John Bedolla1 and Jesse M. Pines2,3 1 Department of Surgery and Perioperative Care, Dell Medical School, University of Texas, Austin, TX, USA 2 US Acute Care Solutions, Canton, OH, USA 3 Department of Emergency Medicine, Drexel University, Philadelphia, PA, USA The first wave of the coronavirus 2019 (COVID‐19) pandemic (2020–early 2021) spurred a massive increase in telemedicine utilization.1,2 The COVID‐19 pandemic made the remote medical evaluation more appealing to patients, hospitals, and clinicians.3,4 It also broke down the two most important barriers to adoption: reimbursement and regulatory constraints.5–7 At the time of this writing, the United States is in the fifth wave of the COVID pandemic, which will likely spur adoption of telemedicine further.5 However, telemedicine is not only increasing due to the COVID‐19 pandemic. Prior to the pandemic, several use cases for telemedicine had been developed and were in place, such as tele‐stroke, tele‐intensive care (ICU), tele‐neonatology, and tele‐emergency department (ED). Going forward, there are multiple forces that ensure telemedicine will play an increasing role in acute care. Patients voice a strong preference for telemedicine as a convenient way to take care of chronic and even acute medical needs. Insurers see telemedicine as a way to drive down costs. Regulators and physician leaders think telemedicine will increase access to underserved populations and decrease the barrier to entry for medical care for all patients. Physicians also voice greater acceptance and satisfaction with telemedicine as an option in their practice profile.8 This revolution in medicine, in which the physician sees the patient not in person but remotely, was not directed by an academic study or detailed long‐term planning. Instead, rapid advances in the quality, security, and cost of two‐way audiovisual technology made it possible for telemedicine to be adopted rapidly in the setting of favorable market forces and a disruptive pandemic.9 For the individual clinician and the physician leader this presents a reversal of the normal adoption process for new medical processes.10 Optimally, medical processes are adopted only after academic studies show their efficacy.11 Regardless, market forces, patient preference, and improving technology all ensure that telemedicine will continue to grow. Emergency groups and clinicians who want to stay relevant in the changing ecosystem need to understand how the emergency telemedicine encounter is similar to, and differs from, the in‐person emergency encounter. There are fundamental differences in the raw clinical data that can be obtained in the two encounter types, and understanding these differences is essential to utilizing telemedicine. Emergency groups and clinicians must therefore ask themselves a series of strategic questions to decide not if telemedicine is going to be part of their practice profile but rather how to adapt to telemedicine and ensure that it is used in the populations, settings, and for clinical conditions where they can provide the best care for their patients. In this chapter, we pose and answer what we consider to be the important strategic questions for the clinician or clinician leader considering adoption of telemedicine. The Society for Academic Emergency Medicine (SAEM) addressed Telehealth in emergency medicine (EM) at the 2020 consensus conference.12 The authors reached consensus on evidence to support the feasibility of telehealth to improve health care access to acute, unscheduled care in a variety of settings and conditions. According to the report, they found that telemedicine has been shown to improve care efficiency including lower length of stays and decreased transfer rates. Yet, the authors report the lack of objective and controlled studies describing benefits to patient‐level or population‐level health outcomes. Telemedicine is a tool that can potentially mitigate disparities in access, and better understanding of how telehealth influences patient’s access and health outcomes in rural and underserved settings are needed. The consensus group created a list of priorities and future research agenda available in Table 61.1. Table 61.1 Research questions for telehealth in emergency care Source: Adapted from [12]. No. Compared with the in‐person evaluation, the telemedicine evaluation provides less perceptual information to the clinician. In the telemedicine evaluation smell and touch are not possible. Relative to the human eye, which can instantaneously scan and focus wherever the clinician directs attention, similar functions of computer and phone cameras are slow and limited. The human eye is equivalent to a 50‐millimeter lens, but most teleconferencing cameras are a wider lens which, relative to the human eye, has a spherical, or “fisheye” distortion. For practical purposes, the limit of resolution of the human eye is about 8K (e.g. a horizontal resolution of 8000 pixels). At either end of the telemedicine encounter, the resolution is usually limited to standard definition (SD) or high definition (HD), which are much lower than 8K. The refresh rate of the human eye is 1000/second or 1000 Hz. By contrast, the standard refresh rate of computer screens is 30 Hz.13–16 Many subtle emotional micro‐expressions and cues happen at 1/100 of a second or faster, far beyond the ability of the video to pick up and limiting the ability of the clinician to pick up on some subtle cues.17–21 Additionally, without special equipment, the telemedicine visual inspection is from a single camera, precluding accurate depth perception. The color spectrum of the camera and computer screen are also compressed compared with natural vision.22,23 Microphones can pick up higher and lower frequency sounds than the human ear, but they are inferior in most other ways. Human hearing is three‐dimensional meaning the human brain stem uses subtle differences in timing and character of the sound in the right versus left ear different ear to generate an “image” of the space and the objects in it. While this is not a high‐resolution ability in humans, it is largely lost in the telemedicine format. Like the human eye can zoom and focus, the human ear has an ability to focus on sound in a particular direction and pitch – this is called the “cocktail party effect” and allows the human ear to pick up conversation even in a complex environment. By contrast, the microphone picks up all sounds with the same affinity.24 There are no head‐to‐head studies comparing the quality and reliability of the in person versus telemedicine history taking in emergency care. There are studies in several disciplines which indirectly compare the quality of history taking by focusing on endpoints intuitively related to the quality of the history taking. In the surgical and anesthesia literature, the endpoint of canceled or delayed surgery has been compared in telemedicine and in‐person presurgical screening. The rate of surgical cancelation due to inadequate or missing elements of the history is close to the same independently if the patient was seen through telemedicine or in person.25–27 Mullen‐Fortino et al.28 performed a retrospective review of 361 patients with telemedicine presurgical evaluations and 7442 patients with in‐person presurgical evaluations and similar rates of cancelation (0% telemedicine versus 1.1% for in‐person). In neurology, there are several head‐to‐head comparisons of clinical efficacy in conditions which require extensive history taking.29–32 Müller et al.33 randomized 409 patients to telemedicine versus in‐person management of nonacute headaches and found no differences in treatment compliance or patient satisfaction, but did find that rural patients in the telemedicine group had less frequent headache visits at 3‐month follow‐up. There is also a robust body of literature showing the noninferiority of telepsychiatry with in‐person psychiatry – a discipline in which the history is the essential evaluation.34–36 Telemedicine software platforms fall under the Food and Drug Administration (FDA) regulation as medical devices.37 The regulation extends to software applications (apps) that might yield information that could be critical and require acute intervention. Examples include apps that connect to electrocardiogram (ECG) equipment, measure physiologic parameters used in diagnosis, calibrate cochlear implants, connect to bedside monitors that transfer data to doctors or nurses, altar pump infusion rates, or amplify sounds from electronic stethoscopes. The FDA generally encourages innovation and has taken a hands‐off approach to most software apps, except when the app provides a diagnosis or attempts to substitute for the clinician’s judgment.38 A recent example was the removal of the Visibly Online Refractive Vision Test, which was judged to provide diagnostic information while excluding the clinician.39 However, devices or apps used synchronously in the telemedicine encounter to enhance the amount of perceptual information, such as high‐resolution cameras, ophthalmoscopes, or otoscope apps or devices, are largely unregulated and will likely remain so in the setting of a continuing pandemic. Most tools designed to increase the amount of perceptual information available to the clinician are not stand‐alone devices. Rather, they are apps the patient can install on a mobile phone or desktop computer. These apps use the native functionality of the device to deliver added information synchronously to the clinician. Examples include eye and retinal visualization apps, middle ear, intranasal and oropharyngeal, visualization apps, skin magnification apps, and stethoscope apps.40 Some stand‐alone peripherals are available such as electronic stethoscopes, tele‐ophthalmoscopes, video‐otoscopes, electronic dermatoscopes, digital endoscopes, and electronic scales.41,42 The primary target customer for these peripherals are clinics, EDs, and hospitals for specialty consultation rather than consumers, due to expense and setup complexity.43–48 These devices do allow for specialty consultation, such as telestroke, teleophthalmology, second opinions, enhanced resident supervision, and teletriage. Most regular telemedicine encounters are still mediated through computers or mobile devices equipped with a camera, visual display, audio input, and audio output. Consumer‐driven wearables for personal and sports use have become commonplace. Examples include smart watches, shirts with built‐in electronic connected hardware, connected jewelry, smartphone apps, eyeglasses, earbuds, and headbands. These devices can deliver cardiac rhythms, step counts, sleep cycles, respiratory rate, accelerometry data, location, distances, temperature, respiratory rate, oxygen saturation, blood pressure, and skin plethysmography data.49–51 Aggregate data from millions of these devices are useful at the population level for limited patient‐specific apps, such as adherence to home quarantine. Yet for making patient‐specific clinical decisions, four problems arise: (i) consumer devices are not reliable enough to make high‐risk decisions, (ii) few of these devices are FDA approved, (iii) there are no reference standards for consumer devices, and (iv) the makers of these devices have largely treated these medical functionalities as marketing tools and not as true medical devices, and consequently few have been tested to a medical standard of reliability. Studies have shown that, outside of the laboratory setting, they are less reliable for measuring heart rate, step‐counting, activity, sleep, and other health measures.52–58 Consumer wearable devices may enhance the telemedicine encounter, but they do not add information that would be considered medically reliable. They should be used with caution in the telemedicine encounter when they are not FDA approved.59 There is published evidence that people without medical training can be directed in real time to obtain a reliable measure of heart rate.60,61 However, accuracy does appear to diminish with advancing age due to age‐related decline in finger sensitivity.62 Accuracy of temperature taking appears to be primarily related to the device used. Since there are no reference standards for consumer‐level thermometers, measurements should be used with caution. Automated blood pressure devices have a reasonable high reliability; however, there is a wide range of reliability in nonvalidated devices. Operator error is also common, and therefore, it is probably best to observe the patient while the self‐measurement takes place. It is best to know the brand and price of the blood pressure device to get a sense of how accurate it is. There are few studies on the reliability of oxygen saturation using consumer devices.63–68 Measurement of respiratory rate is unreliable by most methods. It is often inaccurate even in the hands of professionals because they are noncompliant with waiting a full minute to measure the respiratory rate. It is therefore unlikely that self‐measured respiratory rate is reliable.69–73 One pediatric study included 148 patients and 135 paired observations and reported interclass coefficient rating of 0.95 (confidence interval [CI] 0.93–0.96) showing high concordance between telemedicine and in‐person assessment of dyspnea. The Roth Score, which involves having the patient count to 30 as rapidly as possible and noting the highest number has been shown to be reliable in one small study of 93 patients. The Roth Score was shown to be valuable in the assessment of dyspnea in 500 patients with suspected COVID‐19.74–76 Telemedicine administration of the National Institute of Health Stroke Scale (NIHSS) appears to generate reliable results. Investigators have compared the in person and the telemedicine exam directly and found a strong positive correlation. In a study of 174 patients receiving an in‐person NIHSS versus a telemedicine NIHSS, 2% of telemedicine consultations could not be completed and the telemedicine NIHSS were concordant 88% of the time for a κ = 0.73.77 Another study found high or moderate agreement with all elements except ataxia, which was poor.78 Compared with in‐person NIHSS for tissue plasminogen activator (tPA) or thrombolysis, the telemedicine exam results in equal sometimes faster administration times. The use of telemedicine consultation was also associated with a higher rate of tPA administration in remote locations. Of note, the NIHSS in all these studies is used in a consultative role, not as the only neurological exam performed.79,80 Considering the high stakes and liability involved in stroke care, the telemedicine administered NIHSS remains a consultative rather than stand‐alone modality. For the emergency clinician in‐person administration of the NIHSS by the emergency clinician or the neurologist remains the gold standard, and tele‐neurological evaluation is valuable for confirmation and consultation.81–83 Psychiatric assessment lends itself well to the telemedicine format and has been shown to be effective in multiple studies and meta‐analyses,84–88 including among pediatric patients.89 A systematic review of the use of telepsychiatry in depression found that patient satisfaction is equivalent to or higher than face‐to‐face interventions. Both telemedicine and control groups had improvement on depressive symptoms. Despite the increased cost upfront for telemedicine due to the technology required, telemedicine would eventually be more cost‐effective due to reducing travel expenses.90 Another systematic review regarding the use of telepsychiatry in geriatric patients found that tele mental health is feasible and well accepted when used in inpatient areas and nursing homes for consultation, cognitive testing assessments, dementia diagnosis and treatment, depression management, and psychotherapy.91 This systematic review found that the main barrier to broader implementation of telemedicine for geriatric patients was Medicare reimbursement, limiting the development of telemedicine programs in the pre‐COVID era. Many older adults have mobility problems or difficulties finding a care partner to take them to appointments, and home‐based telemedicine services would allow for better access to care. A systematic review of telemedicine for older adults with dementia during COVID‐19 found that telemedicine was a feasible approach for cognitive and mental health assessments (e.g., Montreal Cognitive Assessment [MoCA], focused assessment with sonography for trauma [FAST], etc. – see Chapter 57). Telemedicine appears effective in connecting persons living with dementia and their health care providers while reducing travel difficulties or challenges.92 A qualitative study on emergency physician’s perspective on using telehealth with older adults found that telemedicine gained acceptability among ED physicians and provided options to patients who may have otherwise deferred care.93 Telemedicine has been used effectively for trauma consultation and as a substitute for follow‐up office fracture care visits.94–96 For acute care of minor injuries, there is a high degree of concordance between in‐person and telemedicine visits, with similar rates of radiographic utilization and similar miss rates. Researchers have noted that visual inspection, capillary refill, color, and goniometry are sensitive and accurate in the telemedicine format. Patients can also palpate their own injury while being watched and can point out areas of tenderness. The rate of X‐ray utilization and the rate of “misses,” defined as an injury assessed to not need an X‐ray, but subsequently found to be a fracture, were similar to in person and in both scenarios’ complications were very low. Clearly, interventions such as splinting cannot be performed by the clinician in the telemedicine format, but the patient can be instructed in methods of home care, including premade splints and wraps.97–99
Chapter 61
Diagnosis in Telemedicine
Educational needs and outcomes
Competencies and training
Educational approaches
Health care access
Patient‐ and population‐level outcomes
Quality of care delivery
Outcomes of telehealth programs
Process measures in telehealth
Quality/safety
Facilitating research
Workforce
Does the telemedicine evaluation have the same fidelity as the in‐person evaluation?
Can you obtain a reliable history of present illness, past history, family history, and social history in the telemedicine format?
Besides the microphone and camera, what other peripheral tools are available to increase the amount of perceptual information available to the clinician?
Can wearable devices enhance the telemedicine encounter?
Can patients accurately measure their own vital signs?
Can you assess dyspnea in the telemedicine format?
Can the National Institute of Health Stroke Scale (NIHSS) be performed in the telemedicine format?
Can a psychiatric assessment be done in the telemedicine format?
Can orthopedic injuries be reliably assessed in the telemedicine format?
Can a patient self‐assess abdominal tenderness to palpation?
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