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Medical Diagnosis by Webcam?

Telemedicine exams are fast and easy — but questions remain

doctor using the ipad

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Telemedicine can include anything from emailing your own doctor to video psychiatry appointments at rural clinics.

En español | Bill Moore was attending his niece's wedding in Utah when he suddenly came down with a headache, sore throat and sinuses that he says were "killing me." He didn't know if his Vermont doctor could prescribe antibiotics several time zones away and disliked the prospect of tracking down a walk-in clinic.

So Moore, now 67, instead set up a video chat with a doctor working for American Well, a telemedicine company. From a list of doctors on call, he chose family medicine practitioner Ingrid Antall, who connected with him by computer from her home in Westlake Village, Calif.

Antall discovered that her new patient had suffered from a mild cold for about a week that had suddenly turned into something much more painful. She asked him to squeeze the glands below his jaw and the area below his eyes to test for sensitivity and to describe "the color of whatever was coming out of my nose."

"You can tell a lot by looking at people," Antall says. After ruling out anything more serious, she prescribed antibiotics for a sinus infection. Within 24 hours of getting an antibiotic, Moore, a custom-home builder, bounced back. "That saved my bacon for the rest of the trip," he says.

With that encounter, Moore joined an increasingly common but still controversial alternative to the traditional office-based visit. Telemedicine — which can include anything from emailing your own doctor to video psychiatry appointments at rural clinics — has been part of medical care for more than four decades. But in recent years, the vastly improved quality and availability of video has expanded the business opportunity for a burgeoning cadre of companies that offer patients the opportunity to virtually visit a doctor via phones, computers and tablets from anywhere — their beds, their office chairs, their vacation homes.

These companies are annually treating hundreds of thousands of patients who opt for convenience and a low fee — typically around $50 — to get medical advice and sometimes a prescription for low-level ills such as allergies, pinkeye, rashes and even sports injuries.

Proponents say telemedicine has the potential to improve access to care, lower costs and provide reliable, specialized care to patients who need it. But some doctors and researchers question to what degree virtual care equates to in-person treatment, and whether these e-physicians might overprescribe drugs to keep patients satisfied, misdiagnose an ailment or miss a more serious medical problem entirely. In Texas, the state medical board passed regulations last year restricting such long-distance consults, a move that has sparked litigation.

A growing trend

The American Telemedicine Association estimates that 1.25 million online patient consults will happen this year. Increasingly, employers and insurers are including the services as part of benefits packages. A recent survey of 140 large employers by the National Business Group on Health found that 74 percent of the nation's largest employers are offering telemedicine services in 2016, up from 48 percent in 2015. Last spring, UnitedHealthcare teamed up with several e-visit companies, including American Well and Doctor on Demand, to offer virtual appointments to some employer-insured patients; it plans to make that option available to as many as 20 million by the end of 2016, according to spokeswoman Lynne High. Access to the virtual docs via video, at a cost of no more than $40 depending on the member's plan, will improve access to "quality, cost-effective health care for minor medical needs," particularly in rural areas, High wrote in an email. Walgreens and MDLIVE, an e-visit company, already provide virtual consults for $49 in 25 states.

The services provide a backup option for mostly minor conditions. Patients are connected to a doctor — licensed in their state, and typically board certified — virtually immediately. Thus, they avoid the time lost from work or other commitments spent in a doctor's waiting room — if they can even land an in-person visit.

Mike Koval, a 64-year-old police captain near Sarasota, Fla., says it sometimes can take at least a week to see his family doctor, whereas he can talk to one through telehealth provider MeMD from his office computer any time his incessant allergies back up yet again into his sinuses. "When you're at work, especially in our line of work, you can't just walk away."

These e-visits could reduce skyrocketing health care costs, proponents say. Savings for doctors, hospitals and other providers are "potentially enormous," wrote David Asch, M.D., of the University of Pennsylvania's Center for Health Care Innovation in the September Annals of Internal Medicine. Not only is the time spent between doctors and patients shorter, but there is no check-in at the desk and no need for expensive waiting rooms.

Tania Elliott, a Doctor on Demand physician licensed to practice in 14 states, estimates that just 5 to 7 percent of her virtual patients ultimately require help from an in-person doctor. The patient might need lab tests or a physical exam, she says, "or if I think they need a higher level of care" she refers patients to their doctor or the emergency room.

Last year, Elliott urged a 60-year-old woman to head straight to the emergency room, worried that she suffered from more than the fatigue and light-headedness that she had initially described. The woman's face on the video screen was "very pale" and her pulse, once Elliott showed her how to take it, beat abnormally fast. She also reported a near-black stool. When Elliott followed up later, she learned that the patient had been diagnosed with bleeding ulcers and needed urgent blood transfusions.

Virtual risks?

Virtual visits are not without their detractors. A seemingly minor condition like a cough — assumed by the patient to be seasonal allergies — could signal a more serious condition such as pneumonia or the early stages of heart failure, says Russell Thomas, who practices family medicine near Houston. "You can't diagnose that unless you are listening to their chest and see what's going on in there." Seeing a virtual doctor could lead to delays in treatment. "If someone is calling in with chest pain, instead of going right to the emergency department, that delay could have important implications for patient safety," says Lori Uscher-Pines, a researcher at the nonprofit research organization RAND. Patients also should bypass virtual care if they're experiencing any neurological symptoms, including slurred speech or difficulty moving an arm, says Adams Dudley, M.D., of the University of California in San Francisco.

As for the risk of overprescribing, the study findings are mixed. One 2013 study in JAMA Internal Medicine showed a higher rate of prescribing medications for sinusitis and urinary tract infections, compared with office visits. However, a 2015 study in the same journal looking at prescription rates for respiratory infections found no significant difference in the number of prescriptions written by virtual doctors and by those who saw patients in their offices.

In Texas, the state's medical board amended its rules last April to stipulate that doctors can't diagnose new patients via telemedicine unless a medical professional is on hand who can provide "objective diagnostic data." Lewisville, Texas-based Teladoc, the country's largest telemedicine company, which conducted more than 550,000 virtual visits in 2015, filed suit, arguing that the board was illegally limiting competition. In May, a judge issued an injunction blocking the rule's enforcement until trial.

Professional groups weigh in

The American Medical Association has kept the door open to prescribing through e-visits, stating that a doctor-patient relationship can be established either in person or "virtually through real-time audio and video technology." In a policy paper last fall, the American College of Physicians adopted a similar stance, writing that a doctor and patient could meet for the first time using telemedicine, as long as appropriate treatment standards are followed.

While 29 states and Washington, D.C., now have laws that require private health plans to reimburse for telemedicine, several states have restrictions that limit the types of prescriptions the doctors can write or require that patients meet the doctor in person before a video conference. To date, Medicare telemedicine coverage has been highly restricted to health care facilities in rural areas.

AARP recommends that patients keep their primary physicians in the loop, but electronic doctor visits can be helpful for patients who need a doctor after hours, says Andrew Scholnick, a senior legislative representative with the association.

While the virtual visits provide an option for minor medical problems, patients should avoid suggesting a self-diagnosis, as it may influence the doctor, UCSF's Dudley says. A patient who blames shortness of breath on asthma, for example, may steer the doctor away from considering other possibilities, such as a heart condition. As with any appointment, patients need to make sure the doctor is attuned to their needs and symptoms, he adds.

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