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Introduction to clinical considerations

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As a clinician, we use a stethoscope to listen to heart sounds, we understand what the tool is keeping you from hearing as well as what you are hearing. So even though one can hear the primary “lub-dub” of the heart with a toy stethoscope, we use a higher quality tool so we can hear the murmurs and faint sounds that allow us to determine the presence or absence of pathology. In the same manner, videoconferencing and other communication tools have their limitations and technical issues that a clinician needs to be aware of—which is what we’ll be focusing on. 

When clinically assessing telehealth related technologies, it may be helpful to keep in mind the following: when a clinical provider is presented a patient, whether in person, by video, phone, or in a textual description of the condition, we inherently consider the information that we have been able to collect and the differential diagnosis of possible conditions. The information collected allows a provider to eliminate various items from the differential list while others remain until enough information is acquired to sufficiently remove them. In the office setting, this often means that after we’ve exhausted the amount of information that we can obtain, we often need to send the patient for additional testing such as labs, imaging, or various procedures. In the setting where the interaction is limited by video, audio, or a textual presentation, it simply means that we are unable to remove some items off the differential when compared to those we may have comfortably removed when seeing the patient in person or at a different setting. 

In this mindset, the goal to assess the telehealth technology from a clinical perspective is to identify what information this technology allows one to collect, and more importantly, what are the limitations of that information, and how will that affect the differential diagnosis. An easy example of using some extremes is to consider the resolution of a photograph or video. The lower the resolution, the less detail an image can portray. At a very low resolution, a provider may easily be able to determine gross findings like the patient is missing their leg below the knee and easily support a request for a referral to a prosthetic lab, but, at that same resolution, have difficulty in determining the characteristics of a rash enough to justify a request to prescribe medication. In such a situation, the ability to work through a differential may or may not be impacted by the resolution of the image depending on the presentation of the clinical situation. 

As technology and devices dedicated to remote assessment improve, the clinical provider may also consider including this technology for the in-person exam and office setting. This is no different than what clinicians do when showing a patient their X-ray and explaining the findings. With telehealth technology, one can easily show the eardrum, a red throat, or retinal finding, all of which in the past, hasn’t been easy to share with the patient.