Physicians, dentists, and advanced practice clinicians who practice telemedicine must consider the components required to complete an effective patient-assisted remote assessment and plan ahead based on their specialty area and the patient’s presenting complaint.
Assessments and Diagnostic Error
The most significant difference between telehealth visits and in-person visits is the provider’s inability to perform a hands-on assessment. Nevertheless, the standard of care remains the same whether the visit is in person or remote.
Accurate patient assessments, conducted via telehealth or in-person, are key to preventing diagnostic errors. To learn more about the relationship between patient assessments and diagnostic error, The Doctors Company studied 428 primary care malpractice claims that closed between 2015 and 2020. Analysts found that 74 percent of the diagnostic error claims involved patient assessment failures. The top three factors contributing to these assessment gaps and, ultimately, to diagnostic error were failure or delay in ordering a diagnostic test (38.8 percent), failure to assess and address continued symptoms (32 percent), and failure to establish a differential diagnosis (23.8 percent).
Providers must ensure that information gleaned during a remote assessment is sufficient to determine the patient’s diagnosis and treatment.
Patient selection and preparation are also essential to the safety and success of the visit. The following strategies can help providers better prepare patients to assist effectively with remote telehealth assessment:
Due to the limitations of patient-assisted assessment, carefully consider which clinical conditions are suitable for visits that include a patient-assisted assessment component. Schedule appropriately. To increase chances of scheduling the correct setting for a visit, provide staff members who schedule appointments with clear guidelines and access to clinical decision makers.
The patient becomes an important partner in the physical assessment process during a telehealth visit. While many patients may purchase a blood pressure cuff or a thermometer for home use, more complex instruments (such as otoscopes, ophthalmoscopes, or digital stethoscopes) may require additional planning and patient education.
Offer a technology check session and ensure that the patient telehealth previsit process includes guidance for patients to obtain the necessary equipment. Base instructions on diagnosis, visit type, and provider specialty. For example, vital sign information and current weight are essential for most visits. Specialty-specific information may include point-of-care blood testing and cardiac monitoring. Advise the patient to practice using the equipment, keep a log or record the results over several days, and share the results ahead of time using the portal or verbally during the visit.
Introduce yourself and confirm the patient’s identity with two identifiers. Evaluate how the patient looks to help determine if the telehealth visit is appropriate. Evaluate the patient’s mental and physical status to determine if the patient can participate appropriately. In visits scheduled with children, frail elderly, and patients with special needs, determine if a caregiver is present and able to assist. Use the opportunity to evaluate the patient’s environment and address any distractions. For additional information on patient distractions in telehealth, read our article, “Telehealth’s Newest Safety Risk: Distracted Patients.”
Confirm the patient’s medication list or, if necessary, conduct a virtual “brown bag” medication check. Ask the patient to give you the vital sign information collected. Document the information in the medical record as “patient self-reported.”
Assessment during a virtual visit is a collaborative effort. A willing patient can be guided through palpation of the neck and submandibular areas to examine for “lumps” and, if noted, to describe pain, induration, shape, and size. Ask patients to stand and take a few steps to assess balance and gait. Evaluate joint pain by assessing range of motion and the use of a pain scale. Ask patients to palpate pulses, provide a heart rate, and describe what they feel. For long-term management of patients with chronic respiratory disease, consider home spirometry in combination with a digital stethoscope. Abdominal assessment can be facilitated by having the patient stand and turn side to side and guiding the patient to palpate any areas of concern.
Observe pediatric patients by asking the parent to position the camera to facilitate watching the child playing on the floor or sitting at a table manipulating objects. Depending on image quality, parents may be able to share pictures of rashes or short videos of concerning behaviors by smartphone.
When documenting the visit, identify the components of the assessment that were completed with the patient’s assistance. For example, “the patient assisted with lymph node assessment” or “self-reported blood pressure is 120/80.” For additional information on documenting telehealth visits, please see our article “Nine Tips for Telehealth Clinical Documentation.”
When used appropriately, a patient-assisted assessment during a telehealth visit is an excellent opportunity to increase the patient’s healthcare engagement and further enhance the provider-patient relationship.
For additional guidance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.