New ways of consulting physicians will require new ways of regulating practices.
In a commercial virtual visit, patients use a website to request a live consultation with a doctor they have not met before. They will consult with the physician through a video conference, telephone or web chat.
Commercial virtual visit companies do not offer in-person care, but they are easy to access, especially for consultations about acute conditions.
They can be an attractive option for patients who have difficulty accessing conventional health care, such as primary care practices, retail clinics and urgent care centers.
In 2013, less than 50% of American adults were able to make an appointment with their physician on the same or the next day, and fewer than 40% had access to care outside regular hours, unless they went to the emergency department.
Virtual health care: a growing trend
The number of companies offering commercial virtual visits has been expanding, and customers are increasingly willing to accept such care. One company states that over 6 million people use their services.
- Analysts estimate there were 2 million video consultations in 2015
- Experts project a 25% growth annually over the next 5 years
- They predict that there will be 27 million video consultations in 2020.
One major insurer in the US now has its own virtual visit service, and, from 2010-2012, the number of large employers offering virtual visits increased threefold.
Concern for standards has caused some state medical boards to limit the ways in which virtual visits can be performed. Restrictions include only allowing telemedicine if there is an on-going physician-patient relationship. One authority requires the visit to be carried out by video conference, rather than web chat or telephone.
There are also questions regarding interstate virtual visits and which government agencies should oversee them.
How urgent the need for a regulatory framework is will depend on the extent to which the quality of care varies among companies offering virtual visits.
Dr. Adam J. Schoenfeld, of the University of California-San Francisco, and colleagues have been looking into the consistency of care accessed through virtual visits.
The team recruited 67 trained, standardized patients to approach eight virtual visit companies from May 2013-June 2014. The patients made 599 commercial virtual visits with 157 physicians specializing in internal medicine, emergency medicine and family practice.
Patients presented with one of six common acute conditions - low back pain, ankle pain, recurrent female urinary tract infection, streptococcal pharyngitis (strep throat), viral pharyngitis (a sore throat) and acute rhinosinusitis (sinus infection) - and participated in 372 videoconferences, 170 telephone consultations and 57 web chats.
Accuracy of diagnosis depends on condition and provider
The authors evaluated the completeness of the history and physical examinations, how correct the diagnosis was, and to what extent physicians followed relevant guidelines for managing the condition, for example, recommending tests or prescribing medication.
Findings showed that:
- In 69.6% of consultations, physicians asked all the recommended history questions and carried out all relevant aspects of physical examination
- In 76.5% of cases, the diagnosis was correct, 14.9% of diagnoses were wrong, and in 8.7% of consultations, no diagnosis was given
- In 54.3% of consultations, clinicians followed guidelines for key management decisions
- In 13.9% of visits, the physician referred patients to local, conventional health care providers.
Overall, results indicate variation regarding the completeness of the history and physical examination and accuracy of diagnosis. Consistency depended on the condition and the company consulted. For example, there was greater variation in consultations for viral pharyngitis and acute rhinosinusitis than for the other conditions.
The authors cite previous studies highlighting variation in traditional care settings, too, for example in failure to follow guidelines.
Limitations include the fact that not all virtual visit companies were included, and the sample size was relatively small.
Nevertheless, the authors conclude:
"We found a significant variation cross companies and by condition. The patterns of variation we observed imply an opportunity to improve and point toward approaches to determine how to make these improvements."
In a linked comment, Dr. Jeffrey A. Linder and Dr. David M. Levine, of Brigham and Women's Hospital in Boston, MA, note that health care is undergoing rapid organizational shifts and changes in financing, giving rise to "growing pains."
They say the high variability and lack of co-ordination seen in this study constitute "low-value care."
High-value care, they say, is "flexible (online, telephone, in-person and emergent), coordinated, longitudinal and proactive based on strong relationships with a primary care team," and it will be the hallmark of mature health care communication technology.
Medical News Today reported recently on how mHealth solutions are revolutionizing patient care.