COMMENTARY

Doctors Demonstrate How to Conduct a Telemedicine Exam

Neal Sikka, MD; Adam J. Rutenberg, DO, MBA

Disclosures

June 17, 2020

This transcript has been edited for clarity.

With the increased use of telemedicine during the COVID-19 pandemic, Medscape asked Neal Sikka, MD, associate professor in the department of emergency medicine at the George Washington University School of Medicine and Health Services, to provide guidance for physicians. Here, Sikka is joined by his fellow instructor in the department, Adam J. Rutenberg, DO, MBA, who is playing the role of a patient, to demonstrate the effective use of telemedicine for a patient exam.

Neal Sikka, MD: It's important to project a professional image when you have a telemedicine visit. This is very important for patient engagement. You should treat your telemedicine visit in the same way you would treat your in-person appointments. You should be professionally dressed, you should have a neutral background, and you should ensure that you are appropriately lit. The patient should be able to see your face completely. You should not have windows or bright lights behind you. Front lighting may be of benefit.

Your head and shoulders should be centered in the frame and you should make sure your patient knows that you'll be looking away to a second screen if you'll be simultaneously documenting in your electronic health record.

Starting the Telemedicine Consultation

Sikka: It's very important to begin your consultation by introducing yourself as well as by confirming the identity of your patient and their location.

You will want to review your telemedicine consent with them verbally during the visit. Confirm who they are, where they are, a callback number, and that they understand any of the risk that may be associated with an online appointment.

Help the Patient Help You to Conduct a Better Exam

Sikka: I'd like to go through a brief neurologic exam with you. One of the things to think about is that often the image can be reversed when you look at video, so you want to give directional commands to the patient, and we'll demonstrate that. One way you can verify whether you're having a mirror problem is to ask the patient to raise the same hand that you are.

[To patient] Do you mind raising your right hand, please? Now we all have context for where we're going to start.

We'll go through some of the cranial nerve exam. I'm going to test your different parts of your brain now, and I'd like you to follow a few of my directions the best that you can. If you don't mind, I'd like you to look all the way to your right. And then I'll have you turn your neck all the way to your left. Great.

Now I'd like to try to get a good look at your eyes, so I'll have you move in a little bit. There you go. And now I want you—without turning your head—to just look with your eyes to your right. Perfect. And now can you look all the way to your left? Excellent. If you can look up... Great. Look down. And then I'll have you look to the upper left. Excellent. Upper right. Lower left. And lower right.

You can also use terms like "look toward your nose or away from your nose."

All right, we're going to check a few other parts of the neurologic exam. Actually, I liked it as you were sitting close to the screen. That'll help me observe your findings. If you can smile for me and show me all your teeth, please. Excellent. And, if you don't mind, close your mouth and fill your cheeks up with air. Perfect.

I'd like you to stick your tongue out, please. Excellent. And can you make the sound "ah"? Perfect.

You might get a better examination of the posterior pharynx if you can have the patient be prepared with a flashlight.

We'll go on with a couple more findings here. I'll have you shrug your shoulders up for me, please. Perfect. Any difficulty doing that now?

Patient: No.

Sikka: We're also going to have you look for weakness—and this is kind of a marker for subtle weakness. If you can close your eyes and put your hands out in front of you or just straight and just hold your hands straight up there. I'm going to count to 10: 1, 2, 3, 4, 5, 6, 7, 8, 9, 10. Okay, you can open your eyes up.

I'm a little concerned that your right arm might be feeling weak. Have you noticed any trouble with that right arm?

Patient: Not really. Maybe sometimes I've noticed I've been a little less coordinated with it. Like when I go to pick up my coffee mug, it's a little harder to grab.

Sikka: What about grasping a doorknob?

Patient: I don't know if I've really noticed, but it's something I can look out for.

Sikka: Well, let's try another evaluation of your power. We'll start with your left arm, and I'll have you put your left arm up in the air. I want you to hold it. Actually, if you don't mind moving a little bit back so I can get a good view of your arm—perfect.

Just hold it there with your thumb up like this. Perfect. I'm going to count to 5. Just hold it steady: 1, 2, 3, 4, 5. Excellent. Now I'll have you shift a little bit on your screen for me. I want to do the same thing with the other side. With your thumb up, I'm going to have you put your arm up in the air, and I want you to hold it for 1, 2, 3, 4, 5. Do you find that a little bit harder to do on the right side than on the left side?

Patient: I do. I do.

Sikka: So that's a concerning finding to me. How long have you been feeling that way?

Patient: Maybe a period of a couple of months.

Sikka: A couple of months. So it's not something that's very new to you?

Patient: No.

Sikka: Well, it's definitely a concerning finding. I think it warrants an in-person examination to get a better sense of what's going on; we should get you into the clinic within the next 24 hours for an evaluation. I'll have the office give you a call to schedule that and give you the location.

[Back to audience] As you saw in the visit, the medicine components of a telemedicine visit are the same as they are in person. You need to elicit the same information you would from your patient and the history component. You need to perform a physical exam within the limitations of the modality you are using and then make decisions the same way you would as if you're seeing the patient in person. You may have to make considerations that the patient would have to leave their home and go to a specific location for testing, such as lab, strep swabs, or x-ray.

One of the most common concerns we hear regarding telemedicine is how to do a physical exam. You saw in the video that we were able to conduct a fairly comprehensive physical exam by having the patient relay exam findings back to me as a provider for interpretation.

Let's look at examples and aspects of the physical exam in more detail.

Vital Signs, Using a Second Device, and Useful Exam Strategies

Sikka: In addition to the general appearance of the patient, the only vital sign you can directly collect over video is the respiratory rate. However, today, many patients have devices such as a smartwatch or fitness tracker, even a blood pressure cuff or a pulse ox, at home. They'll often have a thermometer and a scale as well.

You can use these types of devices to have the patient either collect the information before your consultation or even during your consultation.

Many parts of the examination would be considered an eyeball or visual exam. You may ask your patient to sign into the chat or video consultation with a second device, such as their smartphone, so that you can manipulate a camera from a different angle.

They may also need a flashlight or use the flash on their phone to aid in the exam—for example, in illuminating the back of the throat, a tooth, the eye, or even a rash or a mole.

You can ask your patient to perform many simple physical exam maneuvers that you would do in the office and relay the results back to you.

For example, you can have them pressing their ankles for pitting edema. You could use a family caregiver to help you accomplish a physical exam of the abdomen. You could also have them walk, bend, move their arms or eyes, as well as balance on one foot or jump up and down to elicit pain. These are all strategies we've used when examining the pediatric patient or sometimes when doing a more difficult physical exam in person.

About Neurologic Exams

Sikka: As we've demonstrated in the video, you can carry out a very comprehensive neurologic exam. This has been seen in the extensive use of telestroke.

Just as with an in-person visit, it's really important that you document your visit and that your patient understands your discharge instructions or their next steps after the teleconsultation. You should use verbal counseling and, where possible, these steps should be included in a document that the patient can access easily.

For example, if you have a patient portal or some other type of secure messaging service, this would be a great place to post that information.

Practical Considerations, Contracts, and Regulation

Sikka: Now that you've seen some examples of how simple it is to have a telemedicine encounter with a patient, let's talk about some of the practical considerations.

You probably can't see every single one of your patients via telemedicine. Sometimes their complaint or something about the patient makes it more difficult for you to accomplish the goals you need to over telemedicine, but you will find that a very large percentage of patients will qualify.

You should select patients who can benefit primarily from a cognitive consult, using your experience and expertise to help them accomplish their goals. If you can't perform a procedure, you could do some of the pre-work before they have to come in to the office for the procedure.

You could also do a variety of physical exam techniques over telemedicine to help you determine whether a procedure is actually necessary. You also may want to consider things like patient mobility, comorbidities, or clinical vulnerabilities such as immunosuppression to decide which patients to keep out of the office.

The patchwork nature of licensing and payment rules means that it's important to review the laws and contracts that govern your practice. It's critically important that prior to starting a telemedicine program, you review the specific state regulations and review the individual payer contracts that you have to understand reimbursement and any kind of documentation requirements.

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