Opinions about video physician visits

They and “e-visits” are in early stages in our large medical group. So far for a defined list of complaints that physicians felt could appropriately be handled without hands-on. Honestly the major motive for doing it is the need to compete with the sorts of services being highlighted in this week-end’s NYT article about them.

For us this is a service to be provided to our established patients (and sometimes may branch into a “needs to be seen in person” outcome) but the competition is as it is with the Urgent care clinics.

As patients (consumers of healthcare) does this appeal to you? From that POV what are your concerns?

Physicians and nurses too but please let’s let some non-healthcare professionals offer their thoughts before you opine.

For everyday ailments, I love it.
Nothing worse than taking two hours off work every time you have a sinus infection or just need a scrip renewed for allergies, meanwhile exposing yourself to whatever is going around the medical building that day.
I assume this would only work when the patient has established a history of persobnal responsibility and has been in for a physical in the past year or two.

I am very much in favor, for efficiency reasons.

I’m also in favor of allowing physicians to bill for phone calls. IMO, many people waste enormous amounts of time on doctor’s visits (both their own time and the doctor’s) simply because doctors are not allowed to bill for phone consultations and they can’t make a living unless they drag people in.

Of course, a physician needs judgment as to when an in-person visit is required - which will frequently be the case. But if you can’t trust the judgment of a physician in this regard, then they shouldn’t be physicians altogether.

Yes, video visits are OK, as would phone calls in most cases (I can’t imagine most 80-year olds being comfortable with video chat technology). Especially in rural areas where it’s a long drive to a town big enough to have a clinic, minor issues can certainly be handled remotely. Mayo Clinic is a big proponent of it, while stating they’d always make referrals in case of any questions or doubts.

Well, I’m in the middle of your requested demographic for responding. I was trained as a nurse (LPN, not RN), and briefly worked as one.

I would love it. If I have an asthma attack, and I KNOW I’ve had one (I’m asthmatic and have been for 44 years), I don’t need to get dressed, drag my ass to the car, drag my ass to the doctor’s office, drag my ass to the pharmacy, then drag my ass home. I can talk to the dr., s/he can get my peak flow from me, I can discuss if I’m wheezing and where, and if I have a fever. I do let my docs know that I am able to make these assessments on myself and they have been very good at believing me after one exam that mirrored what I’d told them verbally. :slight_smile:

Ditto a sinus infection.

Ditto an arthritis flare-up or something similarly easy.

Obviously, for something like chest pain, you still need an ER.

And OF COURSE docs should be able to bill for this, as well as phone calls.

I’m strictly a patient who has consumed a lot of healthcare the last year (cancer). I was in the ER several times pre and post-surgery and I’m all for anything that would cut down on the wait time. For myself, I’m pretty paranoid these days and would see a doctor for anything I thought serious, but lately I’ve been prone to sinus infections. I know what they feel like in the beginning stages. It would really be nice to have a quick chat with a doctor to confirm and get a prescription called in.

I just read the article and missed the edit window. I’m in Washington state and my own doctor’s office (University of Washington Physicians) is converting most of their clinics to include urgent care. The last time I was there, they had a virtual care terminal right there in the waiting room.

Hmmm, I hadn’t thought about it for routine sinus infection, sore throat type stuff where I have a pretty good idea what’s going on and know I’m about to pay a $150 doc visit just so that he can call in an antibiotic.
I thought about using it last week when I was having, what I though (and still think, haven’t seen the doc yet) a gallbladder attack. I just assumed, though, that they would say ‘go to the ER/Urgent Care/your doctor’ so I never bothered.

Many of my doctors use the Epic systems which allows me to email them. I love that. A few weeks ago my heartburn got really bad. I was on daily omeprazole and we tried about 4 or so other PPIs and some other things all without me ever having to pick up a phone or having an office visit. To a point, I felt a little bad, I mean, it was nice to be able to do all this online, several meds called in to Walgreens, lots of back and forth emails with PAs and NPs, and not a single office visit. I felt bad because they did a lot of work on my behalf and didn’t see a dime from me. But, hey, they offer the service and I’ll take them up on it.

I wonder how doctors feel about it, that’s a lot of money out of their pocket, or could be if it catches on. If it got really popular, to the point that it was actually taking business away from them, they’d have to do something about it. Either negotiate high rates with insurance companies that encourage patients to start there or not work with them. But how does an office/group say ‘Sorry, we don’t take United Healthcare’. They’d lose a lot of patients that way.
It’ll be interesting to see if it stays as a fringe thing that most people don’t use or if it gets more popular and bites into the doctor’s wallets and they actually do something about it. I could see them asking the insurance companies for a few bucks each time a PT talks to the IC directly or doctors, as a group, requesting that the IC’s charge PTs to do this. I mean, the docs are really losing out on the easy cases. The five minute office visits. I’m guessing a lot of these are the ‘hi dr, this hurts’ and the doc says ‘here’s some Rx, call me in two weeks if it doesn’t get better’.

Anyways, I love this commercial for this new system.

@Helena, if you’ve seen the same doc for sinus infections multiple times, next time you have one try calling and saying “I have another sinus infection, could you have the doctor call in some antibiotics for me?” and see if that gets you anywhere. IME, most of my docs will trust you on that kind of thing. Especially if you add in something like “He usually calls in a Z-Pack, that always works”.
I’ve gotten really lucky (but I have some connections) and managed to just get a refill or two on that kind of stuff. That way the next time it happens I don’t even have to call, I just go to Walgreens and grab the refill.

Have I waited long enough to comment?

First, let’s take the case in the OP. We have somebody presenting with acute sinusitis which is usually a viral infection (estimates in adults range from 90-98% of cases are viral) and does NOT require antibiotics. citecitecite However, because the physician cannot actually examine the patient, rather than practicing evidence based medication, he overtreats and prescribes antibiotics which may or may not be necessary. The patient initially feels better, which she attributes to the antibiotics, contributing to the overuse of antibiotics generally and to the frustration of physicians trying to practice good medication who have to daily deal with the patients complaining “Why won’t you just give me the antibiotics-they worked last time” and have to spend much time and effort convincing these patients that antibiotics are not necessary and the normal course of disease is to get better with or without the antibiotics.

But, you argue, the antibiotics did work for this patient. However, as noted in the article:

It seems to me that had she gone to her primary MD initially, a quick exam would have discovered the nasal polyps and she would have been sent straight to the ENT rather than paying for an unnecessary virtual visit, followed by an actual doctor visit before being treated appropriately.

That said, there are some cases where I think virtual consults may be helpful. I could probably diagnose conjunctivitis or a cold virtually, but since I usually diagnose these over the telephone I doubt that a patient would be willing to pay a copay for something that they get for free now. I do think rashes are something that can be treated remotely. As far as asthma is concerned, if I have a reliable patient like GrumpyBunny they could be treated virtually, but again if I know her well enough to know her usual peak flow values then seeing her on a screen isn’t going to add anything to talking to her over the telephone.

Maybe I’ve been in this too long but the only cases where I think that adding visuals to a telephone call would be if there is something visual to sway the diagnosis, such as a rash (ie the patient I saw today with back pain who turned out to have shingles). Otherwise, if a telephone call won’t do it then they need to be seen.

And because this is my personal pet peeve, other conditions that in the vast majority of cases do NOT require antibiotics in otherwise healthy adult patients (I’ll let the pediatricians here deal with the under 16 crowd):

Most sore throats (except for a small percentage of those that have strep and in that case the antibitoics don’t really help the symptoms; they are only used to prevent cardiac complications)
Bronchitis
Influenza
Conjunctivitis

Just to respond to Joey P above:

I don’t take United. I do correspond with patients via a secure email on the portal, though.
Check my links above. A Z-pack is considered inappropriate for treatment of sinusitis at this time due to resistance (2012 Infectious Disease Society of America guidelines) and if your doctor is prescribing a Z-pack for sinus sx then he is not keeping up to date on the latest recommendations.
Any doctor giving out “extra” courses of antibiotics for patients to use when they feel they need them is IMHO practicing poor medicine and directly contributing to the current epidemic of antibiotic resistance.

Hear hear. I’ve had the same GP for going on 20 years and he knows that I have some common sense, and some relatively minor issues that flare up now and again. And I have a whopping 4 days a year of sick leave. I think he’d be fine with diagnosing an asthma flare-up over the phone, or a rash, etc. And I’d be happy to pay for it and save the time and schlepping. And I trust his judgment re: whether he actually needs to see me in person.

(Have I mentioned how much I love my GP? He is now also Tom Scud’s GP. And I love having the kind of doctor/patient relationship where Tom Scud can page him and say “hey, I’m having a kidney stone - is there anything you can do, or do I need to go to the ER?” and he knows about the history of kidney stones and will call in some Vicodin. Which is pretty much what they would do in the ER anyway, only much more expensively and annoyingly.)

Yeah, psychobunny, I think it’s enough of a chance for the healthcare providers to chime in too.

Indeed in my mind too the inevitable result is going to be even poorer antibiotic stewardship than we have now. (Which is already crappy enough in too many cases.) The article and posts here illustrate that what patients want is the antibiotics that they are already sure is what they need. No need to do a urine culture; no need to do a throat swab; no need for an exam.

I see this being done less within the context of established relationships and more along the line of an app that connects you with someone somewhere who you have not ever seen and never will and who is going to most motivated by a high satisfaction rating in a one time visit interaction and volume (which means give the patient what they think they “know” they need, in the least time possible).

I fear that these interactions will undermine the time I invest in rooms explaining why antibiotics are not needed anywhere near as often as many people think they are and why use when not needed causes real harms.

Indeed we (speaking from my pediatric perspective but I suspect is true on adult side too) do give a lot away for free in phone management and MyChart messaging, often talking people down and explaining why they don’t need to be seen for a URI with day 3 of fever and otherwise acting fine, managing the gastroenteritis with home care, and our asthma action plans already have patients empowered to ramp things up and to know when they need to call us to be seen and/or started on a steroid overnight (rather than having to go to the ED). We will commonly call in ear drops for swimmer’s ear and eye drops for straightforward acute conjunctivitis now just as part of what we do for established patients. We’ve tended to look at that as value added that we provide but yes this does appeal to some as a way to actually capture revenue from that care provided.

Yes, lots of rashes could avoid an in person visit with a video look. I could even see it for acne follow up.

But yes to avoid the app scenario I feel we need to offer it ourselves … in a manner that preserves quality control.

I have no idea what’s used for sinus infections. Z-pack was just the first thing that came to mind.
As for my doc giving me refills, I just didn’t want to switch to a different med. I get chronic Migraines (and take Topomax and Imitrex for them), but a few times a year I’ll get one that I just can’t kick. When that happens I have my doc call in a script for Predisone or a Prednisolone dospack. The last time they called it in, they just stuck a refill on it. That way, the next time I have a four day migraine I can hit the refill button on Walgreens and do a round of that without having to call them, leave a message, wait for a nurse to call me back, explain the situation, wait for the nurse to call me back again to tell me they’re going to call it in, wait 4 or 5 hours for it to get called in and ready to be picked up etc. It’s just ready to go.
(Upon seeing the established patient comment somewhere, I should mention that I’ve been with this Neurologist for over 15 years and they probably trust me, after all this time to know when my headache is beyond the ability of Fiorocet or Imitrex and in need of a steroid).

I’ll agree that taking antibiotics just because you don’t feel good is terrible, but if I can call the doc and say “my nose is stuffed up, it’s been like this for three weeks, I feel like I got punched in the eye, my upper teeth feel like they’re being pushed out of my face and I’m blowing green stuff out of my nose” and the doc can look at my chart and says “every June, just like clock work” (don’t know if they’re triggered by seasonal stuff by mine always showed up in spring), I think that might be a good case for calling them in over the phone or even, say, trusting a long term PT that seems to know his body with a refill for the next time. Of course, if it’s just once a year, I’m okay with calling in.

But, FTR, I do have a problem with people that take antibiotics just because. It always bugs me when I whine to someone at work about some ache or pain or sinus infection and they say ‘Do you want some antibiotics?’. If you want to talk about antibiotic resistance, start with the people that are taking their antibiotics for 3 days, feel better and save the rest for later.
@DSeid, I like that you’re calling it Value Added. A lot of people, myself included will put off going to the doctor because of the cost. There’s been plenty of times where I’ve thought to myself “I’ll give this another few days to see if it goes away…or gets worse, I hate to shell about $150 for the doctor to tell me it’s nothing”. Of course then you end up in the ER on Sunday.

As for doing it yourself, I think video might be tough but (like I said earlier) MyChart/Epic works fairly well. The ability to send pictures might help. But, no, you don’t want to lose out on too much money, I understand that. After a certain point, for example, with what I was saying above, I think it’s fair for the provider to ask the PT to come in so they can talk in person (and collect some money).

JoeyP-I absolutely agree with your neurologist who knows you and has followed your migraines for years treating you as noted. What bothers me is the person who calls and says “Joey had a migraine and his doctor called in prednisone and I’ve got a migraine so I need some prednisone too”. Never mind the fact that they’ve never been diagnosed with migraines or been evaluated for their headaches. FWIW, sinus symptoms for more than 7-10 days do actually call for antibiotics so again, if you called with those symptoms and I knew you well I would treat you over the telephone or via email. (My concern had more to do with giving out refills for antibiotics rather than refills on other medications).

DSeid-thanks for the back-up. Sometimes I still feel like Don Quixote out here when it comes to overuse of antibiotics.

IANAD

This technology, as it stands now, may have limited application for initial diagnosis. I could, however, see it being very valuable for follow up visits. My 3 month, 6 month and future 1 year follow up from hip surgery could easily be done over video chat. It would, of course, be at the discretion of the MD and patient - both would have to be comfortable.

I can’t think of anything I’ve been to the doctor for in the past few years that didn’t require some sort of touch. I hate taking antibiotics (I get the yeast infection, upset tummy, and one time psudotumorcerebri!) so I wouldn’t ever be asking for those. I like having my BP taken regularly and my ears looked in to (I have a history of ear problems).

So while I dislike hauling myself out to my GP, I do enjoy the Minute Clinic.

However - for stuff that is just follow-ups like Doctor Jackson mentioned, I think video chat is brilliant. My dad is on a lot of pain meds that require a face-to-face visit every so often and I think it would be beneficial for him. If and when I am diagnosed with Type 2 Diabetes, I would like my regular checkups to be with a video doc.

Let me briefly share my experience with a video physician visit. I live in Jakarta and have retinal problems that far outstrip the ability of the local medical services to deal with. So, I get all my ophthalmological care in Singapore, which has world-class physicians and facilities.

A few years ago, before my cataracts made an intra-ocular lens replacement a necessity, my Singapore doctor recommended IOL but cautioned me that in my case there were far more risks involved than for a typical patient. He urged me to get a second opinion.

Getting a second opinion in Singapore would have been a rather pricy hassle, but I’d heard about this on-line service and gave it a try. It was great - I was connected with a physician of my choice (I did not choose the ones that the site recommended to me based on my brief description of my reason for wanting a consultation, as they were not retinal specialists) and had a great on-line video chat where I was able to ask questions and get clear answers. The doctor even gave me her email address in case I had any follow-up questions.

As it turned out, everything she said perfectly matched what my doctor in Singapore said, except that she was more confident about the likelihood of positive outcomes (not surprising - my doctor is a risk-averse worrywart).

Getting a second opinion by video is not the same thing as getting immediate care, of course. But I am very pleased with the service I received and based on that experience would probably not hesitate to avail myself of a video consultation for medical purposes in the future.

For what it’s worth, my doctor diagnosed me with shingles over the phone (with a followup picture sent by text to confirm), and I was taking antivirals within a few hours of the appearance of the rash. I never did have to come into the office for it. Doing the same thing by video would have been nice, I suppose, but the phone consultation sufficed. I’m very glad that it was available to me.