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Telemedicine: What effect on the Physician-Patient Relationship?

June 8, 2012
by John DeGaspari
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A primary care physician provides his view on remote consultations

Electronic communication is certainly changing the way physicians and patients interact, and if there is a single area where its impact is most evident, it is in telemedicine. This is worth paying attention to: in a report released last month, WinterGreen Research, Inc., a market research firm based in Lexington, Mass., forecast that the market for telemedicine devices and software will increase from $736 million in 2011 to $2.5 billion in 2018, implying a wide reach that will encompass a growing number of physicians and patients.

The question is what affect telemedicine will have on the quality of care and the relationship between physicians and patients. Alan Rosenthal, M.D., a board-certified internist who practices in Monterey, Calif., provides his perspective as a primary care physician.  Rosenthal has been a network physician for Consult A Doctor, Inc., a telemedicine provider in Miami Beach, Fla., for three years. He has been a physician for 35 years, and is no longer in full practice (although he still sees a limited number of patients). Mostly, though, he divides his time between providing telemedicine consultations for Consult A Doctor and doing utilization reviews for hospital systems.

In his opinion, telemedicine is advantageous to patients, providing them with quick access to physicians, as well as potential cost savings for their employers that are paying for coverage. Health problems are addressed quickly and efficiently, he says, comparing the telemedicine service to concierge medicine. “It offers the benefits of concierge medicine at a fraction of the cost,” he says.

For Rosenthal, the transition to telemedicine was relatively easy. The only thing that takes time is learning how to use telemedicine based on the software they use, and training on it,” he says. Physicians are trained as they practice with the system online. After training, “it takes a couple of times before you feel comfortable with what you are doing and how to do it,” he says.


Most of his patients who use telemedicine are based in the U.S., although the service is also available to patients who are on international travel, Rosenthal says. Patient consultations fall into three categories, depending on the patient’s preference and needs. To request a consultation, patients phone a toll-free number to a call center in Michigan and tell the operator the state where they are located, the type of consultation they want, whether a priority consultation for an immediate medical problem or an informational consultation. The operator accesses the patient’s medical record, which will be available to the physician though the company’s software.

When the patient hangs up from the call center, the operator sends out the call to the physician with a request he contact the patient. Typically, it takes roughly an hour to contact a patient, Rosenthal says. Communication with the patient can be via phone or email. Once contact is made, Rosenthal accesses the patient’s medical history through a secure website. The medical record from the telemedicine provider is equivalent to a medical record that would be pulled up from a physician’s office or a hospital, he says. On the screen is the patient’s chief complaint, a history of the present illness, and past medical history that was provided by the patient when he or she signed up for the service.

Based on that information, Rosenthal makes a diagnosis, or if a diagnosis is not possible, an assessment of the case, and enters it into the record. Following that, Rosenthal enters into a live discussion with the patient regarding the condition, treatment, and what the patient needs to know to handle the problem.

Rosenthal says that consultations fall into three categories. In the first tier, the physician responds to the patient’s questions via email; the second tier is an on-call brief consultation, where the patient is connected with the physician in less than 5 minutes, where the patient seeks immediate answers to general medical questions; he third tier is priority consultations, which comprise most of the longer consultations, ranging from 5 or 10 minutes to 30 minutes, Rosenthal says.


Typical complaints are upper respiratory infections, but Rosenthal adds that his mix of consultations also includes sexually transmitted diseases and injuries such as muscle sprains. Consultations for garden upper respiratory infections take a considerable amount of time, he says. “We explain everything [the patient] needs to do for themselves, and what over-the-counter treatment they would need. If there is an indication of an upper respiratory bacterial infection, we could make a decision, based on the timeframe of the symptoms, whether an antibiotic would be necessary,” he says.

If a prescription is warranted, Rosenthal verifies the name of the local pharmacy with the patient. He makes the prescription via an e-prescribing system (RxNT, Annapolis, Md.). He notes that the e-prescribing system also provides information about allergies and potential drug interactions. “This is a system that has a fail-safe capability of preventing medical errors in prescribing,” he says. He adds that the combination of the e-prescribing system and the patient’s medical record provides an extra level of verification that what the patient is telling the physician about his medication history is accurate.

“The medical history is set up in such a way, that while you are talking to the patient, you can pull it up simultaneously to see if what they are saying comports with what they have said before in their history, so you don’t miss something along the lines of complaints that may be associated or unassociated with the background of their medical problems,” he says.