As Telemedicine Best Practices Emerge, Assess Your Practice
David L. Feldman, MD, MBA, FACS, Chief Medical Officer, The Doctors Company and TDC Group; Senior Vice President, Healthcare Risk Advisors
Many specialties, facing the pandemic’s imperative to improvise, formed discussion groups, which are now disseminating their findings via peer-reviewed medical journals or formulating best practices with their medical professional societies. With 2020’s spike in telemedicine visits followed by 2021’s continued record-breaking increases,1 we now know a surprising amount about how to safely provide telemedicine care.
Specialty Example: Obstetrics
Obstetricians monitor risk indicators like blood pressure and blood glucose, which help them intervene early in cases of preeclampsia and/or gestational diabetes. With the increasing availability of at-home monitors for blood pressure and blood glucose, the option to collect at-home metrics (which, admittedly, some patients do more reliably than others) shows how remote care can sometimes be safer and/or more accessible care.
Specialty Example: Otolaryngology
As in obstetrics, the physical exam needs of otolaryngology might seem impervious to many telemedicine advancements. Yet the author of a 2020 JAMA article argued to his colleagues, “We must rediscover the nuances of palpation and noninvasive inspection. Substantial portions of this examination can be completed without instrumentation or prior experience.” The person without prior experience is the patient: “The clinician can provide instructions to the patient for sequential elements of the examination and then verify correct performance of each maneuver.”2
Specialty Example: Surgery
Surgical specialties present an unexpected number of opportunities for remote care, from consultative conversations all the way through postoperative evaluations. For instance, many post-op evaluations can relocate to the telemedicine space, where questions like how the wound looks and drain output can be evaluated.
Such uses of telemedicine, when appropriate, improve the patient experience, and sometimes patient safety. If we use good clinical judgment, we can offer a version of the post-op house call to some patients with arguably comparable or improved patient safety.
Reducing Medical Malpractice Risks
We still see few medical malpractice lawsuits related to telemedicine, but those we do see mostly connect to diagnostic errors.3 Even with workarounds and patient-assisted maneuvers, sometimes we need to lay hands on the patient. Moreover, since diagnostic errors often derive from communication gaps, we must remain mindful of the ways in which telemedicine amplifies communication challenges.3
Telemedicine for Patient-Centered Care
Gadgets are one of the many aspects of telemedicine that raise questions about patient access to care. Patient safety researchers extol the virtues of programs that reduce device costs for patients in need, and they also promote reimbursement for providers who offer the substantial technology education and orientation some patients need to function as activated patients within the telemedicine landscape.3 Integrating translation services into virtual visits will also have an impact.
- Teladoc Health. 2021 Telehealth benchmark survey results and report.Published 2022. https://www.teladochealth.com/resources/white-paper/HHS/2021-telehealth-benchmark-survey-results/
- McCoul ED. Grasping what we cannot touch: examining the telemedicine patient. JAMA Otolaryngol Head Neck Surg. Published June 18, 2020. https://jamanetwork.com/journals/jamaotolaryngology/article-abstract/2767512
- Khoong EC, Sharma AE, Gupta K, Adler-Milstein J, Sarkar U. The abrupt expansion of ambulatory telemedicine: implications for patient safety. J Gen Intern Med. Published January 19, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8768444/