Medscape... A common lament regarding our online-connected lives is the loss of interpersonal connectivity. Ironically, online connections through e-visits are now becoming more prevalent as the avenue through which to communicate one's most personal of all types of information, healthcare. Is the trend for virtual physician visits a savior for primary care physicians or another nail in the coffin of the noncorporate practice of medicine? One may argue that the question is moot, as the number of primary care private practices continues its incessant decline. However, while virtual visits can be made to work as a lifeline for these practices, the juggling of the time, the expense, and the requirements of the technology have, heretofore, made these services difficult for most small or solo practices to provide on their own.
More recent advances in connectivity, mobile camera resolution, and other relevant developments are leading to a sea change in the ease of adopting these methods of linking up. The issues of liability coverage, HIPAA compliance, and other regulatory and licensing concerns are being more fully vetted, removing other obstacles and creating opportunities for physician participation.
Unfortunately, many of these services are being provided by for-profit hospital systems, insurance companies, or other entities whose own financial motives do not place the necessary degree of emphasis on maintaining an appropriately healthy, robust physician-patient bond.
Is After-Hours Follow-up Problematic?
There has been a quantum shift among the population of American patients in the past 10 years. Even private practices that continue to offer continuous telephone availability from an on-call physician have seen the dissolution of on-call/after hours patient telephone call volumes. Gregory A. Hood, MD
Society seems to have made a collective assumption that once the day's office hours have ended, the physician is no longer available. The famed impatience of Americans may be another contributor, wanting an answer "now" instead of being seen the next day for nonurgent matters, for example. (However rare, 2 AM patient phone calls about nonurgent, routine medication refills do still happen.)
Alternatively, some patients have concluded that it will be more respectful of the physician's time, and of equivalent appropriateness-of-care, to take a visit with a physician or nonphysician provider who is not affiliated with the medical home.
There is a reason that continuity of care with one's personal physician has long been one of the sacred pillars of healthcare. For patients who are medically uncomplicated, these services may work out perfectly fine. However, with great regularity, I see patients of mine in follow-up, only to find that the decisions that were made in an after-hours setting would have qualified as medical errors had they been made with concurrent knowledge of the patient's history. (Typically, these "follow-up" appointments were not arranged by the initial treating physician.) These examples, combined with other examples of unnecessary care/testing/prescribing, are the sources of significant waste and inefficiency in today's healthcare world. They also increase the rates of antibiotic resistance, drug interactions, and other lamentable outcomes. Doctors Can't Survive on Complex Cases Only
Some proponents boast that virtual visits will save the US healthcare system billions of dollars and relieve "pressure" on primary care practices, but their estimates do not tell the full story. The "quick and easy" visits that are most often cited as appropriate for these services are the financial lubrication by which primary care practices survive. Accepting the diversion of this medical care away from the primary care office of record is the same thinking that led to the "Walmartization" of small-town America.
The engine of a small, personalized primary care office cannot continue to run if only fed the complex, time-consuming cases. Similarly, diverting the revenues from visits, including e-visits, from the patient's medical home will only accelerate primary care's decline.
The evaluation of health and illness is very complex. This is precisely why the purveyors of virtual visits provided independent of the patient's primary care home reiterate that they only want "the best of the best" providing their visits. If the nation expects brick-and-mortar physician offices to "be there" when care is needed, then depriving the practice of its lifeblood, or altering the chemistry of what is infused into the practice, should be minimized, not promoted.
Are the Reported Savings Inflated?
Siloed bookkeeping can make it appear that there are inflated savings to be reaped, but these estimates must be tempered against such factors as complications of care, managing (accelerated) microbial resistance, follow-up visits for unresolved/exacerbated issues, and so forth. This commentary is not idle conjecture. There is no reason to expect that the error rate would be lower than an average face-to-face encounter. There is reason to expect the rates to be comparable or perhaps higher.
JAMA Internal Medicine published a report[1] showing that medical errors in a large, urban Veterans Affairs facility and a large, integrated private healthcare system occurred in "almost 40% of patients who unexpectedly returned after an initial primary care visit had been misdiagnosed." The researchers noted that most errors were the direct result of miscommunication between providers and patients during an office visit—a factor common to virtual visits but potentially compounded by the unfamiliarity of virtual visits when provided by a third party rather than from within the primary care medical home.
"Breakdowns involving the patient-practitioner clinical encounter were most often judged to be due to data-gathering and synthesis problems (i.e., cognitive errors) related to the medical history (56.3%), physical examination (47.4%), ordering of diagnostic tests for further workup (57.4%), and failure to review previous documentation (15.3%)," the researchers explained.
Given that no physical examination or review of the patient's primary record is possible, and that some states and healthcare systems forbid the ordering of tests, aggressive estimates of health-system cost savings need to be viewed with restraint. Noncontinuous care, without physical examination, and often without subsequent communication with the primary care office, can be a recipe for disaster.
Making Video Visits Work for Primary Care
So, how can this style of service, which is clearly here to stay, work more appropriately in the service of the patient and healthcare as a whole? There are two principal points.
First, without question, the fragmentation and uncoordinated nature of the provision of these services by entities that are not aligned with or do not represent the primary care physician should be discouraged. This care should be redirected, either in an e-visit or an actual visit, to the patient's primary care office. Political and health economic influences should be apportioned in such a manner as to maximize the support of primary care practices' participation in e-visits.
Second, patients should be provided with education that details the important preconditions for a successful diagnostic encounter. These include a basis in physical exam which, if not concurrent with the complaint being addressed, should at a minimum be implicit within the context of the patient affiliation with the practice. Patients Need to Be Involved and Accountable
Ultimately, because it is the patient's own health that may be at stake in these encounters, it is essential that patients take a more proactive role in their own healthcare. Of course, that is explicitly what they are trying to do when they engage systems of virtual office visits.
Medical offices must—today—do a better job of educating patients on the availability of their services. This includes methods of accessing normal hours of care, after-hours phone care, electronic portal communication and, if available, virtual visits.
The healthcare system as a whole must honestly communicate with patients, free of ulterior biases, about the nature of the fragmentation of today's health records system. In particular, the consequences of making decisions when not all of the historical records and facts are in evidence must be underscored. Transparency should be improved as to the current morass of interoperability of medical records, electronic and otherwise.
Patients in the United States, across the spectrum of demographics and health status, must take a new approach to healthcare. They need to devote a magnitude of attention to these issues that is as serious and studious as the massive disproportionate degree of expenditures on healthcare and variances in outcome (as measured both within the US and in comparing the US to the world) would clearly indicate is long past due.
Poster Comment:
E-mail consult offers greater clarity and reduced possibility of misunderstanding of a diagnosis. Would particularly benefit out-of-town patients.