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An evidence-base for e-consultations

More research is required before telemedicine becomes mainstream practice

First of all, a confession: Bless me, for I have sinned.

‘What is Houston going to admit to’, you are wondering.

Hopefully a scandal of tabloid proportions? Or maybe, after years of personal probity, the true nature of the man is about to be revealed?

Well, actually, the confession is a tad less dramatic than that. But it’s a confession nonetheless: I have been highly suspicious of video consultations for some years now. Making decisions about patients without the option of physically examining them just seemed fundamentally wrong.

How could a doctor possibly stand over clinical decisions made at such a remove? To say that I was wary of some forms of telemedicine would have been an understatement.

Then along came Covid-19, and the mass switching to telemedicine by doctors in all disciplines. It was forced on us overnight as part of social distancing and limiting the spread of the novel coronavirus. Yet it has worked remarkably well, despite the rushed introduction. One prominent GP now refers to his ‘kitchen-table’ consultations with some satisfaction. And the public are voting with their feet. Instead of trotting down to the local surgery, they have been happily engaging in teleconsultations with their doctors. Whatever about us, they don’t seem to have a problem with the obvious limitations of ‘hands-off’ consultations.

What do the medical defence organisations have to say? Here is Medisec’s advice:

 “While it is obviously preferable to consult with patients in person, remote consultations by telephone or video link are becoming more and more frequent in order to protect everyone’s safety and help prevent the spread of Covid-19.

 “Be clear about what you are offering on the call — whether it is medical advice, triage or Covid-19 related guidance. If it is general medical advice, consider whether it can be safely given over the phone or whether a face-to-face consultation or immediate referral may be necessary.”

Medisec goes on to warn about inappropriate remote consultations, such as those for patients with chest pain.

“A protocol should be in place to ensure a plan for patients seeking these types of consultations. If you have doubts that it would be in the patient’s best interests to proceed with a remote consultation, then you should recommend the most appropriate route for the patient to seek medical assistance, in accordance with HSE/HPSC guidance”, it advises.

So far, so cautious, as you would expect from a highly-respected organisation. An acknowledgment of the new reality, but with the primacy of hands-on consulting clearly emphasised. But for professional bodies to move to a position of encouraging a greater degree of remote consulting will require good evidence of safety and efficacy.

One of the most recent pieces of research is into the practice of e-medicine, specifically the use of email consults by primary care physicians with specialists.

Writing in the Annals of Internal Medicine, Salman Ahmed and colleagues from the Brigham and Women’s Hospital in Boston developed novel metrics to evaluate the appropriateness of email consults and their effectiveness in avoiding face-to-face visits. To evaluate appropriateness, they reviewed a random sample of 150 medical records from each of five specialties with a high volume of email consults: Psychiatry, haematology, dermatology, infectious disease, and rheumatology. Appropriate email consults asked questions that met all four of the following criteria: They could not be answered by reference to guidelines; they were not about a logistics issue; they were non-urgent; and they were appropriately complex for evaluation via medical record review.

This research, which predated the emergence of Covid-19, found 70 per cent of email consults to be appropriate, ranging from 61 per cent in rheumatology, to 78 per cent in psychiatry. Across all specialties, some 81 per cent of email consults were associated with avoided visits; this percentage ranged from 62 in dermatology to 93 in psychiatry.

Interestingly, the authors found that email consults may affect healthcare use on several fronts outside of face-to-face visits. They shift responsibility for care back to the referring provider, so use of primary care or emergency services may actually increase.

Although the research did not look at telemedicine consultations per se, it is a good example of the kind of robust research needed to back-up a major change in clinical practice. Clinicians and policy-makers (and yours truly!) need robust information on how telemedicine consults affect outcomes and change healthcare use before recent developments become mainstream practice.

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