The virtual world has become reality for many because of its convenience and flexibility. For patients, the potential benefits are enormous: less time away from work/need for babysitters, no trouble with directions/parking, potential to connect over long distances to super-specialists and less exposure time in waiting areas, hospitals and offices. Some might ask why it took so long to catch on?
Getting Past Face-to-Face
The main challenge to full implementation of telehealth is designing the means for physicians to perform a physical examination on the patient. This typically is a key element that complements the patient’s history and imaging in completing the assessment and plan. Despite the remarkable advances in wearable fitness trackers, little focus has been given to medical applications.
In the world of neurological assessment ( stroke, trauma, Parkinson’s disease, multiple sclerosis) and particularly in spine evaluation, detecting weakness, altered sensation and other neurological changes is absolutely essential. What current options address this need? After years leading the charge, the physicians at Cleveland Clinic Neurological Institute recommend:
— Utilizing creativity and collaboration.
— Using symmetry/asymmetry assessment.
— Recognizing the value of imperfect but good information.
— Knowing when a face-to-face visit is required.
The first lesson is the importance of creativity and collaboration. Having a second person to hold the camera and participate in the testing is extremely helpful, so making this recommendation should be included in all pre-visit instructions. This also helps engage everyone in figuring out what’s working and what doesn’t work so well, bridging the gap between the virtual and physical world.
Physicians must recognize that how this testing has been done for decades cannot and should not try to be reproduced. Learning to give clear and concise instructions for testing becomes a new set of communication skills that takes practice. The other participants who are with the patient can easily do things like stroke the skin and ask for any changes. They can also do strength testing after a simple demonstration and report anything that seems off. After years of performing such telehealth visits, I have found most to be remarkably facile in being the doctor’s surrogate.
Next, test the patient against themselves or have them do an activity that can reveal imbalance or asymmetry of function. An easy example would be having the patient link their fingers and pull; the weaker side will break free. Walking on the toes or heels or standing on one foot can often uncover subtle muscle weakness. Dexterity and fatigue can also be utilized to reveal subtle functional changes.
Finally, each physician must become adept at detecting subtle changes and accepting that even limited information can be enormously helpful in getting to the right diagnosis and treatment plan.
When questions remain, a brief and directed visit may still be necessary.
On the Horizon
Currently, there is no quantitative, objective, low-cost, reliable means to analyze strength and gait, but an innovations team at the Cleveland Clinic Neurological Institute hopes to have a prototype ready soon. Their simple but elegant system marries smartphone technology, machine-learning analysis and seamless integration with a patient’s electronic medical record to assess and predict disease progression and treatment response, plus aids in clinical decisions. Through study, this type of system may serve as a biological early warning system for patients, such as when fall risk is likely to escalate.
Silver Lining in the Pandemic
Since the onset of the pandemic in the U.S. in March 2020, patients and physicians have been reeling. There has been considerable stress on the entire system, limitations on access to care, delay of routine well care and screening and more. One of the few silver linings has been the acceleration of delivery of virtual care to patients. There are three major hurdles to overcome to make this a reality:
— Appropriate compensation.
— Available technology and platforms that nearly every patient can use.
— Capacity to examine patients effectively.
Starting with a waiver in March 2020 and then made permanent in December, the Centers for Medicare & Medicaid Services permitted payment for provision of telehealth across the country. Most private insurers have followed suit (though more recently have started to roll back coverage, which is concerning). This policy change permitted many to retain critical access to healthcare during extended periods of lockdown and limits to hospital/office services. If continued, these will largely answer the compensation issues.
Most large health care systems have rapidly deployed variations of FaceTime, Zoom and equivalent programs linked with the patient’s electronic medical record to expand virtual visit capacity. These systems are relatively easy for even those who are technologically challenged to navigate. While still far from optimal, it has largely closed the gap between patients and physicians. The meteoric rise in virtual social connections required by COVID-19 isolation has further enhanced the viability and utility, even among the elderly, of telehealth platforms.
Certainly, the technology platforms still have considerable room for improvement in ease of use, and there are still some who do not have access to the required internet and camera requirements for a smooth and effective visit. Innovations that enhance the capacity to perform critical components of the physical exam are essential. The time has come that we must “…make that world look real, act real, sound real, feel real.”
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