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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.

ANY TIME, ANYWHERE

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.

REMOTE DIAGNOSIS

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.

At the end of the consultation, Rosenthal asks the patient if he has any questions about what has been told him, or if he has any other concerns. “In my opinion, this is a much more comprehensive way of dealing with patients, and the feedback I get is outstanding,” he says.

Rosenthal works on the computer during his phone consultations. Physicians who are not on the computer at the time of the consultation have the option of playing back the phone conversation and entering notes into the record at a later time. He says that the better a note taker a physician is, the more accurate the patient’s information becomes. “Telemedicine requires you to be as good a history taker as you could ever imagine yourself being,” he says, adding that the physician is making a diagnosis predicated on histories without any backup of a physical examination. “In the vast majority of cases in medicine today—whether telemedicine or not—you can actually make a very accurate diagnosis predicated on a history,” he says. “The only thing a physical examination does, is give you the opportunity to confirm accurately what you thought was the case based on the history.”

Nonetheless, if Rosenthal has a sense that he does not have enough information based on the patient’s complaint to make a diagnosis, he will recommend that the patient see a doctor directly. “There are only a couple of percent of people who are opposed to the idea of seeing somebody, despite the fact that it is not medically appropriate for me to do anything more with the patient than advise him that he be seen right away—that day in fact,” he says.

Rosenthal says he deals with two categories of patients generally. One is uninsured, with fears that an office visit will run up a bill astronomically. The other is complacent, who simply doesn’t want to go through the inconvenience of an office visit. Most follow his advice, he says.

ANOTHER AVENUE OF INCOME

Physicians are paid by Consult A Doctor, which sets the fees. “Once you finish, you don’t have to do the billing. It’s an efficient system and it works well,” Rosenthal says.

Rosenthal says there are two tiers of doctors in the telemedicine network: there are those who practice actively; who use the telemedicine network to supplement their practice; and there are those who, like himself, are no longer practicing full time, “but who have the ability, in the home care setting, to take these calls without the sensation of being rushed to be able to do something in addition to the patient’s care.”

Rosenthal believes that telemedicine is a win for patients as well as for physicians—particularly primary care physicians. “Doctors are out there looking for other avenues to supplement what used to be better income than what they are getting now,” he says, adding that the costs of running a practice has risen dramatically, and in many cases doctors are underpaid. “In my case, I’m doing it because I enjoy it. I can still do patient care without being in primary care practice,” he says.


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