We spend a lot of time at Spruce thinking about which patient presentations work best for telemedicine. Though telemedicine is new and can seem foreign, it’s really just another practice setting in a long list of possible places to see patients: the office, an inpatient ward, the emergency department, a house call or urgent care center, etc. As with any practice setting, certain types of information and interventions are available, and others aren’t, and this fundamentally determines what types of patients you can see safely and effectively. Once you realize that you can adopt telemedicine without being obligated to use it for every patient in your practice, it’s much easier to get excited about just how many patients you actually can help from afar without sacrificing any quality. To whet your appetite, let’s take a look at five of the best types of telemedicine patients and how you can successfully assess and treat them.
This one makes a lot of sense, but it’s all about picking the right patient population. Your sense of pre-test probabilities guides your workup in person, and telemedicine shouldn’t be any different: anticoagulated 80-year-olds with head injuries usually get a CT scan, but healthy 20-year-olds generally don’t. With potential urinary tract infections, the specific subpopulation of otherwise-healthy young women is often a perfect fit for management via telemedicine, and there are both research studies and society guidelines to support you in this.
“Two recent studies have shown that some women who self-diagnose a UTI may be treated safely with telephone management. Women who have had acute uncomplicated cystitis previously are usually accurate in determining when they are having another episode.”
“It is a common practice among primary care physicians to empirically treat women with symptoms of a lower UTI without performing laboratory analyses. […] Women with frequent recurrences and prior confirmation by diagnostic tests who are aware of their symptoms may be empirically treated without recurrent testing for pyuria.“
A good history from a reliable patient will also help you exclude pyelonephritis, sexually-transmitted infections, and other differential diagnoses, setting you up for a high degree of diagnostic accuracy before any physical exam or laboratory testing is even considered.
With patients who are savvy and well-known to you, you may not need a physical exam at all. For others, an assessment of general appearance, a temperature, and a heart rate are typically easy to gather without any unusual equipment, and these can further your case against dangerous pathology being present. You likely won’t be able to elicit a reliable exam of abdominal or costovertebral angle tenderness, though, so make sure to spend extra time with the history to establish that these would be unlikely in your patient. Additionally, urinalysis, while not always necessary, is certainly possible to obtain in most telemedicine environments, so don’t be afraid to order it and send your patient to the lab when you would do the same thing in person.
When you deliver your assessment and plan, make sure to give your patient careful “return” precautions, such as fever, vomiting, or back pain, and encourage her to get a hold of you quickly if these emerge. Also make a note to follow up with her in a few days to ensure symptom resolution. Diligent adherence to these practices is important for in-person medicine, and it is equally essential for telemedicine; the sooner you can verify the correctness (or incorrectness) of an empiric management choice, the better.
2) Birth Control
Hormonal birth control is common and generally safe, and telemedicine can be used very effectively to make sure that a particular female patient will be a good candidate for it. Most importantly, the CDC publishes a guideline, “US Medical Eligibility Criteria for Contraceptive Use,” with extremely specific recommendations for birth control prescribing choices, and these are endorsed by many professional organizations, including AAFP and ACOG.3 This guideline is the source of the typical birth control questions we’re all familiar with (“Are you younger than 35? Do you smoke? Do you have migraines with aura?”), but it goes far deeper than the abbreviated subset that most physicians can recall offhand. Did you know, for example, that combined hormonal contraceptives are generally not recommended (category 3) for a woman with symptomatic gallbladder disease? Maybe so, but did you also know that the same woman will still only be category 2 after a cholecystectomy? A telemedicine platform that helps you remember exactly what questions to ask for every woman, every time, will help you avoid medical errors and may even elevate the standard of your practice above typical in-person visits.
As for the physical exam, the CDC weighs in on this as well, and all you need to know is a blood pressure:4
“Among healthy women, few examinations or tests are needed before initiation of combined hormonal contraceptives. Blood pressure should be measured before initiation of combined hormonal contraceptives. Baseline weight and BMI measurements might be useful for monitoring combined hormonal contraceptive users over time. Women with known medical problems or other special conditions might need additional examinations or tests before being determined to be appropriate candidates for a particular method of contraception.“
This blood pressure reading can be obtained via the free machines that are found in almost any drugstore; simply have your patient use one and report the reading to you. Other organizations agree, and AAFP has even gone so far as to make this a policy point in their Choosing Wisely recommendations:5
“Hormonal contraceptives are safe, effective and well-tolerated for most women. Data do not support the necessity of performing a pelvic or breast examination to prescribe oral contraceptive medications. Hormonal contraception can be safely provided on the basis of medical history and blood pressure measurement.“
3) Rashes (of course!)
Dermatology as a field has been way ahead on telemedicine, and it makes a ton of sense: a good history and a solid set of images for visual diagnosis can go a long way toward appropriate dermatologic assessment. At Spruce, we’ve had several years of experience with this, and our results agree with the general consensus in the field that teledermatology can be safe and effective. With that said, there are several keys to practicing at your best with teledermatology:
- Don’t neglect the history. The time course of a rash, the patient’s recent international travel, the presence of other illness symptoms (fever! malaise!); all of these and more are critical to dermatologic assessment, so make sure you don’t shortchange them. Don’t be tempted to anchor on the physical exam too early.
- Respect the limits of the teledermatologic physical exam. First of all, make sure that the pictures or video images that you’re getting are diagnostic. If they’re blurry, poorly lit, or low resolution, then get different ones or ask the patient to be seen in person. Second, always remember the aspects of the dermatologic exam that are not purely visual. It might be difficult to properly assess for findings like texture, tenderness, warmth, sloughing, pitting, or blanching, so always keep in mind what you might be missing by not having this information.
- Don’t forget about dermoscopy and biopsy. These are vital and common tests for most dermatologists for good reason. Be wary of settling on (or excluding) diagnoses that are best evaluated with either or both of these tools.
If you are going to manage dermatology cases via telemedicine, it makes sense to read through the AAD’s position statement on telemedicine first.6
Headache as a complaint can conjure images of meningitis, subarachnoid hemorrhage (SAH), and other scary entities, but bear with us here. The majority of headaches are benign primary headaches like migraines, and huge numbers of patients would be well served to have theirs managed via telemedicine.
As with all complaints, history is hugely important, and the right story can make virtually any type of significant pathology very unlikely. This fact is exploited in and proven by the modern proliferation of validated clinical decision rules, including the recent Ottawa SAH rule.7 Using only historical elements and one telemedicine-friendly physical exam maneuver (neck flexion), this tool can effectively exclude SAH from the list of likely differential diagnoses for many patients with headache. While there isn’t yet a rule to exclude every type of secondary headache, the fact remains that headache is a complaint that is particularly amenable to exploration via a good history, which can be accomplished easily in a telemedicine encounter. The International Classification of Headache Disorders is a valuable resource in this pursuit, as it provides very detailed criteria for diagnosing nearly any type of headache.8
The physical exam for headache patients can also be quite robust via telemedicine. Cranial nerves, motor testing, coordination maneuvers, and gait can all be assessed well remotely, and even aspects of the sensory exam can be performed by reliable patients. Reflexes may be a bridge too far for most telemedicine situations, but these are arguably dispensable in the neurologic examination of a typical headache patient. Additionally, teleneurologic examination is supported by the AAN, especially for telestroke applications, and there are many studies validating such programs.9 If you can obtain a low-risk history and complete, benign physical exam for a headache patient, there is no reason they can’t be managed well via telemedicine.
5) Minor Injuries
Raise your hand if you’ve had a friend or family member text you a picture of a cut they recently sustained or a concerned story about their toddler who just hit his head on something. Okay, so that’s all of us. But it makes sense: telemedicine can be great for injury triage and even sometimes for definitive care. Your friend who cut her hand while making dinner? You probably told her to wash it out well under running water, to hold direct pressure until the bleeding stopped, and if it didn’t look like it needed stitches, to dress it, maybe with a little antibiotic ointment or some butterfly closures underneath. You also probably had her go through some maneuvers to make sure she hadn’t hit a tendon or other important structure, and you likely asked about the timing of her last tetanus vaccine update. If all of this checked out, you saved her a trip to urgent care and rightfully so, since those are the exact things that would have been done there, too.
The truth is that complete advice or, at least, good first aid for many injuries can be directed via telemedicine. As discussed above, most key aspects of the neurologic exam can be performed remotely, and much of the musculoskeletal exam, including active and passive range of motion, is also very feasible. A true appreciation of certain findings, such as tenderness, is likely not possible, but whether these are necessary depends on the pre-test probability established by factors such as mechanism of injury, patient demographics, and existing medical history (e.g., osteoporosis). In many patients, for example, a video of them walking easily on their just-twisted ankle will likely be enough for you to say that they don’t need the emergency department and can wait instead for an office visit the next day (or not at all). Telemedicine has an obvious and valuable role in most injuries that are not emergent trauma, and you’ve likely already been using it for this purpose, even if you didn’t think of it that way.
- Colgan, R. & Williams, M. Diagnosis and treatment of acute uncomplicated cystitis. Am. Fam. Physician 84, 771–776 (2011).
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 91: Treatment of urinary tract infections in nonpregnant women. Obstet. Gynecol. 111, 785–794 (2008).
- Centers for Disease Control and Prevention (CDC). US Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR 59, 1–86 (2010).
- Centers for Disease Control and Prevention (CDC). US selected practice recommendations for contraceptive use, 2013. MMWR 62, (2013).
- American Academy of Family Physicians (AAFP). American Academy of Family Physicians | Choosing Wisely. Choosing Wisely (2013).
- American Academy of Dermatology. AAD Position Statement on Telemedicine (2015 version). (American Academy of Dermatology, 2015).
- Perry, J. J. et al. Clinical decision rules to rule out subarachnoid hemorrhage for acute headache. JAMA 310, 1248–1255 (2013).
- Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia 33, 629–808 (2013).
- Wechsler, L. R. et al. Teleneurology applications: Report of the Telemedicine Work Group of the American Academy of Neurology. Neurology 80, 670–676 (2013).