Once the decision to integrate telemedicine into routine care delivery is made, frontline care teams must begin to deliver telemedicine efficiently, safely, and equitably.
Here is one of the key considerations for frontline teams.
Diagnostic Safety Considerations. Many clinicians may have concerns that with telemedicine, they may make an incorrect diagnosis or miss a clinically important finding leading to an adverse event. Patient follow-up during the COVID-19 pandemic is also variable, and it may be more challenging to obtain recommended labs or other testing needed for a correct diagnosis. Evidence has shown that telemedicine has similar diagnostic accuracy as in-person visits for common conditions, though if uncertainties or red flags arise, appropriate triage and referral to in-person care is important.
- Agency for Healthcare Research and Quality: Telediagnosis for Acute Care — This PDF issue brief, released in August 2020, discusses implications of telemedicine on the quality and safety of diagnosis.
- Telemedicine Journal and e-Health: How Accurate Are First Visit Diagnoses Using Synchronous Video Visits with Physicians? — This article about telediagnosis compares the diagnostic precision in telemedicine encounters and in-person encounters. The authors find that telemedicine diagnostic accuracy has high correlation with in-person diagnoses.
- International Journal of Emergency Medicine: Telemedicine in Pre-Hospital Care: A Review of Telemedicine Applications in the Pre-Hospital Environment — This review article looks at telemedicine use in emergency medical or pre-hospital care settings. The authors find that telemedicine improves the timeliness of stroke and myocardial infarction diagnosis and treatment.
Clinical Assessment. The following are some suggestions and strategies for providers to ensure you are assessing and diagnosing conditions as safely as possible via telemedicine services and continuing to provide patient-centered care. Reviewing best practices prior to your first telemedicine visit is an important starting place.
A telephone or video encounter enables clinicians to gather the same SUBJECTIVE information as an in-person encounter (history of present illness, past medical history, etc). In fact, the medication reconciliation may be more accurate as the patient can review their pill bottles at home. For OBJECTIVE information, a patient may be able to check their own temperature, blood pressure, and pulse if they have home equipment, and can often palpate areas of the body or test range of motion with your instruction. With this information, be systematic in formulating a differential diagnosis and recognize that a remote context means your differential may be broader — avoid “premature closure,” meaning narrowing or finalizing a diagnosis too early.
- National Telehealth Technology Assessment Resource Center: Video Platforms: Clinical Considerations — This webpage has information and a video outlining clinical considerations to keep in mind when using video platforms. They advise, “When a clinical provider is presented a patient.., we inherently consider the information that we have been able to collect and the differential diagnosis of possible conditions….In the setting where the interaction is limited by video, audio, or a textual presentation, it simply means that we are unable to remove some items off the differential when compared to those we may have comfortably removed when seeing the patient in person, or a different setting.”
- Mid-Atlantic Telehealth Resource Center: Telehealth Resources for COVID-19 — Within the “Best Practices for Conducting a Telehealth Visit” section of this webpage, there are resources on “Clinical Assessment and the Physical Exam,” including a series of videos on conducting physical exams via telemedicine. In addition, the “Other Useful Implementation Resources for Clinicians and Practices” (also within “Best Practices for Conducting a Telehealth Visit”) has links to specialty-specific resources on clinical considerations for providing care via telemedicine.