Telediagnosis for Acute Care: Implications for the Quality and Safety of Diagnosis

• The tools (phones, video chats, others) are familiar to many and generally available.
• The general approach is similar enough to in-person care.
• Widely used videoconferencing tools may provide opportunities to engage disadvantaged patients.

• Disadvantaged patients may lack internet access or video-chat tools.
• Infrastructure is immature compared with in-person care.
• Standardized language and protocols have yet to emerge.
• Providers may need specific training to perform telediagnosis well.
• Some platforms are not HIPAA compliant (Note: During the COVID-19 pandemic, the Office for Civil Rights has waived civil monetary penalties for noncompliance, however, it remains a legal requirement to use HIPAA-compliant software [U.S. Department of Health and Human Services; Office for Civil Rights, 2020 #7516]).²⁵

• E-visits can provide enhanced access to healthcare professionals.
• Multiple platforms are potentially usable.
• Video visits may offer enhanced “presence” vs. telephone (e.g., more eye contact, deeper listening).
• Tips on how to strengthen “presence” are emerging.

• Creating relationships and presence via phone and video may be challenging. Telehealth experts suggest that it can be difficult to replace the value of “touch” when establishing trust in the therapeutic relationship.
• Some platforms are not HIPAA compliant.

• History should be comparable to the office-based history.
• It may be better than an office-based history to the extent that other family members can be involved and the clinician can get a sense of the home environment.

• Getting the patient history may be problematic with non-English speakers although this issue may be mitigated through improved access to translation services and family members.
• Telehealth programs may not be set up to allow patients to pre-enter health information before the visit.

Physical Examination

• With full knowledge of the limitations, virtually all aspects of the in-person visit can be conducted effectively.
• At-home devices can augment the ability to collect physical findings (ECG, others).

• Clinicians cannot visualize the tympanic membrane or the retina or listen to heart or lung sounds.
• Incidental findings that might have been detected in an office-based visit may be missed.

• For challenging diagnostic scenarios, telediagnosis could enable timely convening of multiple clinicians (peers, consultants from other specialties, or other health professionals) to be involved in the clinical reasoning process.

• The impact of telediagnosis on the clinical reasoning process is hard to predict and will require focused study.

• At-home testing tools could enhance testing for some conditions (diabetes, asthma, chronic obstructive pulmonary disease, others).

• Most laboratory tests and imaging require a separate visit.
• If lab testing or imaging requires a separate in-person visit, it may discourage their completion and followup.

• Virtual conferences with patient, family, and different members of clinical team may be facilitated by technology.
• Consults are easily ordered.
• In-person evaluation can be arranged for those who need it.

• Virtual visits may not allow a patient’s full engagement or the engagement of the full diagnostic team. For example, the patient may be less likely to stop by and chat with the dietitian or social worker and fewer opportunities arise for exposure to patient education materials or health screening.

• Communication may be  enhanced if family members participate and facilitate communication and understanding.

• Communication is probably reduced if the diagnostic team (for example, the nurse, pharmacist, therapist) is not engaging to the same extent as they would in person.

• Monitoring simplifies followup possibilities for patients and providers.
• Followup reminders can be set.

• Most telehealth programs as yet do not have systems in place to monitor quality and safety.

• Safety may be enhanced by improved access, a better sense of the patient’s home environment, and participation of family members.

• Safety may be reduced by missed physical findings, lack of presence, and decreased participation of onsite team members (nurses, pharmacists, others).

• Video visits provide an opportunity to engage patients and families.
• Video visits provide a glimpse into the patient’s living environment.

• It can be difficult to discuss issues of violence or abuse if the patient cannot complete the visit in a private location.