It might seem silly to discuss the purpose of telemedicine but it will help clinicians better understand their responsibilities when performing these digital patient visits.

I have heard it from a few colleagues that they don’t like this new trend of telemedicine taking over traditional in-person visits. This post will shed some light on the topic and is meant to delineate how we practice in-person versus how we practice virtually.

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Telemedicine isn’t New

I was having a discussion with a doctor who does consulting work for telemedicine from Beverly Hills. He’s been doing telemedicine for 14 years and runs his own urgent care in BH.

He started his practice 25 years ago and quickly realized that a large percentage of his patients were too busy to come into the office. They were happy to check in with him over the phone and were comfortable with him prescribing them medication over the phone.

He just wasn’t able to bill for his time with these telephone visits and didn’t have an efficient way of documenting the interaction.

We have all been doing telemedicine since residency, we just never called it that. We referred to it as the ‘mommy pager’. Patients would page us if they had questions about their health after-hours. It wasn’t an accepted business practice to charge for this care but that’s changing rapidly.

Busy Clinics

Primary care and urgent care clinics have gotten busier than ever before. In part due to population growth, an aging population, declining health of the US population, and the desire for more medical intervention.

We order more tests and have a growing complication rate due to medical intervention which requires more follow-up visits. With telemedicine now more mainstream, clinicians are adopting telemedicine as a way to bill for their digital time spent with patients.

Telemedicine isn’t meant so much to replace the in-person visit. Rather, it’s a way to offload some of the less clinical cases from the busy clinician. Such cases often require nothing more than a verbal triage, a lab order placed, medication refilled, or advice offered.

Purpose of Telemedicine

The purpose of telemedicine isn’t to replace the office visit. We are a long ways away from doing a digital pelvic exam or draining an abscess through our browsers.

Patients, too, aren’t ready to trade their office visits for a digital one unless it makes sense to do so. However, they aren’t necessarily happy waiting several hours just to have their Lexapro refilled.

Sexually active women, too, are frustrated with the bureaucratic requirements of a pelvic exam before being prescribed birth control. They have enough barriers against obtaining such medications, they don’t need the 3-hour appointment wait times to add to it.

1. Non-Clinical Cases

Many non-medical issues, too, can be resolved through telemedicine. It might be a prescription clarification or filling out paperwork for the patient. An excuse-note can also be easily handled via telemedicine.

These cases can take up valuable office time and interrupt the workflow of a busy-minded clinician. Telemedicine can filter out the non-clinical cases and maintain the clinical environment of a doctor’s office.

2. Billing for Time

I can’t talk to a lawyer without getting a bill. Their time is valuable and their knowledge shouldn’t be free. Just like you can’t get a free tile job from a contractor, you shouldn’t get the services of a doctor for free.

Especially in medicine, where our actions and opinions carry high risks, we might as well bill the patient to make up for the eventual financial loss of a legal battle.

3. Triaging

Since many of us will be the pioneers of telemedicine, we carry the responsibility of not causing poor patient habits. Treating the virtual visit as another clinic visit will create a headache for us and a disappointment for patients.

Instead, we should use it as a way to triage our patients and take care of their out-of-office needs while still being able to document it in the chart and bill for it.

• -“Yes, you can manage that at home with xyz.”
• “Based on what you have said, I would recommend going into the urgent care and having the following studies done.”
• “Your symptoms aren’t severe enough to require immediate attention but if you don’t see an improvement after a week then please schedule a primary care appointment to have xyz done.”

4. Second Opinion

Telemedicine is often an efficient way for patients to get a second opinion on their condition or treatment options. This is becoming a more common chief complaints in my telemedicine visits.

Imagine the patient just left the doctor’s office and they had a shy moment or didn’t feel comfortable questioning the decisions of the doctor. Now they want to run it by someone whom they feel more comfortable speaking to.

Commonly, you’ll see that it’s not even the caller but their loved one, on whose behalf they are calling. Often an elderly parent or a child.

• “I just left the doctor’s office and they gave me antibiotics but I really don’t think I need it. Can you give me your opinion?”
• “My mother’s doctor wants to do a shoulder surgery but she only has occasional pains, can’t she just try physical therapy first or have a cortisone shot?”
• “My LDL is 101 and my doctor wants to start Lipitor. That seems overly aggressive with me and from what I read….”

5. Hospital/Surgery Follow-Up

A patient who just left the hospital or had surgery performed doesn’t always have easy access to their treating doctors. The nurse might be hard to reach or they are waiting for a response and have gotten lost in the shuffle.

“My foley catheter fell out after I left the hospital but I’m peeing fine, do I need to go back to have it replaced?”

“I am having non-stop vomiting after my abdominal surgery last night and need to know if I can wait it out or if I should go back to the hospital.”

“I went into the hospital with lisinopril and they discharged me with captopril. Should I continue the lisinopril as well?”

Acute Infections

The topic of acute infections requires its own section. As clinicians we are somewhat brainwashed to think that every cellulitis, UTI, and acute sinusitis will die unless they receive antibiotics.

In fact, very few infections are emergencies. They can be monitored in most cases and signs of progression and worsening are obvious. A reliable patient can be tasked with monitoring for changes and going in if things worsen.

Urinary Tract Infections

Many UTI’s will resolve on their own. Other potential UTI cases are dysurias due to urethritis, dysuria due to diarrhea, bladder spasms, vaginitis, or interstitial cystitis.

An uncomplicated UTI can be managed conservatively or treated over the phone with antibiotics. I prefer the former.

A pyelonephritis shouldn’t be managed over the phone. A urine culture and a urine analysis, at the very least, make for a more defensible medical practice.

Cellulitis

I’m not referring to cellulitis of the face, cellulitis in a diabetic, or a cellulitis with high fevers, fatigue, nausea, or other symptoms.

However, quite a few cellulitis presentations, even with lymphangitis, in an otherwise healthy individual can be monitored or managed conservatively while watching for potential progression.

Hydration, limb elevation, dietary modifications, and avoidance of anti-inflammatories are good ways to manage uncomplicated cellulitis conservatively.

Delay of Care

The counter argument might be, what about the potential of delay of care?

I have developed a habit of not diagnosing patients over telephone, text, or video. Without an exam I often can’t be sure. I tell them what I suspect but prefer to not definitely diagnose a certain disease.

To prevent yourself of being accused of delay of care, advise the patient to seek care and treatment right away. However, give them further information so that they can make their own decisions.

“Based on the picture I saw and how you are describing the area, I suspect the beginning of cellulitis on your shin. You can go to the urgent care and get antibiotics to treat this to prevent it from advancing. However, it might be mild enough and you are healthy enough that it could resolve on its own. I will describe to you how it will progress, if it does in fact progress, and you can decide what the best option for you is.”

You’ll find that some patients will prefer a more aggressive option while others gravitate towards a more conservative approach.