The Option for Virtual Medical Encounters Should Stay

Last December, I provided vacation coverage for a physician with a PA/LTC practice.  Because of the pandemic, I obtained the agreement of the facility administrative team, that our first approach to changes of condition (COC) would be a telemedicine visit, rather than the usual triage by fax or phone. 

My first case was an older long-stay resident with dementia and an acute PUI with new cough and diffuse rales.  The text messages from her nurse indicated the patient had stable vital signs, normal SaO2 and that a nasopharyngeal swab for COVID-19 by PCR had been sent, and cough medicine requested.  The text ended with “this is just an FYI.”  

I was uncomfortable not becoming more involved, so I called, began asking questions and quickly found the nurse hadn’t reviewed past history, current/new meds, allergies, end-of-life care preferences, or whether rales had ever been heard before.  I advised I would review the electronic records for this information and requested she FaceTime me from the patient’s room once she could fit that in her schedule and be in full PPE.  The records revealed the previous chest exams were clear, but that this 86-year-old woman had a past medical history of moderate high blood pressure, Rheumatoid Arthritis controlled with weekly Methotrexate injections, frailty, and frequent falls.  On our subsequent FaceTime encounter, I saw this patient sitting up in a chair.  She didn’t look sick, but was coughing frequently.  She readily acknowledged some weakness, but volunteered she had gone to the bathroom by herself by “wall walking.”  She couldn’t recall having a headache, nasal congestion, sore throat, hemoptysis, chest pain, or nausea.  On the POLST Form, she had previously chosen selective care, including the option for non-invasive positive pressure ventilation (e.g., BiPAP).  However, at this moment, her main concern was not giving COVID to anyone else.  She was willing to receive IV monoclonal antibodies, but didn’t want any nebulized therapy, since she didn’t want to risk spreading COVID to others.  I subsequently called her family member with DPOAHC, who confirmed these choices.  With the nurse still at the bedside, I ordered a new nasopharyngeal swab for POC antigen test for COVID, Influenza, and RSV.  A portable chest X-ray was ordered, which confirmed a diffuse viral-like pneumonia.  I requested more frequent monitoring of vital signs, SaO2, meal and fluid intake, and greater mobility support to reduce her fall risk.  

Having laid my eyes on this patient, taken a history, and discussed care options, I was much more comfortable with the new, modified care plan.  In addition, I was able to create a note in the medical record documenting this change of condition (COC) for future use by our team as well as her PCP.  I also demonstrated to this relatively new nurse the value of a real-time team assessment of COCs.  In particular, she was not aware of the IV monoclonal antibody option as well as the impression that it is most effective given within the first 3 days of symptoms, and therefore should have a same day POC antigen test.   This patient proved to be negative for COVID, though, and subsequently did well.   

In thinking about this case, the virtual process allowed me to do a better off-site assessment, directly involve the treating nurse without wasting her time, document my findings, and bill for my services.  If there had been a bad outcome in this case after the above FYI text message or after my virtual assessment, the latter would provide a much better defense when investigated by DHS or a plaintiff attorney.  

From my perspective, virtual medicine is likely to be a better practice for managing COCs by covering physicians who don’t know the patient.  This process will likely take more provider time than traditional triage approaches, but the greater diagnostic precision, timely care plan modifications, improved documentation, and billable encounter should improve patient outcomes and lower provider and facility risk for regulatory actions and litigation.  

I used FaceTime for these visits, since the facility had very limited capacity for more secure virtual platforms (mainly charge nurses).  In the future, I hope facilities will make a more secure platform available to all their licensed staff.  

From my perspective, the virtual process passes the “my mother test.”  I hope your facility and providers will make this a high priority in 2021.

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