The main differences between telehealth visits and office-based patient visits are the location of the patient (geography), the insertion of technology between the provider and the patient, and the performance of the physical assessment. While much has been written about the challenges of geography and technology in telehealth visits, clinical literature and specialty society journals are beginning to address patient-assisted telehealth assessments.1 The strategies outlined in this article can help physicians perform a successful patient-assisted assessment.
Physicians who practice telemedicine must carefully consider the components required to complete an effective remote assessment and plan ahead based on their specialty area and the patient’s presenting complaint. While many patients may purchase a blood pressure cuff or a thermometer, accessing a more complex instrument—such as an otoscope, ophthalmoscope, or digital stethoscope—may be beyond the ability of a typical patient unless the visit occurs in a retail kiosk or pod. Either way, the patient (or caregiver) becomes an essential partner in the assessment process.
The important role that assessment plays in the diagnostic process and the prevention of diagnostic error cannot be understated as illustrated in our recent analysis. The Doctors Company studied 286 primary care malpractice claims that closed between 2014 and 2018. Analysts found that 51 percent of the claims involved assessment failures. The top two contributing factors were failure to establish a differential diagnosis (16.7 percent) and failure to assess and address continued symptoms (14 percent). The standard of care remains the same whether the visit is in person or remote. It is the provider’s responsibility to ensure that information gleaned during a remote assessment is sufficient to determine the patient’s diagnosis and treatment.
The following strategies can help providers better prepare patients to assist effectively with the remote assessment:
- Previsit Preparation
In addition to offering a technology test session, ensure that the patient telehealth previsit process includes instructions to patients for obtaining the equipment necessary to measure vital signs. Based on diagnosis and provider specialty, the instruction can be patient specific—such as a blood pressure and oxygen saturation monitor—or general, such as a thermometer and scale. Advise the patient to practice using the equipment and to measure and write down the results over the course of several days, including on the morning of the telehealth visit.
- Visit Initiation
Establish rapport. Smile. Confirm audio and video function, and ask the patient how the sign-in process went. Introduce yourself and confirm the patient’s identity with two identifiers. Evaluate how the patient looks in order to determine if a telehealth visit is appropriate. Evaluate the patient’s mental and physical status to determine if the patient can participate appropriately. In the case of 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.”
- Physical Assessment
Assessment during a virtual visit is, by necessity, a collaborative effort. The provider observes and directs the patient or caregiver to assist. Patients can be directed to position themselves to facilitate visual inspection of head and neck structures. 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. Patients can be asked to stand and take a few steps to assess balance and gait. Any joint pain can be further evaluated with range of motion and the use of a pain scale. Patients can be asked to palpate pulses, provide a heart rate, and describe what they are feeling. Respiratory function can be assessed by having the patient sit quietly and take deep breaths while the provider and patient listen for any wheezing or coughing. Abdominal assessment can be facilitated by having the patient stand and turn side to side as well as guiding the patient to palpate any areas of concern.
Carefully document the portions of the assessment observed by the provider and those that were “patient assisted.” For example, “the patient assisted with lymph node assessment.”
Because of the limitations of patient-assisted assessment, carefully consider the clinical conditions that can be evaluated using this approach versus conditions that require an in-person visit. For the comfort and consideration of both the provider and patient, this decision is best made at the time of scheduling as opposed to during the telehealth visit. For staff who schedule appointments, having clear guidelines and ready access to clinical decision makers will increase the chance of making an appropriate determination regarding the type of visit to be scheduled.
When used appropriately, a patient-assisted assessment during a telehealth visit is a wonderful opportunity to increase patient engagement in their own healthcare and further enhance the provider-patient relationship.