By David L. Feldman, MD

Early in the pandemic, I heard an obstetrician say that a medical setting was the last place many patients were willing to go. As a result, he was checking on prenatal patients using telemedicine. With questions about standard of care in mind, I gathered obstetric leaders into a meeting group where providers discussed ways to safely utilize phone and video modalities to continue prenatal care beyond the pandemic. Would this modality, necessary in a time of crisis, be continued in the “new normal”?

Many specialties, facing the pandemic’s imperative to improvise, formed similar discussion groups, which are now disseminating their findings via peer-reviewed medical journals or formulating best practices with their medical professional societies. Fortunately, each specialty’s findings have connotations for patients in a variety of settings. With 2020’s spike in telemedicine visits followed by 2021’s continued record-breaking increases,¹ we now know a surprising amount about how to safely provide telemedicine care.

As practices and hospitals work to integrate their telemedicine platforms more smoothly into their workflows,¹ this moment calls for us to reconsider how we are using telemedicine relative to care access, quality, safety, and the core principles of patient-centered care.

Specialty Example: Obstetrics

Obstetricians monitor risk indicators like blood pressure and blood glucose, which help them intervene early in cases of preeclampsia and/or gestational diabetes. With the increasing availability of at-home monitors for blood pressure and blood glucose, the option to collect at-home metrics (which, admittedly, some patients do more reliably than others) shows how remote care can sometimes be safer and/or more accessible care.

Surprisingly, I’ve heard obstetricians say they value telemedicine most with their high-risk patients, simply because it facilitates more frequent conversations. This finding also turns up in other specialties.

Specialty Example: Otolaryngology

As in obstetrics, the physical exam needs of otolaryngology might seem impervious to many telemedicine advancements. Yet the author of a 2020 JAMA article argued to his colleagues, “We must rediscover the nuances of palpation and noninvasive inspection. Substantial portions of this examination can be completed without instrumentation or prior experience.” The person without prior experience is the patient: “The clinician can provide instructions to the patient for sequential elements of the examination and then verify correct performance of each maneuver.”²

This collaborative spirit (which the author frames in terms of what Eric Topol, MD, of Scripps, has called the “activated patient”) aligns with the core principles of patient-centered care: “Patients are partners with their health care providers.”³ This partnership—facilitated by the practitioner while considering the patient’s emotional, social, and financial perspectives—is more than a remote-care convenience: “The activated patient is empowered to participate in their care in a manner hitherto unappreciated, and in so doing, they may well enjoy greater engagement and satisfaction.”²

Specialty Example: Surgery

Surgical specialties present an unexpected number of opportunities for remote care, from consultative conversations all the way through postoperative evaluations. For instance, many post-op evaluations can relocate to the telemedicine space, where questions like how the wound looks and drain output can be evaluated.

Such uses of telemedicine, when appropriate, improve the patient experience, and sometimes patient safety. After all, post-op patients don’t want to leave home, and sometimes safety is an issue. I know I’m not the only one who has ever made a house call during icy weather. If we use good clinical judgment, we can offer a version of the post-op house call to some patients with arguably comparable or improved patient safety.

Reducing Medical Malpractice Risks

Some of the state-to-state restrictions lifted early in the pandemic have resumed, so check with the relevant state medical licensing boards. It remains important to know where your patients are: Practicing medicine without a license is still illegal, and your medical malpractice insurer cannot cover you if you were doing something criminal, even inadvertently.

We still see few medical malpractice lawsuits related to telemedicine, but those we do see mostly connect to diagnostic errors.⁴ Of course, the physical exam still matters: Even with workarounds and patient-assisted maneuvers, sometimes we need to lay hands on the patient. Moreover, since diagnostic errors often derive from communication gaps, we must remain mindful of the ways in which telemedicine amplifies communication challenges.⁴

That said, some methods of mitigating diagnostic error risks are contained within our challenge to embed telemedicine within workflows. Systems that require the physician to fulfill the role of a tech support professional and/or medical assistant increase cognitive load. Such distractions increase the chances that a significant symptom will be overlooked. Further, systems that make it difficult to track referrals or test results amplify diagnostic risks.

Therefore, better integrating telemedicine appointments into workflow serves both provider sanity and patient safety by optimizing patient-provider communication. You can engage experts like my colleagues at Medical Advantage to help your practice with this process.

Telemedicine for Patient-Centered Care

A recent survey found that 62 percent of responding organizations are expanding their telehealth programs, versus being in maintenance mode.¹ This is the perfect time to rethink both what we need to do in person and how frequently we need to do it (e.g., ultrasounds during pregnancy), while accounting for the increasing availability of at-home gadgets, such as otoscopes and ultrasound solutions.

Gadgets are one of the many aspects of telemedicine that raise questions about patient access to care. Patient safety researchers extol the virtues of programs that reduce device costs for patients in need, and they also promote reimbursement for providers who offer the substantial technology education and orientation some patients need to function as activated patients within the telemedicine landscape.⁴ Integrating translation services into virtual visits will also have an impact.

The access question is two-sided, because for every patient who could not access a telemedicine visit for lack of bandwidth or because they live in crowded conditions without privacy, there is a patient who could access their visit only because remote care comes without the price tag of childcare, transportation, or a missed shift. Despite its difficulties, telemedicine is a net gain to our armamentarium for providing patient-centered care.

 David L. Feldman, MD, MBA, FACS, is Chief Medical Officer for The Doctors Company and TDC Group and Senior Vice President, Healthcare Risk Advisors

References

1. Teladoc Health. 2021 Telehealth benchmark survey results and report.Published 2022. https://www.teladochealth.com/resources/white-paper/HHS/2021-telehealth-benchmark-survey-results/
2. McCoul ED. Grasping what we cannot touch: examining the telemedicine patient. JAMA Otolaryngol Head Neck Surg. Published June 18, 2020. https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2767512
3. What is patient-centered care? NEJM Catalyst.Published January 1, 2017. https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0559
4. Khoong EC, Sharma AE, Gupta K, Adler-Milstein J, Sarkar U. The abrupt expansion of ambulatory telemedicine: implications for patient safety. J Gen Intern Med. Published January 19, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8768444/