Recently, Dr. Andrew Schmitt wrote about how careful and ethical implementation of telemedicine can provide a solution to the “Iron Triangle” of Access, Quality, and Cost in healthcare. While remote physicians can increase access to care at lower cost, providing quality services remotely presents more of a challenge.
Central to the provision of telemedicine is the tenet that remote physicians utilizing telemedicine equipment must be able to provide at least the same services during an encounter that they would provide in person. Indeed, in many states this is enshrined in state healthcare law.
One essential component of individual patient encounters where telemedicine providers must strive for parity with their traditional counterparts is the physical examination. Recently, a patient under my care via Beam telemedicine presented a new physical examination finding which highlighted the importance of continued vigilance during the examination, the cutting-edge capabilities of telemedicine equipment, and perhaps most critically, effective communication between care team members.
I was consulted to care for Ms. Barker (not her real name) via telemedicine. Ms. Barker developed sudden abdominal pain and was found in the emergency room to have diverticulitis, or infection of her large intestine that did not require surgery. While examining Ms. Barker, I was able to identify a new heart murmur using the remote stethoscope. The emergency room nurse that was helping me perform the physical examination also reported to me that the patient had cool and clammy skin on her arms and legs. These two findings did not tally with what was already known about the patient, and I expressed my concerns about the new murmur to the daytime hospitalist, who confirmed the murmur. His workup ultimately uncovered a serious heart condition known as hypertrophic cardiomyopathy. Knowing about the hypertrophic cardiomyopathy helped the daytime physician choose correct medications to manage her unstable blood pressures while she was battling the colon infection and sepsis. Ms. Barker was eventually transferred out of the ICU and discharged home in good condition.
This case highlights three facets of a high quality telemedicine encounter: vigilance on the part of the admitting physician, high quality equipment that enables a realistic physical examination, and process-driven teamwork that is the standard of care at Beam Healthcare.
Unexpected new heart murmurs like Ms. Barker’s are not uncommon and can frequently be overlooked or ignored. Identifying her cardiac condition required a key observation from the onsite nurse that Ms. Barker’s arms and legs were cool. This is another finding which could be overlooked by itself, but when combined with a new and unexplained heart murmur causes concern for a significant heart problem.
Many of us physicians have a tendency to perform the routines of physical examination without careful attention to possible findings. This is multifactorial, but may be accentuated during remote encounters. Continued vigilance to exam findings is essential during both remote and in-person encounters. Finally, this patient’s care could have been compromised without conscientious handoff between the remote nocturnal physician and the in-person day physician. As in any patient care handoff, telemedicine providers must continue to relay patient information in a concise, detailed manner.
This patient’s diagnosis was facilitated by Beam Healthcare’s standardized approach to telemedicine processes. Beam physicians are trained with learning modules and patient mock-ups to use a checklist based approach for all patient encounters. This helps ensure that Beam physicians are able to use cutting edge technology to maximum potential, providing immediate access to excellent high quality care at a reduced cost. Ms. Barker’s case demonstrates that remote physicians can provide high quality care using telemedicine equipment, and that the physical examination remains effective when physicians employ vigilance, trust in their findings, and good communication skills.