Telehealth technology is amazing. Who would have thought that medical care could be delivered to children through a video screen? I was never trained in telemedicine during medical school or residency…partly because it didn’t exist at the time of my training. However, we did have training in telephone triage and would receive phone calls from parents about their children regarding a variety of problems during my pediatric residency. The current technology has raised the bar on remote medical assessments.
After my pediatric residency training, I experienced hospital and community telemedicine encounters. In the intensive care unit (ICU), we had telemedicine robots that we could operate from home, when we didn’t have in-house attending physician coverage in the pediatric ICU. I was able to check in on patients and manage care remotely with the staff and equipment available. I was even able to help supervise and assist with the initial management of a cardiac arrest in the pediatric cardiothoracic ICU with the ICU fellow before driving in to manage the patient in person, as the child was stabilized. In the outpatient arena, I managed sick visits from an urgent care to help parents with their ill children. The available resources were not the same as in a hospital ICU setting, so the level of management was different and the decision of whether or not to have the child be seen in person was a question that was always a consideration. While a lot was able to be accomplished with these encounters, the limitations of remote medical care were always a consideration.
Limitations of remote medical care and management are usually defined by the information that is able to be obtained on the patient side of the interaction. Some telemedicine systems are elaborate and have equipment that has a stethoscope, otoscope, or light attachments where the lungs and heart can be heard and the ear canals and mouth can be visualized by the physician on the other end of the remote encounter. As opposed to a hospital setting where staff and equipment are universally available on the patient side, the common community telemedicine encounters are different. Sometimes there are medical assistants or other staff that show up at the family residence with equipment to assist with a physician’s remote evaluation or perform specific point-of-care testing, if that has been incorporated into the telemedicine program design. However, for a majority of interactions, the medical provider is providing care with just a visual unit and does not have the luxury of obtaining a professional examination or testing with the accessory staff or equipment. For purposes of this discussion, the limitations of the common, basic telemedicine platforms with just audio and visual functions will be explored, since the majority of telemedicine encounters are performed in this manner.
1. Most Telehealth Equipment Can’t Provide a Comprehensive Physical Exam
If you are needing to listen to the lungs for wheezing or signs of pneumonia, look in the ears for signs of an ear infection, or view the throat to see if there is pus on the tonsils, you are out of luck with most telemedicine platforms. The exam that you get is usually a superficial visual one (viewing the skin, eyes, breathing effort, movement of limbs, etc.). Anything more involved or invasive usually requires specialized equipment (like an otoscope or stethoscope), as well as a hands-on evaluation. Parents can press on the abdomen or move a limb, so we can see the child’s response. But, some of the finer details of the physical exam are missed without doing it yourself. Also, sometimes the internet connection, camera resolution, or ambient lighting impairs the visual acuity of the physician during the remote exam.
Rashes, lacerations, conjunctivitis, increased work of breathing or respiratory distress, and limb injuries are a few health concerns that the standard telemedicine platforms are useful for initial evaluations. But, a comprehensive physical exam should never be the expectation during the visit. There are just some health issues that require a more extensive examination than can be provided by the telemedicine encounter.
2. Routine Laboratory or Radiologic Testing Can’t be Performed
Without some routine laboratory or radiologic testing, there are just some diseases that can’t be accurately diagnosed by obtaining a history and physical examination, even under the best in-person visits. Telemedicine usually is hampered by not having available resources such as performing a urinalysis/urine culture to check for a urinary tract infection, a rapid strep test to evaluate for strep throat, or obtaining blood work to check for diabetes. Even with a history consistent with a urinary tract infection, strep throat, and diabetes, confirmatory testing is required to make the definitive diagnosis. Furthermore, x-rays are needed in most cases to differentiate a sprain from a fracture, even with the best in-person physical examination skills. So, unless a limb or finger is significantly deformed on visual inspection, an x-ray is usually required to identify most fractures. And, if a limb or finger is significantly deformed on visual inspection and a fracture is suspected, that person needs to be seen in person for an x-ray and stabilization of the fracture anyway!
3. Prolonged Monitoring is Not Feasible in Most Settings
Prolonged monitoring is not usually feasible in most outpatient telemedicine settings. The scenarios presented in the telemedicine encounter are acute situations that are usually managed for a discrete amount of time. Checking in for repeated evaluations of a condition is not unreasonable. But, continuous monitoring of a condition involving breathing effort or mental status changes is not practical for the outpatient telemedicine encounter. In the urgent care or ER setting, children can be monitored for hours to see how their respiratory condition will change or stabilize with croup or mental status will improve or worsen after a traumatic head injury. This is not feasible for most telemedicine programs. Some intensive care units have continuous remote monitoring of patients via video cameras and continuous vital sign reading technology by a staff member, but these are special programs with specialized equipment beyond that of the routine outpatient telemedicine encounter. The time expectation of a routine telemedicine encounter should be relatively short. Any condition that requires monitoring for an extended period of time will require monitoring at an in-person facility.
4. Procedures Can’t Be Performed
Parents can be instructed to perform certain basic procedures, such as wound care for superficial abrasions or burns, superficial foreign body removals, basic splinting of injured limbs (if materials are available), and other non-invasive procedures. However, if a laceration needs to be sutured, an abscess needs to be drained, or a bead up the nose can’t be removed at home, the child needs to be seen in person. While there are machines that can assist with actual surgery, the technology has not been passed to the outpatient telemedicine encounter yet. Besides, these individuals still need to be in an operating room, somewhere. So, even if the surgeon is not physically in the operating room performing the surgery, the patient still needs to be in the hospital. Telemedicine does not have the ability to perform complex procedures without being cared for in person.
5. No Direct Administration of Medications
Staff assistance with administering certain medications can only be performed in person. For example, giving ondansetron (an anti-nausea or anti-vomiting medication) as an intramuscular or intravenous injection because the child is vomiting everything ingested is one scenario where in-person assistance is warranted. For that matter, giving intravenous fluids for dehydration is something that can’t be performed via telemedicine. While some concierge or mobile medical services can provide intravenous hydration, they are usually not comfortable or skilled in administering intravenous fluids to young children. Also, repeated breathing treatments for asthma are best given in an in-person facility because the reason they are being given is that a child is having trouble breathing. Anything having to do with worsening breathing problems is not a telemedicine issue.
Finally, sometimes it is even reasonable to bypass a telemedicine visit to be seen in person to give some children oral medications. Seasoned medical staff possess tricks to give even routine oral acetaminophen or ibuprofen to young children who don’t like taking medicine. You would be surprised at how often parents are frustrated by their toddler who spits out or vomits acetaminophen every time they try to give it, despite the fact that the child will feel better once they take it and their fever comes down. Nevertheless, an in-person visit trumps a telemedicine visit when parents can be physically shown how to give medications to their children by those with this highly sought-after expertise.
The current technology has raised the bar on remote medical assessments. And, by far, the most important part of a medical visit is obtaining a good history which can easily be obtained via telemedicine technology. Physical exams, labs, and studies confirm what a clinician already suspects by the given history. Yet, telehealth does have its limitations. There are times when in-person physical exams, labs, and studies are required. The expectation of receiving antibiotics for a sore throat or ear pain, a return-to-sports note after a head injury/concussion, or differentiating a sprain from a fracture are issues that are best left to in-person evaluations. Even with that said, telemedicine is amazing and there is a definite role for it in healthcare. But, by understanding the limitations of telemedicine encounters, expectations about what can actually be cared for at these visits and what should be deferred to in-person evaluation can be managed appropriately.
What other limitations do you see with telemedicine visits?
Despite the telehealth limitations, do you find telemedicine visits a more attractive option than in-person medical appointments?