The Quality of Virtual Visits

Virtual visits are increasingly the rage amongst forward-thinking healthcare providers that want to jump on the telehealth band wagon.  Extending the office visit across distance, using the same technology we use to keep in touch with loved ones (videoconferencing such as Skype and FaceTime), is a safe and logical way for providers to venture into a new tech-enabled world that may still be scary for some.
One way to think of this trend is to consider virtual visits an extension of the brick and mortar care model made famous a decade ago by companies like Minute Clinic.  Offer convenient access to a care provider for a limited number of conditions.
Virtual visits can take place by either video or voice connection.  These interactions are most often for indications that are non-life threatening, acute problems such as sore throat, ear ache, urinary tract infection and the like.  There is also a role for this technology in follow up care for conditions such as diabetes and hypertension, but for this post we’ll focus on acute care.
Employers and health plans are interested in this mode of care delivery too.  In a relatively short period of time, virtual visits have gone from a curiosity to a ‘table stakes’ offering in the world of employee health.  Several companies now offer services in the space, most notably Teladoc (now publically traded) and American Well.  These companies are interesting in that they can offer a complete service (i.e., software platform for access and a network of physicians who are waiting by the (video)phone for your call) or pieces of the service (for instance, just the software platform).  This has led to some confusion in the marketplace.  A consumer can now get a virtual visit from Walgreens or CVS (using the complete approach noted above).  Blue Cross of MA offers its fully insured members access to virtual visits through American Well’s software and network.
You can see why provider organizations would sit up and take notice, with concerns about loss of revenue in the very important segment of primary care, as well as fragmented care. Hence, providers are looking very carefully at how they can offer these services themselves, before they are disrupted by the likes of CVS, Walgreens and their local health plan.
With this backdrop, I read two interesting journal articles this month.  The first, published in JAMA Internal Medicine, employed individuals trained to act as patients with the following acute illnesses:  ankle pain, strep throat, common cold, low back pain and urinary tract infection.  These were chosen because there are recognized quality measures (which go by the acronym HEDIS) for how they are to be handled in an outpatient setting.
These fake patients performed 599 virtual visits across a number of different vendor scenarios.  The findings revealed that quality of care delivered by this method is variable.  For instance, the correct diagnosis was arrived at in 458/599 visits.  Rates of guideline-adherent care ranged from 206 visits to 396 across eight different vendors.  The big challenge with this —  and something we have trouble talking about — is lack of comparison to the face-to-face office visit.  For example, in traditional office-based circumstances, doctors misdiagnose and sometimes do not follow established guidelines.
Senior Patient Having Medical Exam With Doctor In Office
The second paper was published in the Journal of Telemedicine and eHealth.  The authors specifically targeted virtual visits from Teladoc and they did the comparison with office visits.  The approach was different, however, in that it involved a retrospective insurance claims analysis from a specific organization, the California Public Employees Retirement System.
The first interesting data point is that of 233,000 eligible individuals, 3,000 took advantage of virtual visits, accounting for just over 4,600 visits.  Utilization of just 1.3% is worth noting for those of us preparing to offer these services in the near future.  We probably don’t need to anticipate an avalanche of demand.
The punch line from this study: Teladoc doctors performed worse on a number of indicators than office-based practitioners.  Specifically, they did not order strep tests as much as office providers and they ordered antibiotics for bronchitis more often.  This makes some intuitive sense, as it is additional work and bother for the virtual doctor to insist the patient get a strep test. (The patient will also be thinking, “Why did I bother to do this virtually and why do they offer this service if I have to travel for a strep test?”)  In the case of antibiotics, the virtual provider may be more cautious without the person in the same room and err on the side of treating with antibiotics.
Both of these papers highlight how early we still are in the widespread adoption of virtual visits.  Though there is lots of pressure to move, and we should do so, we have some time to get it right.  We can take comfort in the low utilization, and work on educating providers on the pitfalls of the virtual environment.  We can also educate our patients up front that even though their entry into the healthcare system will be virtual, they may need to travel to get additional diagnostic services, etc.
It seems that anytime a new tool or technology is introduced, we inevitably apply it broadly, learning as we go that the tool has ideal applications.  Think about how we reflexively use text messaging, email, voice calls and in-person meetings in the context of our work lives.  With time and a thoughtful approach, we’ll get there with virtual visits as well.
Of course there will come a time when that strep test can be done in-home, at the time of the virtual visit (or even before).  We’ll have better tools for determining which cases of bronchitis should be treated with antibiotics.  Who knows, we might even be able to do some sort of portable imaging for your low back pain.
Until then, we’ll be well served to educate both providers and consumers regarding both the excitement and the limitations of virtual visits.