While most doctors are cautious as they embark on a telemedicine program, others are plunging right in, seeing and treating unfamiliar patients.

At least one private insurance company is using its website to advertise for patients, telling them they can get a diagnosis and even a prescription, 24/7.  All the patients have to do is log on and select a physician.  If they are new to the Web site, they probably have never seen the stable of doctors before.  Granted, studies have shown a telemedicine visit is just as effective as one in-person.  What I have yet to see is a peer-review study that a physical examination done telemedically is the same as one done in-person.  Personally, I don’t think there’s any difference as long as guidelines are developed, approved and followed.  Without them, we can’t expect states that require an in-person physical exam and complete medical history for the establishment of the doctor-patient relationship to modify their statutes and rules so the exam requirement can be accomplished via videoconference.

Physicians who prescribe prescription medication to unfamiliar patients run the risk of a medical board inquiry because their actions could be interpreted as “Internet prescribing,” a no-no in all but one state.  Some would argue this is the same as a physician’s colleague taking emergency calls from his patients on weekends.  Au contraire mon frere!  The patient calling the doctor who is covering for his colleague already has a doctor-patient relationship with the physician who is away.  Even then, stand-in physicians are very cautious about prescribing, let alone diagnosing the patient’s condition.

Regarding guidelines for physician exams done telemedically to establish the doctor-patient relationship, I suggest that they require a licensed healthcare professional on the patient end to act as the “patient presenter.”  The presenter could be a physical therapist if licensed and trained in exams.  Some states license medical assistants.  Whether it’s a clinic or doctor’s office setting, a nurse normally takes and records your vital signs and jots down your complaint so the doctor doesn’t waste time doing that.  For a telemedicine physical exam, these should be required and provided to the remote physician.  In fact, much of the patient’s medical history can be documented by the presenter in advance of seeing the doctor.

At the request of the physician, presenters should be able to palpate glands or areas of the body where patients experience pain and report what and where the problem seems to be.  It’s helpful if the physician can control the main video camera to watch what is being done.  If the patient has moles, or other skin issues, these should be memorialized with a separate examination camera that can provide close-ups and with image automation software that can pause the video and save the images.  The telemedicine system must also have the ability to share the images live with the remote physician and then preserve them in the patient’s electronic medical record for review at a later date.

The telemedicine system is another tool a doctor can use to extend his practice into areas where there is a shortage of primary care providers.  A kind of fear of the unknown tends to hold doctors back from considering a telemedicine aspect to their practices.  If these new insurance company business models gain popularity and bring in outside doctors via the Internet, physicians may have to get into telemedicine to compete.

Still, without those guidelines for examining new patients, I fear we could easily see some bad outcomes or unintended consequences due to the “wild west” pursuit of patients.