What exactly comprises an online doctor visit? And is it safe? The role of telemedicine and telehealth is emerging as technology now makes it easier to care for patients online. Some services offer “one-off” consultations. Others, like Cirrus Medical Network (CirrusMED), offer online primary care physicians for a monthly fee. Some larger health systems offer telehealth solutions. Physicians will indeed need to become accustomed to this new visit type. Though somewhat of a medical-legal gray zone, one doesn’t have to look too far to see that even the government has placed less emphasis on the physical exam. The relatively new Medicare “Annual Wellness Visit” does not have a single covered service that requires the doctor to place his or her hands on the patient, save for the digital rectal exam and pap test. Virtual visits are rarely covered by insurance even though they take place all day long during a typical day in the primary care physicians’ office. Possibly one driver in the steeped tradition of having patients make an appointment whether it’s something minor, or a chronic medical condition, often much to the patients’ chagrin.

Historically, doctor consultations were made face-to-face. It is ingrained as a legacy workflow from the beginning of time. Doctors are trained to follow the “SOAP” note method, or if it’s a first time or more comprehensive visit, additional past medical, surgical, family, and social history are obtained. The traditional SOAP note includes:

Subjective: The patient’s complaints, in their own words or from their perspective. Additional pertinent positives and negatives are included in this section. Example: 55 year old female complains of nasal congestion and frontal headaches for 5 days. She states that they are “excruciating”. She has a history of sinusitis and seasonal allergies. She denies fever, ear pain, and neck pain. She does have a minimally productive cough in the mornings.

Objective: The physical examination, including vital signs. This is usually the hands-on portion of the the visit which may either be focused on the problem at hand, or more comprehensive. Example: Afebrile. BP 130/80 HR 76. Appears malaised with a nasal sounding voice and sniffling. Ear exam showed clear effusion, otherwise normal. Nares reveals boggy, swollen anterior turbinates. Post pharynx shows post-nasal drip. No cervical lymphadenopathy. Lungs clear and Heart rate and rhythm normal.

Assessment: The diagnosis. Sometimes it is a list of working diagnosis’, especially if the diagnosis is unclear or yet to be ruled out or in. Example: Acute Sinusitis. Probable allergic component.

Plan: The treatment plan, including prescriptions, referrals, diagnostic studies (labs, x-rays, etc.), and advice. Often a follow-up plan is included here. Example: Saline irrigation, antihistamines/decongestants as tolerated. Consider course of antibiotics if no improvement in 72 hours. Use an inhaled corticosteroid around allergy season to control allergy symptoms.

Naturally, with the online doctor visit, parts of the objective/physical examination cannot be performed. So how can an online doctor make a correct and/or accurate diagnosis?

Let’s rewind a little and look at how medical education over the years has evolved. For the sake of simplicity, let’s focus on primary care medicine, the Primary Care Physicians (PCP’s, which include Family Medicine, Internal Medicine, Pediatrics, etc). Some of the more common presenting complaints include minor infections (respiratory, sinus, ear, throat, bladder, etc.), pain, high blood pressure, high cholesterol, diabetes, depression/anxiety, and wellness. Being on the front line of care, and often considered the gatekeeper, the list of presenting complaints is infinite. The objective physical exam usually starts off with vital signs and then works head to toe. A focused physical may be the ears, nose, throat, neck, lungs, and heart for someone presenting with sinus congestion. No need to do a rectal exam, right? So, the physician, armed with a stethoscope, a light, and an otoscope can check out each of the areas and note pertinent normals and abnormals. Remember, this has been going on since the days of Hippocrates.

The legacy of the physical exam still holds, but over time it’s relevance as waned.Though many are reluctant to admit it, the physical exam may be a dying art. Why? It may be multifactorial. One reason may be the time constraints placed on PCP’s who are trying to document frantically on their trusty little laptops or tablets in the exam room at the point-of-care. Another reason is that newer technologies have trumped the physical exam, such that doctors whom may be unsure of about a whether they have heard a heart murmur, will order an echocardiogram; or if a patient swears they have pneumonia, one better order the chest x-ray just in case one gets called to court; and abdominal pain often triggers and ultrasound or CT scan since costs have come down and liability has gone up. Technology is moving closer to Star Trek-like devices as well. With the advent of the smartphone, numerous interfaces and apps have been developed to allow for “at home diagnostics” such as heart/lung sounds, blood pressure, pulse oximetry, otoscopy (ear exam), and throat exams. Older patients recall the days of getting undressed and wearing that awful hospital gown once they stepped into the exam room. These days, the typical primary care visit takes place in more of a conference-like setting, with the patient in a chair (clothed), and the doctor tapping away on his/her computer. Not too unlike talking with a banker.

So, does the face-to-face physical exam matter? Yes, and no. There are clearly some situations where a face-to-face examination is necessary. However, more and more conditions can be managed virtually utilizing today’s technology and a thorough history. As patients become more comfortable communicating via messaging and video, online doctor visit will be more accepted.

The online doctor visit shortens the SOAP note to the SVAP:

Subjective: Same as above
Vitals and Video Exam: Vitals are easily taken at home. Video and/or app derived physical examination information
Assessment: Same as above.
Plan: Same as above.

Vitals are easily obtained at home. The video exam is still emerging and has been slow to adopt by primary care physicians. Traditional telemedicine applications have used telemedicine to relay images and video to aid in remote diagnosis in the fields of dermatology and radiology. And telepsychiatry has gained in popularity given the shortage of psychiatrists and the fact that the psychiatric “Objective” exam is rather limited. There is even a television series mocking telepsychiatry.

The video exam has it’s limits though. Clearly, it would not be possible to obtain a good abdominal, pelvic, or musculoskeletal exam via video. In these cases, history taking is paramount, and the physician would have to use his/her judgement to triage the case appropriately. Which brings up another pearl of telehealth: online doctor visits, like in-person doctor visits, always weigh the risks vs. benefits. Online physicians must know their limits and practice at the level of standard of care, using their professional judgement when managing patients in any given setting.

More comprehensive “Establish Care” and “Annual Wellness Visits” can easily be performed virtually, as much of the history can be entered ahead of the visit using online forms. In fact, this is often preferable to the lengthy paper forms many doctor offices hand out to new patients.

What are the risks of seeing an online doctor? For the doctor, most risk depends on the discourse and rapport between the physician and the patient. The risk drops precipitously as the doctor becomes more familiar with the patient over time. Thus, one-off consultations likely carry a higher risk than a retained online physician who may provide continuity of care. Again, it ultimately is up to the doctor to weigh the risks and benefits in any decision that is made. Patient risk generally depends on how forthcoming they are with their online doctor. The virtual visit does make it easier for the patient to withhold information. On the other hand, some feel more comfortable sharing information online. Again, over time, when a patient develops trust and a rapport with their doctor, this becomes less of an issue. An online doctor consultation can be just that: advice. It may be simply “You need to go to the emergency room.” Or, “Clearly we can take care of your issue today”. Not too different from the traditional brick-and-mortar doctor’s office.

Until insurance covers online doctor visits, one may have to pay cash for the visit. Surprisingly, this service is often less than a typical co-pay for an office visit. With services such as Cirrus Medical Network (CirrusMED), for a nominal monthly fee, one’s online “concierge” physician can manage both acute and chronic medical conditions, prescribe medications, order labs/diagnostic testing, and send referrals to specialists if needed. All of this, outside of the constraints of insurance. It is a win-win situation for the patient, and the doctor.

 

Christopher C. Highley D.O.

Founder, Cirrus Medical Network LLC (CirrusMED)

 

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