Is Telemedicine the Best Fit?

Telemedicine is a new alternative to in-person appointments, but not all patients and present conditions are a good fit for each appointment.

Telemedicine is a new1 alternative to in-person appointments, but not all patients and presenting conditions are a safe or effective fit. According to the Federation of State Medical Boards, whether delivering care electronically or in-person, physicians must prioritize, among several things, the patient’s welfare and acceptable and appropriate medical practice standards. In a professional liability lawsuit, the physician’s telemedical care will be held to the same legal standard (i.e. what a reasonable and prudent physician with similar training and experience would do under the same or similar circumstances) as in-person care. Yet, virtual physical examinations have limits, and the available clinical data may be insufficient to support an accurate diagnosis via telemedicine.2 A selection methodology that considers the presenting clinical concern and individual patient factors will help practice staff schedule the most appropriate type of appointment.

Presenting Clinical Concern

A primary consideration for an in-person appointment is the patient’s presenting clinical concern. According to The American Telemedicine Association (“ATA”) Practice Guidelines for Live, On Demand Primary and Urgent Care,3 telemedicine usually is not appropriate where a hands-on examination is necessary “due to the severity of the presenting symptoms, the necessity of haptic information, the need for protocol-driven procedures, or the need for aggressive interventions.” Similarly, situations warranting escalation to the emergency department are not appropriate for telemedicine.

The Guidelines state that telemedicine is generally suitable for uncomplicated conditions where “there is a reasonable level of certainty in establishing a diagnosis and generating a treatment plan,” especially when visual information, diagnostic studies, and imaging are available. The Guidelines suggest fitting medical conditions4 for management through telemedicine and other interactive technologies supported by peripheral devices and ancillary tests, including:

    • allergy/asthma;

    • chronic bronchitis;

    • conjunctivitis;

    • genitourinary conditions;
    • low back pain;

    • otitis media;

    • rashes;

    • upper respiratory infections;

    • monitoring of chronic conditions such as mental illness and behavioral health, chronic obstructive pulmonary disease, congestive heart failure, diabetes, and hypertension; and/or

    • consultations regarding prevention and wellness services (i.e. immunizations, smoking cessation, and diet/physical activity).

There may be peer consensus supporting virtual visits for some patient conditions. In a July 2020 survey, UCLA Health primary care physicians rated the following patient complaints as the least appropriate5 for a video visit:

    • chest pain;

    • shortness of breath with no history of lung disease;

    • ear pain or hearing changes, concern for infection;

    • abdominal pain; and

    • leg swelling.

Patient concerns the UCLA physicians considered more appropriate for virtual care included:

    • depression/anxiety;

    • mild upper respiratory symptoms; and

    • diabetes management.

Patient Factors

Patient factors may compromise a clinician’s ability to deliver effective virtual care and should be incorporated into the telemedicine patient selection/triage process. Potential factors for ineffective telemedicine appointments identified by the ATA Guidelines and the UCLA Health survey include:

    • poor cognitive function;

    • language barrier;

    • over age 70;

    • intoxication or a strong history of drug/alcohol abuse;
    • patient’s first visit; and

    • lack of patient access to technology.

Other Considerations

    • Clinicians should review any telemedicine-related clinical guidelines, applicable statutes and regulations, licensing board policies, position statements, or standards issued by the medical organizations and/or specialty societies to which they belong, and, as appropriate, incorporate the information into the appointment selection process.

    • Before deciding what medical conditions the physician can safely and effectively evaluate via telemedicine, conduct a candid assessment of the physician’s and practice’s technological capabilities, comfort with the technology, and depth of experience in providing virtual care.

    • A triage protocol, like the one implemented by UCLA Health, will guide practice staff through the process of selecting in-person or virtual care.

    • Another approach is to develop individual clinical protocols by condition and corresponding ICD code. Each protocol should specify the type(s) of care delivery that can be utilized to treat the condition (i.e. in-person, video, phone, etc.). See the ATA Guidelines for additional clinical protocol components that correspond with video, telephone, and/or office visits.

    • Direct staff to consult a physician or other clinician whenever they are in doubt about in-person or virtual care.

To reduce the risk of missed or delayed diagnoses, physicians and practices should develop a standardized screening process, incorporated into the scheduling workflow, to ensure the most appropriate type of appointment.

1 While telemedicine is not a new concept, reimbursement restrictions inhibited widespread implementation prior to the pandemic. 

2 Physicians should collect all information necessary to make well-grounded clinical recommendations when they are unable to personally conduct a physical exam. See American Medical Association Ethics Opinion 1.2.12, Ethical Practice in Telemedicine.

3 ATA has published other specialty-specific telemedicine practice guidelines available through the Southwest Telehealth Resource Center.

4 The Guidelines provide citations to studies evaluating the use of telemedicine to treat uncomplicated cases of these various conditions. According to the ATA, “The development of these guidelines followed a rigorous process of evidence review and expert assessment of more than 600 studies regarding the practice of telemedicine in primary and urgent care.”

5 UCLA Health defined an “appropriate” visit as one provided in a timely manner and meeting professionally recognized standards of acceptable medical care.

The content of this publication or presentation is intended for educational purposes only; is not an official position statement of Mutual Insurance Company of Arizona (MICA); and should not be considered or relied upon as professional, medical, or legal advice or as a substitute for your professional judgment. Consult your attorney about your individual situation and the applicable laws. The authors, presenters, and editors made a reasonable effort to ensure the accuracy of the information at the time of publication or presentation but do not warrant or guarantee accuracy, completeness, or currency of such information. As medical and legal information is constantly changing and evolving, check for updated information and consult your attorney before making decisions.

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