep it short, keep it neutral. “As I mentioned, it appears you have a sinus issue that’s likely viral or allergic. Based on the information I gathered I don’t see antibiotics as a safe or appropriate option. If you feel that something else is going on than what I have assessed, please visit a walk-in clinic for an in-person evaluation.”
And you’re done. Everyone is happy. Don’t leave room for more questions. It will only confuse the patient.
My buddy said it best “To succeed in the urgent care, we can’t let patients leave empty-handed”. He is referring to prescribing patients something, anything.
Mobic. Bentyl. Prednisone. Macrobid. Sudafed. Augmentin. Amoxicillin. Triamcinolone. Oflox. Trazodone. Keflex. Mupirocin. Albuterol. Viagra. Premarin.
Make it a habit not to prescribe anything during your telemedicine visits. Keep the concept of triaging in mind – that’s your goal.
I have done telemedicine for 3 years now and I have maintained a 6-8% prescription rate. Whether good or bad, this has worked quite well for me, so far.
A patient who needs antibiotics should probably be seen in person unless they have the most obvious of symptoms and histories. Such slam-dunk cases are rare. I give the occasional antibiotics for a classic UTI or a secondary yeast infection after antibiotic usage.
Your goal should be to have patients use whatever they have at home or whatever is over the counter to manage their disease. If it’s something more complicated which needs a prescription, they should be seen in person.
- don’t diagnose PNA on a telemedicine visit
- don’t diagnose thrush on telemedicine
- don’t diagnose pyelonephritis
- don’t diagnose diverticulitis
- don’t start antidepressants
- don’t give ED meds unless it’s a refill and patient has been worked up
- don’t prescribe antibiotic eye drops unless it’s meant to hold them over until they are seen the next day (contact lens)
- don’t treat anyone for an STI unless it’s recurrent HSV
- don’t ever diagnose acute otitis media
- don’t treat onychomycosis
- don’t treat a dental abscess with antibiotics
- don’t treat an abscess with antibiotics
- don’t prescribe meds for gout
- don’t start hormone therapy
Certain diagnosis are quite easy to make and a big time saver but even these don’t always need to be treated with prescription medication:
- uncomplicated conjunctivitis
- atopic dermatitis
- angular cheilitis
- tinea pedis
- tinea corporis
- tinea capitis
- cold sores
- recurrent genital herpes
- hidradenitis suppurativa
- Seborrheic dermatitis
- yeast infection
Most commonly prescribed medications in telemedicine visits:
High Volume Visits
You guys have commented on my posts how I can see 10-12 patients in 1 hour. And this is how. The above methods are what I use to get through a visit in less than 5 minutes. This minimizes the need for documentation and ordering unnecessary medications.
I have 98% patient satisfaction scores on every telemedicine platform. Including: DoD, Teladoc, Roman, American Well, Remedy, and JustAnswer.
You will create less work for yourself, see more patients, and earn more money. All with happier patients whose time and resources isn’t wasted.
One way to prevent a visit from dragging on is to decide early what you will do. If I am on a telemedicine call with a patient who is telling me that they are having fevers, chills, weakness, dizziness, and coughing with some shortness of breath then the visit ends there. They need to be seen in person.
I may continue to ask a few questions so that the patient doesn’t feel dismissed. But I’ve made up my mind and my questioning will only solidify the case for my ensuing recommendations.
They might push back and ask what they can do at home and I’m happy to give some suggestions but I’m not going to run through a DDx of fever and cough without being able to assess them in-person.
PS: this is post #901 – nice!