How telehealth can work best for our patients

Remote diagnosis comes with a caveat

Some primary care practices have found that images of skin lesions submitted by patients (usually by cell phone) suffice for accurate diagnosis in lieu of office visits.⁸ With chronic conditions, home-based remote monitoring of vital signs may assist in diagnosing and managing acute issues. More efficient triage of patients is increasingly possible with the receipt of still images or video files of concerning lesions (eg, burns, rash, chronic wounds) sent from smartphones alone^9,10 or with devices attached to smartphones (eg, parent-managed otoscopes).^11,12

CMS reimburses for video visits at the same rate it does for in-person visits, but telephone-only visits are still limited in coverage.

Family physicians historically have relied on in-person visits for holistic assessment and diagnosis. Telehealth video visits have the potential to assist with this goal, but there are risks. For example, one patient cut her foot while swimming and the wound became infected. In a video telehealth visit with a physician assistant, the patient was prescribed an oral antibiotic for cellulitis. However, redness and swelling of the wound continued to increase. Subsequent messages left by the patient went unheeded, and she then visited her local emergency department where she received intravenous antibiotics.¹³ Another patient, who had cervical neck discomfort, had a video visit with an urgent care clinic. The initial diagnosis was sciatica; however, the pain continued with the addition of chills, sweats, and subjective fever.¹⁴ Physical examination at the hospital and lab tests revealed endocarditis. These case reports show the limitations of video visits.

Specific conditions usually suitable for telehealth evaluation

The pandemic helped us understand that some situations and conditions are better suited than others to coverage by telehealth. The National Ambulatory Medical Care Survey examined 850 million patient–­physician encounters and found that 66% of all ambulatory primary care visits required in-­office care,¹⁵ suggesting that about one-third of patient encounters could be treated via ­telehealth.

As an example, our southeastern Wisconsin urban clinic has about 20,000 office visits per year. We launched telehealth in March 2020 in direct response to the pandemic. Telehealth usage peaked at the beginning of the pandemic (FIGURE), fell gradually, hit a lower peak in November and December as COVID case counts increased, and then decreased again as our community changed from a “quarantine/lockdown” mentality to “opening up/back to new normal.”

Some conditions can be managed favorably with the telehealth format:

Infectious diseases may be treatable remotely.^16,17 Following an initial telehealth visit, the physician can evaluate and recommend further care.

Stable, chronic conditions. Telehealth can be used for stable, chronic conditions such as diabetes, chronic obstructive pulmonary disease, and heart failure when lab or imaging studies are not needed.¹⁸

Mental health. Telehealth can be useful in counseling and providing mental health and social support.¹⁸ Safeguards can be put in place to protect patient privacy in this setting.¹⁹

Behavioral change. Telehealth can be effective in providing support for patients actively trying to quit smoking or lose weight, and for caregivers. A physician who “checks in” can be a positive motivator and can promote a patient’s continued success.²⁰

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