5 health systems on how they're making sure diagnoses aren't missed virtually

With the shift to digital and telehealth that accelerated during the pandemic, providers have to accurately diagnose and treat diseases in patients who they may only see over a computer screen.

A recent Mayo Clinic study published in JAMA Network Open found telemedicine can be just as accurate as in-person visits for diagnosing a variety of medical conditions. The provisional diagnosis over video matched the in-person reference standard in 87 percent of cases, according to the sample of 2,393 patients who had video appointments followed by a face-to-face outpatient visit within 90 days.

But is anything lost in the digital translation? Are missed diagnoses that could be a matter of life or death still possible?

Becker's posed those questions to chief digital officers and other healthcare leaders and asked how their health systems were reacting. Here are five who responded.

Note: Their remarks have been lightly edited for clarity.

Bart Demaerschalk, MD. Medical Director of Research and Outcomes for the Center for Digital Health at Mayo Clinic (Rochester, Minn.): At Mayo Clinic, the increase in telemedicine volume during the COVID-19 pandemic enabled our organization to gather data on video telemedicine visits on a larger scale than had previously been possible. At Mayo Clinic Center for Digital Health, we made it our objective [for the JAMA study] to determine the accuracy of provisional diagnoses established at a video telemedicine visit with diagnoses established at an in-person visit for patients presenting with a new clinical problem.

To mitigate the risk of certain conditions being missed by telemedicine, Mayo Clinic adopts a variety of strategies, including:

  • Effective strategic appointment intake
  • Screening and triaging
  • Pre-visit planning
  • Matching clinical concerns of existing and new patients with visit modalities (e.g., portal messaging, interactive care plans, remote patient monitoring, e-consultations, telephone visits, video telemedicine, and on-campus, in-office consultations)
  • Moving beyond hybrid care to fully integrating in-person and virtual care based on clinical appropriateness

Tony Ambrozie. Senior Vice President and Chief Digital and Information Officer for Baptist Health South Florida (Coral Gables): First, we need to modify the simplistic idea of an either/or choice for virtual and physical encounters. They are both part of a continuum of care, used contextually and situationally. For example, care can start virtually and then continue physically followed by other virtual encounters.

Second, it is not impossible but by no means probable that, during a virtual encounter, a condition could potentially be missed that otherwise could conceivably be detected in a physical encounter. But location is not destiny, and we rely on the dedicated judgment of physicians to ask meaningful questions in a virtual visit that could lead them to request a physical encounter to further explore an avenue of diagnostics. Furthermore, most providers do ask for regular physical encounters to catch any other symptoms that patients may miss reporting in an unrelated virtual encounter.

Finally, and most importantly, what virtual visits uniquely add is additional access to encounters and thus care that otherwise may not be available or convenient at the time of need. Short of the emergency department, only virtual visits are available and accessible 24/7 — and extended time availability is not just a matter of urgent access but of convenience to busy, unable-to-easily-travel or procrastinating patients. That virtual visit provides the immediate care path and could also act as an early triage for investigations into more serious issues that otherwise would not have been detected early enough without the virtual visit in the first place.

Ashis Barad, MD. Chief Digital Officer of Allegheny Health Network (Pittsburgh): At Allegheny Health Network, we have placed a tremendous amount of focus on creating access and convenience with virtual and digital health tools, especially at the height of the pandemic. We believe in an omnichannel care experience with both synchronous and asynchronous tools. This allows us to shift to an "always-on" model of care to be with our patients and members in order to give them guided choices.

In order to avoid missed conditions, it's important to move into a personalized and proactive care model. That is what we are doing with [Allegheny parent company] Highmark Health's Living Health model. We have partnered with Google Cloud and Verily to develop an analytical, data-driven engine to step in ahead of time and engage people in their health even before they think of scheduling a doctor's visit. We will deliver this in a curated design that will deliver a plan for health when, where and how people need it. Guided, personalized, proactive, always-on navigation with a consumer-friendly experience is how we see the future of digital health.

Edmondo Robinson, MD. Senior Vice President and Chief Digital Officer of Moffitt Cancer Center (Tampa, Fla.): Remote or virtual engagements with patients are clearly not appropriate in all cases. One approach to addressing this could be to develop evidence-based algorithms that determine the optimal patient engagement channel (digital or otherwise) based on the presenting characteristics of the patient. Importantly, those presenting characteristics should not just be clinical but should also take patient preference into account.

Topher Sharp, MD. Chief Medical Information Officer of Stanford Health Care (Palo Alto, Calif.): Stanford Health Care is committed to digital health and telehealth in service of our patients. As of September 2022, we are providing approximately 30 percent of all ambulatory care through telehealth. Stanford Health Care has taken specific measures to ensure diagnoses and conditions are not missed that would have been caught at in-person visits.

First, we have established telehealth clinical appropriateness criteria at specialty and condition-specific levels. Second, we have identified equivalent quality by monitoring the need for urgent repeat appointments or emergency department visits. Stanford Health Care also uses a hybrid (i.e., both telehealth and in-person) approach to ensure a high quality of care.

In oncology, for example, while many patients interface with their physician (oncologist) via telehealth, the actual therapies (e.g., chemotherapy) are administered by specialized nurses who evaluate these patients in person and are in constant communication with the physicians and care teams. This hybrid, team-centered approach allows us to extend telehealth to a broader population while ensuring the same high quality of care.

Last, training is essential to ensure care that is provided through telehealth meets the same examination standards and creates a meaningful connection with patients.

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