May 15, 2009
Virtual Medical Visits Work As Well As Real Ones?
Why take the trouble of going to a doctor's office when a virtual visit will work as well?
BOSTON – Travelers book plane tickets online, bank customers can check their accounts at any computer, and busy families can grocery shop online. Someday, even doctor visits could be among the conveniences offered via the Internet. Researchers considering the feasibility and effectiveness of virtual doctors visits report that , according a study published in the May issue of the Journal of Telemedicine and Telecare.
Of course this won't work for everything. Blood samples and other tests will still need to be done in some visits. But the sample taking could be decoupled from the time of the consultation in some cases. Go to a store front that has a nurse who takes blood, urine, tissue, and other samples. Perhaps stand in front of a machine that takes very high resolution pictures of your retinas, mouth, and other parts. Then video consult with your specialist hundreds or thousands of miles away when the test results come in.
"There is growing evidence that the use of videoconferencing in the medical environment is useful for a variety of acute and chronic issues," says Ronald F. Dixon, MD, an internist at Massachusetts General Hospital and the study's senior author. "Videoconferencing between a provider and patients allows for the evaluation of many issues that may not require an office visit and can be achieved in a shorter time."
We desperately need ways to cut costs. Also, old folks can find it hard to even get to a doctor's office once they become too old to drive. Plus, people in rural areas can find it very hard to find a general practitioner or specialist in driving distance.
The healthcare delivery model in the United States is under scrutiny. Reduced access to providers, rapidly increasing costs and an aging population represent major challenges for the healthcare system. Telemedicine projects, including virtual visits (a patient-physician real-time encounters using videoconferencing technology) are being examined to evaluate their capacity to improve patient access to care and lower healthcare costs.
This study, the largest trial of virtual visits versus face-to-face visits done to date, randomized patients to one of two arms. In the first arm, the patients completed a visit (virtual or face-to-face) with a physician; they then completed a second visit via the other modality with another physician. In the second arm of the study, subjects had both visits face-to-face with two different physicians. All physicians and patients completed evaluation questionnaires after each visit.
Patients found virtual visits similar to face-to-face visits on most measures, including time spent with the physician, ease of interaction and personal aspects of the interaction. Physicians scored virtual visits similar to face-to-face visits on measures including history taking and medication dispensing. Though they were less satisfied on measures of clinical skill and overall satisfaction, those ratings were still in the good to excellent range.
The diagnostic agreement between physicians was 84 percent between face-to-face and virtual visits; it was 80 percent between the two face-to-face visits.
We also need web-based diagnostic expert systems that you can interact with and that can access your full medical history. Get an even better diagnosis than the average doctor can provide.
How is this only now being discussed?
We should have had the ability for years to email a photo to a doctor and talk to them by instant messaging. I read an article recently about a young doctor who has set up a very profitable clinic that is designed around online accessibility in this manner. When they sign up, patients have to come in for a face-to-face visit, which costs extra, but for most patients their healthcare costs are a fraction of what they are with conventional healthcare.
I recently visited 6 different doctors with a basic question and they all gave different responses. I still don't know which answer is best. Medical treatment seems to be significantly not a science.
Clayton Christensen (of "The Innovator's Dilemma") has been arguing medical costs could be greatly reduced by reducing the need for doctors. This is an example of the kind of change that would do that. Increased use of sophisticated diagnostic software (statistics-based expert systems) is another example.
Part of what you describe is already standard practice. I don't get blood tests in my doctor's office, I get them from a lab which has facilities scattered around and does tests for lots and lots of doctors.
My guess is that more doctors would be happy to provide remote diagnostics...if there wasn't an enormous risk of getting sued for getting the wrong answer. Same with the expert systems--who gets sued?
Virtual visits would be a Godsend for many moms like me. Most of the time when we go to the doctor, it's to get a prescription for something already diagnosed, like an antibiotic for the secondary bronchial infections to which my family is prone, or a medication refill for meds we've been on for years. Instead of having to find someone to babysit the other kids (some of whom are inevitably also sick), or haul the whole brood out to the office and try to manage them all in a confined space, it would be great to sit the kid in front of the webcam and say "Hey doc, boy got a cold 2 weeks ago and has been wheezing ever since, inhaler doesn't help. Again. Can we have another round of Zithromax?"
Or if you have an ongoing medical condition, go to the lab and get your tests done, THEN talk to the doctor about the results. None of this "go to the doctor, get the test order, go to the lab, wait a week, go back to the doctor" stuff. You could go to your doctor and say "I think I have problem X" and he could say "Let's start with these lab tests..." and give the order without you having to take time off work.
Wonderful - the problem is that the cost of replacing the physical contact with patients has been seen in the escalating use and subsequent cost in medical imaging studies. Don't have anyone around to touch the patient - scan them instead...and see the big bucks roll. [And then we get to discuss the long term cost of all the radiation exposure cumulative over the life of the patient, or substitute the lesser diagnostic certainty of ultrasound technology with attendant liability issues...].
A certain amount of routine primary care can be done by email - the same subset of care that is or could be done by phone - treatment for routine urinary tract infections, follow up on routine procedures not involving physical inspection of an incision, etc.
Just be careful what you wish for - the law of unintended consequences in king in the field of medicine - [as in economics and government].
I'm sure that insurors and patients will want to provide that same virtual payment they now provide for phone calls with their physician. Why should it cost anything? All the doctor did was talk or send an email.
And the virtual lawyers, on the other hand, will have their meters running full tilt at all times, and nobody questions that.
No way to bill for this service now. As soon as the insurance companies decide to pay for a virtual visit then docs will do it. Right now the a doc can charge (meaning bill insurance) only if there is a face to face visit.
The more I study history, the more astonished I am how damned competent Americans were during World War II (granted, nothing and no one in this world is perfect). One of the umpteen examples is how Uncle Sam dealt with a doctor shortage-- 1. Long term, shifting medical school (and colleges too) to the Navy V-12 schedule. Trimester schedules meant medical school took less than three years to complete. 2. More immediately, the first stage of recruit medical and mental screening was accomplished by standardized tests, allowing the available physicians to focus their scrutiny on the borderline cases. After the war, The Cornell Selectee Index was renamed the Cornell Medical index and did a solid job, in that pre-computer era, of quickly screening large population for health and mental isses. Though the CMI is still used overseas, Cornell hasn't updated it decades and doesn't permit its clinical use in the US.
There are several published clinical studies comparing physical or mental diagnoses-- derived from a patient's answers to the CMI's 195 yes-no questions-- to the diagnoses reached by physician examination. The Cornell Medical Index had approximately the same (80%) accuracy rate as this "virtual medicine" trial. You want a good use of stimulus funding? Throw money at Cornell to update and computerize the CMI and put it online for free.