As we enter an era of massive technological changes to the healthcare platform, we have to wonder what other changes are in store for us. We’ve already experienced a substantial change in our healthcare coverage with government-subsidized insurance. Consequently, and as a result of these changes, some physicians have had to restructure the way they treat and interact with patients.
Some call it “inventing the future of healthcare.” Physicians have opted to have virtual office visits instead of face-to-face interaction. Some say this integration cuts back on the overall cost of running a medical office, having to obtain malpractice insurance, and providing employees with benefits. Also, by reducing the time they spend with each patient, they are able to see more patients and ultimately increase revenue. Others agree that being able to see your doctor from the comfort of your own home is very convenient.
But we have to ask, is it really convenient and safe to see one’s physician through a video camera? Because ultimately, it boils down to safety, doesn’t it?
A recent ABC News article reported that virtual consultations with a doctor for minor ailments are more convenient and can be cheaper than an office or emergency room visit.1 It has become an affordable alternative to an emergency room for non-emergent care. The cost for a virtual visit can be less than $50 per visit. Therefore, it’s no surprise that the subsidized healthcare system is pushing for these types of office visits. Even some of the diagnostic tools and technology, which were created to enhance our doctor-patient experience, are being used to minimize doctor-patient contact. Examples of these are remote cardiac monitoring, telemetry blood pressure monitoring, remote glucose and INR/coumadin machines — even the electronic monitoring of vital signs are now being sent via email. We are left with less office visits, less face-to-face assessment, and less in-office time with your doctor. Are patients ready for this type of medical management?
The Fading Out of Face-to-Face Assessment
When did we lose the face-to-face assessment and patient contact with our doctors? As a child, I suffered from sinus infections and was often placed on antibiotics; because of this, I had to have frequent blood draws to check for anemia. Being a kid, I was already distrustful of doctors and did not trust anyone with a needle. My pediatrician was amazing; he took his time with me and made me feel at ease. He made my visit very personable, and he was the reason I lost my fear of going to the doctor.
Nowadays, office visit intervals are getting shorter and insurance companies keep denying the need for frequent office visits. As a result of government-subsidized healthcare, the need for quantity vs quality is becoming the set modality. Physicians are being held accountable for reducing in-office visit times, in order to make way for more patients. One reason for these changes is Medicare reimbursement. Physician reimbursement for their services has been cut by 5.9 percent a year (totaling a 16.7 percent cut in income), followed by a seven-year freeze at the reduced levels.
What happened to quality of care? How accurately can you access a complicated patient in 10 minutes or less? (Not to mention, some of this time is already being taken by a nurse getting vitals and medical history.) I was taught in paramedic school the importance of the head-to-toe assessment. The amount of information that can be missed by not properly assessing your patient is great. For example, your patient tells you he or she is running a fever; without patient contact, how can you assess this vital sign? Your assessment of this patient may fall short and could be inaccurate based on the little information you have. The relationship between clinician and patient in the clinical setting is a fundamental aspect of the healthcare system. Previous studies have indicated that there is a lack of high-quality research and evaluation regarding consultation dynamics.
One metric of assessing the quality of the clinician-patient relationship is patient satisfaction. We are being reimbursed by Medicare based on patient satisfaction. A patient’s satisfaction is closely related to the clinician-patient relationship, the quality of healthcare, and adherence to medical treatment. While many dimensions may contribute to patient satisfaction (e.g., waiting time, hospital location, care delivery, and communication skills), the quality of communication with clinicians can influence patient perceptions of their clinicians and the quality of care they are receiving. One report has suggested that 85% of patients changed or were considering changing their physician due to poor communication skills. Touch is another nonverbal interaction that is important for the development of empathy and might be fading out in the future of virtual assessments.
The Era of Remote Monitoring Devices
A study done by the Pennsylvania Patient Safety Advisory found that most patients in noncritical settings may have underlying cardiac conditions or demonstrate unexpected symptoms and condition changes that require continuous or physiological cardiac monitoring.2 Therefore, many facilities implement remote cardiac monitoring to facilitate alarm notification. Remote cardiac monitoring of patients in noncritical care areas alerts healthcare providers about patient condition changes, which may avoid further deterioration of patient conditions and potential cardiac arrests. However, remote cardiac monitoring alone does not ensure patient condition changes are successfully communicated to appropriate healthcare providers. Seventy-four percent of the 194 Incidents and Serious Events reported to the Pennsylvania Patient Safety Authority from June 2004 to December 2008 were associated with remote cardiac monitoring; most of these issues were due to communication or monitoring problems. Monitoring problems include the failure to monitor, the unavailability of monitors, or delay in monitoring. Healthcare providers may consider incorporating risk reduction strategies that include more effective communication between care areas, delineation of personnel responsibility, and standard protocols for alarm conditions.
I have been an advocate of remote monitoring systems since we piloted this type of program at our facility back in 2006. While implementing these patient health monitoring systems, we recognized that it came with great responsibility. We took measures to make sure that patient safety would be our number one priority. One of these priorities was to have the staffing adequate enough to handle the demand that it takes to run a cardiac monitoring system. It seems that lack of resources has been the demise for some of these remote care clinics.
Web-based ECG monitoring is also on the rise. AliveCor has an app (www.alivecor.com/home) that lets you take a real-time ECG, which you’re able to send to your physician in a matter of seconds. The company uses an Apple or Android phone device to read your electrical impulses by placing your fingers on two metal plates at the back of the phone case. The 10-second EKG is transferred into a PDF file that can be sent via email to your doctor.
Virtual Patient Care
Virtual patient care programs that have been integrated into doctors’ office visits throughout the U.S. have brought a new era of patient care. At the Cleveland Clinic Foundation, patients can interact virtually with some of our doctors either by web or email. We have also established Q&A sessions in which patients can ask our doctors a series of health-related questions, while a live physician is answering them at the other end. They can also follow-up after medical advice has been given. This program helps a lot of patients that have ambulatory conditions to be able to get some answers from a certified professional in that particular field, instead of getting their questions “answered” inaccurately by Wikipedia or Google.
Several new companies have made a living by doing virtual doctor integration. One of these companies is MeMD.com. The company is strictly web-based, and they treat a number of ailments. This can be a very convenient and inexpensive way to be seen by a doctor, especially if the patient has no means of transportation, is wheelchair bound, or has problems with mobility. Patients can receive treatment for $49.95 per consult. Some of these services can come in handy for patients who don’t want to leave their home because of PTSD; patients with a new baby who are being treated for post-partum depression; and patients who are in jail, including patients who could present a risk of harm to their psychiatrist.
We must recognize that virtual patient care does have its advantages and conveniences. However, it is not without its limitations. Will the future of patient care be web based? Only time will tell.
Disclosure: The author has no conflicts of interest to report regarding the content herein.
- Save Money, Time by Bringing the Doctor to You With Telemedicine. ABC News. Published May 19, 2014. Available online at http://abcnews.go.com/blogs/health/2014/05/19/save-money-time-by-bringing-the-doctor-to-you-with-telemedicine/. Accessed February 9, 2016.
- Connecting Remote Cardiac Monitoring Issues with Care Areas. Pennsylvania Patient Safety Advisory. Published September 2009. Volume 6, Number 3, Pages 79-83. Available online at http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Sep6%283%29/Documents/sep;6%283%29.pdf. Accessed February 9, 2016.