by Kevin Campbell

First posted on his blog on 12/31/2012

Kevin R. Campbell, MD, FACC

It may seem like science fiction from an episode of the once popular futuristic cartoon series The Jetsons, but virtual doctor visits are now here.  As chronicled in a recent New York Times article, insurers are now rolling out services where patients can interact with physicians via webcams and receive treatment for minor illnesses.  Obviously, the insurance companies are motivated by lower costs–however, with a soon-to-be flooded healthcare system in the US today, virtual consults may also be able to ease the primary care shortage.  However, these novel doctor-patient relationships are not without controversy.  Many physicians warn of the incompleteness of the evaluation without a physical exam.  Government regulators worry over the lack of oversight–in fact, only 13 states actually recognize virtual visits as a true doctor patient interaction allowing the physician to prescribe drug therapy.  Many attorneys see this as an opportunity for even more lucrative (and frivolous, in my opinion) malpractice litigation.  But, ultimately, we must find new ways to simultaneously decrease healthcare costs, improve outcomes and reach the millions of Americans who desperately need  medical attention.

The idea of webcam medical visits is not a new one.  Many doctors in remote locations have used virtual consults to help make diagnoses.  In a recent bestselling book, Nantucket surgeon Dr Timothy Lepore writes about using electronic visits with specialists in Boston to help triage patients for medical evacuation to the mainland.  In this particular application of virtual medicine, a specialist or colleague is used to provide a second opinion;  the patient is still under the direct care of a physician who is present at the bedside.  However, the virtual consult proves critical in the decision of whether or not the patient should be flown to Boston for more advanced care (at significant expense).  I believe that webcam visits, when used in this context, can meet the goal of significantly decreasing unnecessary expense while at the same time improving care and impacting outcome.  Moreover, specialists are able to support general surgeons, family physicians and internists in underserved areas on a routine basis.  Rather than waiting for a cardiologist to show up to see patients in person once a month on the island, the cardiologist can see patients daily via virtual visits.  Care becomes more efficient and remains centralized through the primary care provider.

In contrast there are other things about remote physician visits that are less than ideal.  In my previous blogs, I have written about the critical nature of the doctor-patient relationship.  It has been shown in many different studies that engagement of patients in their own healthcare clearly impacts outcomes.  I worry that in routine visits with a virtual doctor that no real engagement can occur.  Regardless of all the fancy bells and whistles now available to physicians, the practice of medicine remains a very personal and human relationship.  Eye contact, gentle touch, non verbal cues and body language–all important in a human relationship–do not translate well to a virtual visit.  Much of the art of medicine is found in the relationship between doctor and patient.   In all fairness, there are ways that relationships can be built via virtual visits–regular webcam “appointments” with the same provider will go a long way to making the best of the lack of physical presence.  Just as in a regular doctor visit, follow up is critical to success.  From a diagnostic side, much information can be gleaned from the physical exam.  In a virtual visit, observation is still possible but there is no way to place a stethoscope on the chest or to palpate the abdomen.  Many of my mentors in medical school stated many times over my years of training that “80% of diagnosis in medicine is the history and physical exam”.  This lack of a physical exam cannot be bridged or replaced without a physician at the bedside.

As in most areas of medicine, government regulation will be looking to play a major role in virtual medicine.  Currently only 13 states recognize webcam visits as an actual physician encounter.  In order for for a physician to legally prescribe a medicine, a well documented visit must occur.  For virtual doctor visits to be a viable option, legislation must address these types of visits.  In addition, medicare and other third party payors must be given guidelines and codes (yes, more codes) in order for billing and reimbursement to occur.  For physicians, particularly in this time of declining reimbursements, adequate compensation for time spent in virtual office visits and consultations must be quantified, defined and approved by both insurance companies and government agencies alike.

Lastly, we must deal proactively with the inevitable litigation that will come with webcam or virtual physician encounters.  I am certain that the trial lawyers out there are already looking into ways in which virtual physicians can be sued.  In order to have any opportunity to curtail healthcare costs and implement remote medicine, we must continue to push for tort reform and limit the activities of litigation-happy attorneys.  That topic, however, is much too big to address here–it will require its own blog entry altogether.

Ultimately, I believe that virtual medicine and webcam consultations will be an important part of medicine in the future.  However, there are many challenges that must be faced as we implement these new technologies.  Most importantly, we must preserve the art of medicine and continue to provide excellent patient care.  Physicians, insurance companies, government agencies (and even trial lawyers) must work together to make these new innovations both possible and cost effective.