A Country Doctor Practices Telemedicine

Walking gingerly, one small step at a time like an old man, I slowly made my way down our icy driveway to the mailbox this morning. The cold wind circled around my neck and the sleet pounded against my cheeks. March was surely coming in like a lion here in the Northeast.

Inside the black metal mailbox were the usual bills and journals, but also a small post card. I brought it closer to try to read it through my wet eyeglasses. It was from a company looking for primary care physicians for telemedicine services.

Telemedicine is an integral part of rural health care. When an accident victim has a CT scan of the brain or cervical spine in the middle of the night, a radiologist in a different time zone reads the images while our own radiologist gets his well-deserved sleep. The specialists who fly or drive here to do consultations sometimes use the hospital’s teleconferencing capabilities for virtual follow-up appointments. We even have telepsychiatry with doctors from Boston and the southern parts of our state.

“Telemedicine for primary care doctors”, I thought as I inched my way up the slippery driveway in the bitter cold sleet storm. I imagined myself in my slippers and cardigan, comfortably doing telephone consultations by the fire. I saw myself poolside in my swim trunks, sipping from one of those parasol drinks, making money on the phone while working on my tan.

I have already done some telemedicine. Last weekend my daughter sent me a picture on my cell phone with the question what kind of rash my grandson had. It was a classic case of erythema annulare. He happened to have an appointment with his doctor a few days later, and I understand the diagnosis was confirmed in person then.

Then I remembered I had been less successful a few weeks before that when my granddaughter had a host of symptoms, including a fever and, as my daughter added: “She won’t eat”. It all sounded pretty viral to me, so I gave the usual advice. A couple of days later, I found out the child had a flaming case of strep throat.

I asked sheepishly “How sore was her throat?”

“Real bad, didn’t I say that?” My daughter seemed puzzled.

“I only heard that she wouldn’t eat”, I said.

“Yeah, because her throat was so sore”, she answered.

A visual would definitely have helped there. If it was that hard to diagnose my own granddaughter over the phone, I can imagine the challenge of trying to do more than the simplest triage over the phone with a complete stranger who is paying for the call.

I kicked the snow off my boots and entered the glassed-in front porch. My eyeglasses were frosted on the outside and fogged up instantly. I took my boots off, put the journals on my reading pile and the bills on the staircase to the upstairs. I turned the post card over one more time, shrugged to myself, put it in the kitchen trash and poured myself another cup of hot coffee.

6 Responses to “A Country Doctor Practices Telemedicine”

  1. 1 Greg Billings March 7, 2012 at 7:43 pm

    Your article was a very interesting read, and points to an issue that we commonly receive at the Robert J. Waters Center for Telehealth and e-Health Law (www.ctel.org). The issue of prescribing without a face to face examination or first establishing a physician-patient relationship.

    State medical boards have confirmed your conclusion of the potential difficulty of treating a patient (in your case over the phone) without the benefit of an in person examination.

    We received one phone call from a physician nearly in tears because he was in jeopardy of losing his medical license for prescribing without an in person examination. He, too, may have received a post card, like you, inviting him to practice via telephone with patients he had never met in person. He did his due diligence, talking to the company’s lawyers, and to his own. Given his summons before the state medical board, it appears he may have received the wrong advice.

    In our research, we have found a handful of states that permit an electronic examination to take the place of an in person examination if the standard of care can be met.

    However, for most medical boards we’ve consulted, even that visual exam would not be appropriate to diagnose strep throat. We are not doctors at CTeL, but we consult those who are. We’re told there is only one way to diagnose strep throat, and it isn’t over the phone!

    Telemedicine can provide an excellent opportunity to get care to places where specialties cannot be found. You’ve outlined the practical difficulty of practicing without establishing the proper physician-patient relationship. We at CTeL try to provide the factual research that helps telemedicine programs and providers stay compliant with state laws and regulations. And keep doctors from losing their licenses.

  2. 2 Roger Downey March 7, 2012 at 11:17 pm

    Doctor, certainly telemedicine isn’t everyone’s cup of tea. But primary care telemedicine is simply primary care medicine at a distance. True, you can’t palpate the patient and you can’t smell the patient, but with the examination cameras and other video peripherals available today, a physician can often see the throat, nasal passages, ears and skin issues better via telemedicine than in person. You will find that telemedicine is leading the way in preserving patient images in EMRs via the “cloud.” And I’m sure you’re aware of the opportunity telemedicine provides to link a neurologist or neurosurgeon with a stroke patient in an underserved rural area. Similarly, emergency department physicians in smaller hospitals working late at night or on weekends no longer have to mark time waiting for an Australian radiologist’s report on a head trauma patient. The CT Scan can be in the hands of an urban neurosurgeon in minutes. That consultation can lead to the decision to transfer the patient to a higher level of care. Or, the specialist can tell the ED doc that the patient can be treated in his hospital. In either case, the attending physician can know more, sooner, about his patient. And now the CT Scans, MRIs and x-rays, along with visible light images of a throat, skin or eye, can be viewed by the physician on his iPad or smartphone within minutes of their acquisition. Just say, telemedicine has come along way from a conversation on the phone. Throw the card away, not the concept.

    • 3 Greg Billings March 8, 2012 at 1:01 am

      Roger did an excellent job of describing the benefits of telemedicine. Spoken like an expert in the field! I should have done a better job of making the distinction of diagnosing with the use of the telemedicine technology that he described.

      I would make one observation though with his description of primary care at a distance. Whether by phone or with the cameras and video, many states have the same requirement. A physician-patient relationship must be established before prescribing. The video equipment Roger described for primary care at a distance would work great with established patients.

      However, like a simple telephone examination/consultation, it would do little to satisfy the physician-patient relationship requirement in many states for a first time patient. That is what CTeL has been told by many state medical boards in the research we have conducted and through our direct interactions with the boards.

      • 4 Michael Iaquinta March 14, 2012 at 8:31 pm

        The elephant in the room “Access to care resulting from a shortage of PCP’s”

        Our company is at the heart of this matter and work closely with our medical board to become the measuring stick for those that follow. A physician seeking a tan or having a poolside “parasol” drink would not be welcome to practice telemedicine at any legitimate telemedicine company.

        Furthermore, it is no secret that providers are seeing fewer patients and billing more CPT codes which creates a larger void to offset the financial deficit resulting in seeing fewer patients.

        Our company has perfomed over 200 cases and our findings will be presented to the medical board:

        • Physician telephone consultations have had a significant impact on improving access to healthcare and brought resolution to a number of short term illnesses
        • With virtually every member surveyed, the patient response to this type of service has been overwhelmingly positive
        • With limited access to appropriate healthcare due to the shortage of primary care physicians, telephone consultations have delivered a cost effective alternative to emergency rooms and urgent care centers
        • In lieu of an actual real time physical exam, physicians can effectively and appropriately diagnose, plan treatment and bring resolution to a number of non emergent illnesses through the exchange of up to date health history and specific patient symptoms
        • Convenient access delivers the incentive to patients to learn more about their tell tale symptoms that allow early detection for catastrophic illnesses

        The information gathered over the past 18 months has demonstrated, free of any legal maneuvering or special interest group influence that telephone consultations close the primary healthcare gap. With the availability of information on the internet, patients can now access their health records for the purpose of resolving self diagnosed non-life threatening illnesses. Residents can and currently proactively utilize sites such as WebMD or nurse lines to receive healthcare information that previously did not exist.

        As demonstrated and confirmed by the physicians, the physical exam had no real contribution to the diagnosis or resolution of the non emergent issue. The case/example made by the country physician lacked a number of the protocols that must be present to effectively plan treatment over the phone which may include the prescribing of an over the counter remedy or non narcortic medication.

  3. 5 Arsheeya March 12, 2012 at 12:11 am

    What a great story. I love your descriptions.

  1. 1 Telephone Medicine: Telehealth or Telemedicine? « Center for Telehealth and e-Health Law Trackback on March 12, 2012 at 4:45 pm

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