Telemedicine can help to ensure that patients receive timely medical care

Introduction

Telephone consultations (teleconsultations) have increasingly been used as a means of health-care delivery. ^1,2 A good working definition of teleconsultations is ‘the process where calls from people with a health-care problem are received, assessed and managed by giving advice or by referral to a more appropriate service’. ³ One of the main purposes for introducing such services is to help callers manage their own health problems, which in turn reduces unnecessary use of other health-care providers and the associated costs. ^4,5 It has been shown that teleconsultation services reduce the number of immediate visits to physicians without causing adverse events such as subsequent hospitalisations, visits to emergency departments or deaths. ⁶

As well as reducing unnecessary physician visits, teleconsultation services can help to identify patients with serious medical problems, and ensure they receive timely acute care, even if this was not the initial intention of the patient. ⁶ We report a case illustrating this in an out-of-hours teleconsultation performed at a large teleconsultation centre in Switzerland (Swiss Center for Telemedicine Medgate). This centre provides up to 400 medical teleconsultations per day, covering a wide spectrum of medical questions from acute health problems to health behaviour questions. Our services are freely available to all those whose health insurers have a service contract with us, which currently includes well over half of the Swiss population. There are no additional costs for the individual caller, as the fees for our services are not passed on directly. ⁷

Case report

The 69-year-old patient's wife called the Swiss Center for Telemedicine on a Saturday evening because her husband was experiencing freezing, chills and sweating. The couple did not want to bother their general practitioner during the weekend and both felt that the symptoms were not serious. However, they wanted reassurance from a doctor.

The patient was scheduled for hip replacement the following week and had undergone a preoperative check-up the day before the call. This check-up included a physical examination, a chest X-ray and an electrocardiogram, none of which revealed any contraindications for elective surgery. The only pathological finding was a slight anaemia (haemoglobin 128 g/l, reference values 140–180 g/l). The patient was told that there was no immediate need for intervention or further diagnosis, but that his red blood cell count should be monitored.

The teleconsultation was performed by a physician with several years of experience in internal and general medicine, but without a specialty qualification. As an essential part of the consultation, a detailed and structured medical history was taken. This revealed further important information, including the fact that the patient had lost 5 kg in weight during the past two months without dieting. Given this medical history, including age, weight loss, fever and anaemia, one of the differential diagnoses was a potential malignancy, such as a colon carcinoma in combination with a Streptococcus bovis infection. ^8,9

Since this clinical picture was indicative of a serious pathology, the physician at the centre for telemedicine advised the patient to go to the emergency room immediately. The in-patient diagnostic evaluation performed there revealed a systemic inflammatory response syndrome, and a CT scan did indeed show a colonic focus suggestive of cancer. Furthermore, after colonoscopy and a biopsy, an adenocarcinoma of the sigmoid colon was diagnosed. Antibiotic therapy was commenced immediately after admission. Once the signs of inflammation decreased, the patient underwent colon resection and he was discharged from the hospital in good health.

Discussion

Our case report illustrates that even when patients receive highly specialised medical care, health problems pertaining to other medical disciplines may be missed. Teleconsultation services cover a broad range of medical disciplines from a general practice perspective, and are therefore well positioned to identify problems a specialist might overlook. Obviously telemedical diagnosis and treatment have inherent limitations, but telemedical triage and screening clearly have the potential to help improve quality and efficiency by transferring the patient to the appropriate point of care without delay. In the present case, if telemedicine had not been used, the patient might have undergone the scheduled hip replacement, his colon cancer might eventually have been diagnosed, and he might have been at very high risk of life-threatening complications due to sepsis.

This case also demonstrates that teleconsultation services can lower the psychological and physical barriers preventing people in need from accessing medical care. Previous studies have identified a number of such barriers, such as the doctor's lack of responsiveness to patient concerns, medical bills, transportation and reluctance to drive. ¹⁰ Calling a telemedical service centre is relatively anonymous, requires no travel, and has reduced waiting times compared to face-to-face consultations. Patients may prefer to access this type of medical care when they are reluctant to ‘disturb’ their primary care giver, request physical care, or when they seek a second medical opinion. This is of particular significance when the cause of their reluctance is underestimation of the seriousness of their symptoms. These persons might not request medical care in time if teleconsultation services are not available. ^2,11 In the present case, the couple did not wish to disturb their own doctor at the weekend, but were willing to call the telemedicine centre for a teleconsultation, at which point the seriousness of the situation was immediately recognized and the necessary steps were taken.

We also observe that in some instances, the medical history can be a more sensitive diagnostic tool than laboratory and imaging procedures. Even though our patient had undergone an extensive preoperative check-up the day before which did not detect any contraindications for surgery, there was a clear need for immediate referral to emergency care. This was identified purely on the basis of careful, comprehensive medical history-taking. In the majority of cases, this is the only diagnostic tool available to physicians working by telephone. It is therefore crucial that training of physicians working over the phone focuses on good medical history taking. ¹²

The economic effects of teleconsultation services are challenging to measure. It has been shown that about 50% of calls can be managed without having to refer the caller elsewhere. ⁶ These are situations in which assessment shows that home-care measures are appropriate. Following careful selection and counselling, the patients are able to manage their health problem on their own. ⁷ Referring persons to face-to-face encounters who would not have sought physical medical care may initially increase the number of physician visits and hospital admissions. However, the underlying hypothesis is that the overall costs of care will decrease, as the proportion of avoidable serious and expensive outcomes, such as the need for intensive care, will be reduced. ^2,5,6

In conclusion, medical teleconsultation services may not only avoid unnecessary physician visits, but may also facilitate access to appropriate medical care for persons at medical risk who would otherwise not seek treatment in the appropriate time interval. By reducing the threshold discouraging patients from accessing care, teleconsultations can prevent further harm due to delayed medical support, and may even lower costs by reducing the risk of complications. In order to investigate this hypothesis, systematic analyses of the economic effects are needed.