Can This Problem be Handled Virtually or Should the Patient be Seen in Person?

The COVID-19 pandemic fueled an unprecedented surge in the use of telehealth visits. It is estimated that 200 million telehealth visits will be conducted by the end of 2020¹. 

Telehealth visits are not a new concept. It is remarkable to learn that an article published in 1879 in the Lancet talked about using the telephone to reduce unnecessary office visits, video calls were imagined and proposed in 1925².  Adoption of virtual visits was slow and very gradual until the last three months when the global viral pandemic caused a dramatic decrease of in-person doctor office visits.  Many practices across multiple specialties quickly adopted new telehealth technology and shifted, almost overnight, 30% to 50% of their total visits to telehealth visits.   

Practices have grappled with creating guidelines that help clinical teams determine whether a patient’s needs are best met with a virtual visit, or if their clinical circumstances require an in-person visit. This is a novel task that is still actively being refined. Creating clear criteria to decide the best course of action enhances the ability of non-clinical team members performing telephonic triage and scheduling tasks to make sound decisions that allow patients seamless interactions with the practice. Once these guidelines are created, they can be communicated to patients in a consistent and clear way.

There are clinical settings in which virtual care is appropriate and highly effective:

• Screening for highly contagious illness such as COVID-19 to determine whether the patient needs to be seen in an emergency room or referred to a “sick building” or practice if deemed high risk

• Follow up on stable chronic conditions where home measurements such as blood glucose levels or blood pressure readings are available

• Wellness visits like those recommended by Medicare which require evaluation and review of current health issues and preventative recommendations, but do not require physical examination or testing

• Behavioral health services lend themselves extremely well to virtual care

• Uncomplicated postoperative care

• Screening to determine the urgency of suspicious dermatological lesions or follow up on healing of chronic skin lesions like leg ulcers

• Medication review and renewal visits

• Laboratory test review and discussion

• Care management visits, patient education sessions

• Patients in areas with specialty care shortages (rural areas and underserved urban areas) can gain significantly from virtual visits.  If necessary, these can be collaborative visits with a local primary care physician providing the details of the physical exam

There are also several criteria to help ascertain which patient issues require an in-person appointment:  

• Patients where there is significant diagnostic uncertainty, or patients with monitoring needs who require a detailed physical exam are better served in a face-to-face visit

• Patients that require either diagnostic or therapeutic procedures who cannot have these needs met virtually  

• Patients that require conversations that are so highly sensitive that they are only possible in person. Examples would be end of life conversations or the delivery of bad news, which invariably require the kind of human connection and intimacy that are not possible virtually

• Patients who have unsafe home environments should be seen in person to allow the necessary conversation to occur in the privacy and safety of the office  

Patient preference remains a central driver of the decision to pursue an in-person visit, as some patients might struggle with technological challenges, others may have hearing loss that makes participating in a remote visit difficult. Some patients just prefer in person visits since they have always done so. 

Many gray areas remain, therefore more research and evidence will need to be evaluated in order to determine the best approach in some cases. Practices are rapidly gaining a great deal of experience with virtual visits and have already developed unique guidelines required to triage patients to ensure that those who need to be seen in person will be encouraged to come in to the office, and patients who can safely benefit from the convenience of a virtual visit will do so.   

¹https://www.beckershospitalreview.com/telehealth/telehealth-may-see-big-long-term-gains-due-to-covid-19-10-observations.html

²https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1081896/pdf/medhist00108-0074.pdf