PracticalDermatology

One of the fastest growing segments in the so-called “digital health” space (#digitalhealth for the tweeters out there) is the proliferation of telemedicine and tele-consultation tools, which leverage cloud computing and ubiquitous mobile technology for delivery of health care. This article will not focus on any one product (the author has actually invested in a couple of companies that provide telemedicine services for different specialties or use cases) but rather on the promises and pitfalls of remote medical consultation and care delivery with an eye to the aesthetics industry.

What is Telemedicine?

First, a definition from everybody’s favorite reference Wikipedia: Telemedicine is the use of telecommunication and information technologies in order to provide clinical health care at a distance. Common uses of telemedicine include emergency triage, dermatologic screening for rashes and skin lesions, radiologic study review, remote vital sign monitoring, or even telesurgery using robotic systems. In the aesthetic and plastic surgery space, the most common uses of telemedicine technologies involve initial cosmetic consultations and later follow-up sessions for out-of-town patients, and a variety of implementations in early postoperative tracking, wound triage, and recovery coaching. The advantages of telemedicine include the capacity to store-and-forward information, perform remote data gathering using mobile technologies, and having simultaneous interactions despite physical separation.

The ability to store information at the patient’s location (for example, a picture of a healing incision, a laceration that may or may not require plastic surgical closure, an area of bruising after a facelift, etc.), and to forward it to the physician for evaluation when the patient and physician need not be present or online simultaneously, may confer some time-saving advantages to the provider’s practice, in that after-hours care may be appropriate for certain issues. Remote monitoring can facilitate wellness assessments with the tracking of nutritional intake, physical activity, laboratory testing (like in-home blood sugar monitoring), sleep patterns, and, with Apple’s recent HealthKit announcements, even reproductive health. Full interactive software suites offer real-time video and audio tools, text chatting capabilities and potentially supplemental media sharing opportunities (like photo or pre-recorded video clip transmission), creating a rich experience for patient and physician. Newer telemedicine systems feature direct integration into the electronic health record, allowing capture of the remote encounters into the patient’s virtual chart without requiring extra steps from the office staff to memorialize the event and the content of the encounter.

I personally utilize tele-consultation tools on occasion for out-of-town patients as a screening tool for candidacy for surgery but always with the caveat that a tele-consultation is not a substitute for an in-person examination. It is critical that providers using tele-consultation for preoperative aesthetic patients inform the patients that in-person examination findings may change the physician’s recommendations or even eliminate the patient from candidacy for a proposed procedure. It is not uncommon, for example to make an altered recommendation regarding mastopexy to a patient initially seeking teleconsultation for a breast augmentation, as physical exam findings and measurements not easily gleaned from a remote session may alter the surgeon’s opinion regarding the most appropriate procedure. If an out-of-town patient’s expectations are not properly set in such a scenario, there may be a disconnect between the patient’s goals, budget or perceptions and what the surgeon can realistically offer and deliver. It is equally, if not more important to exercise prudence in the use of telemedicine tools for aftercare—determining whether a red spot on an incision is a stitch abscess, rash from topical adhesives, or a threatened implant infection requiring hospitalization may only be feasible in person, although a tele-consultation may help the surgeon appropriately triage the remote patient to obtain a more rapid in-person examination while providing some level of reassurance and continuity of care.

Mitigating the Downside

Telemedicine is not without its drawbacks. One of the most important aspects is the concept of disclosure and informed consent. It is easily imaginable that non-qualified practitioners or even laypeople could masquerade as qualified providers when the first or main point of contact does not require verification of a physical office or the provider’s identity and credentials, let alone any paper trail confirming consent to treatment or privacy notifications, etc. Naturally, this ought to be a rare occurrence, but then again, I have practiced in South Florida for over a decade, so…no. A good strategy would be to not initiate tele-consultation services until a patient has had a routine initial phone call and completed standard office paperwork consenting to care, furnishing intake data, and signing HIPAA notifications, which can be completed remotely and securely transmitted back to the office. Physicians should take time to learn their states’ statutory regulations on the use of telemedicine as well as the licensure requirements to offer such services, as these vary from state to state. Likewise, insurance providers are evolving in their approach to coverage for telemedicine services, with many providing parity of payment for remote visits and in-person ones, while others may discount the tele-visit payment rate. Physicians taking insurance may need to balance the potential convenience and “office extending” capability of telemedicine tools against the reimbursement for these services. It is possible that tele-encounters may actually decrease office productivity due to the all-too-frequent experience of technical difficulties initializing and commencing with a remote session even in today’s ultra-mobile and interconnected world. I can’t even estimate the number of times I have had to go through permutations of checking internet server status, wi-fi connectedness, VPN accessibility, password correctness, audio input settings, poor lighting conditions, and audio-video latency turning what was meant to be an efficient, state-of-the-art tele-consultation session into some laughable parody of a poorly dubbed martial arts movie. Another major drawback of tele-medicine is the inability to deliver initial hands-on service at the point of care in real-time, such as starting an IV to hydrate the pallid patient (or is that just the color balance on my Roku device?), provide medication samples, drain an apparent hematoma, or manage some other issue that could benefit from immediate intervention. Finally, it goes without saying that HIPAA privacy and secure messaging are part of a “best practices” approach to telemedicine delivery.

Enhancing Delivery

Telemedicine has incredible potential to enhance the delivery of consultative and postoperative care in the aesthetic space, with the promise for improved patient and physician time management and a comprehensive end-to-end periprocedural experience for difficult-to-manage remote patients. n

Tim A. Sayed, MD is a double board-certified plastic surgeon in California and Florida. He works in the healthcare technology space as a developer, consultant, and investor.