Tuesday, April 27, 2010

In-person or virtual?

As it becomes easier to interact digitally, there will be plenty of opportunities to see your doctor without the two of you being in the same room at the same time. In many instances this will be more convenient, with equal quality, and with potentially lower costs to the health care system.

On the one hand, a virtual visit can be a fabulous thing all around, but there are certainly times when an in-person visit is more appropriate. So the question I'm asking myself lately is,

How do we decide between an in-person visit and a virtual visit?

The easiest, and possibly best, answer is, "Let the patient choose." This initially looks like the patient-centered approach. And we essentially let the patient choose today in most situations, as patients choose whether to call on the phone, email, or schedule an in-person appointment. But I'm guessing that approach oversimplifies the situation.

There will certainly be situations in which the health care provider should strongly recommend an in-person visit, even when the patient initially prefers a virtual visit. Possible criteria for an in-person visit include:
  • a physical examination is needed
  • an emotionally intense decision needs to be addressed
  • the patient and their primary physician don't yet have a solid relationship, and an in-person visit could help establish rapport that could then be carried over into future virtual visits
Conversely, what are the indications that a virtual visit is more appropriate? When should the health care provider strongly recommend a virtual visit? Here are a few possibilities:
  • the ordeal of traveling to the clinic would be unhealthy
  • biometrics are needed that can be more accurately measured when the patient hasn't just spent two hours walking, riding buses, and being quizzed by people in white coats
  • time is of the essence and a virtual visit could take place sooner than an in-person visit (this criteria could be applied, e.g., in rural areas or anywhere that has long distances between patients and providers)
These are some starting points, hopefully raising interesting and useful questions. Here are a few:
  • Who has done work on this problem? I'm particularly interested in any efforts to quantify the analysis.
  • What metrics can be used to assess the relative value of an in-person or virtual visit? The obvious starting places are quality, cost, and satisfaction, but we would need some way to measure these across a wide variety of contexts, and I fear the measurement would quickly get too complex.
  • How can we apply the tools of human-centered design to these questions? E.g., are there opportunities for rapid prototyping of a decision tool to choose between in-person and virtual?
  • How can we ensure patient safety while experimenting in this space?
  • What are the implications for pricing of care? Should all virtual visits and all in-person visits be covered, or only those deemed "appropriate"?
  • Has anyone attempted to bake this decision into a clinical guideline?
  • Telephone nurse triage systems currently have similar decisions built into their protocols--can we take care of this person over the phone, or do we need to see them? Care models that use telephone MD visits are also relevant. How can we expand what we've learned from these experiences to address a new type of interaction that is typically a less rich than an in-person visit, and more rich than a phone call?
I can't help but come back to the original, simplest answer: an in-person visit is appropriate when the patient wants an in-person visit. The challenge for health care providers is the same challenge as usual: how can we apply our knowledge, expertise, and compassion to help people make sound judgments in the face of uncertainty? Despite the complexities of reimbursement, diagnostics, relationships, and technology, the patient should get to decide. How can we best help them with that decision?

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