The basis of the teleconsult is the technology used to speak with and see the patient. There are a number of tools available for this purpose and these are broadly categroized in Fig. 6.1 . At the time of writing this book, there are waivers in place due to the COVID-19 pandemic, which allow the use of most video call services, but there will be a time again, when such waivers may not exist, and entirely compliant systems will be required. While many may now employ their smartphone and use the associated video chat functions for telehealth provision, this will not last forever. The use of such systems almost creates a presence in the metaverse for the urologist, who depending on personal preference, may choose to have a separate device, phone number, contracts, and online accounts to separate their telehealth practitioner digital life from their in-person, brick-and-mortar urology practice.
The patient–doctor relationship
Whatever about disrupting healthcare, telehealth has been accused of disrupting the patient–doctor relationship. While telehealth offers to span the geographic distance between patient home and physician office, it could also create distance between patient and doctor, as it could feel impersonal and impact care. Many might be delighted about the newfound promptness with which consultations can be ended in a virtual world, where social norms and etiquette would make a real-world interaction last longer, especially if one of the parties opts to linger longer and share one last anecdote before parting. While some might find these interactions anything from enjoyable to infuriating, they are but one of the many intangibles that form connections between patient and doctor, and promote holistic healing. This relationship between physician and patient can be leveraged to help improve their healthcare, in much the same way physicians use this relationship to help patients improve their health by engaging with new treatments, or to help encourage compliance with care.
Eliminating these unpredictable events can eliminate the authentic nature of individuals in the moment, where that moment, for good or for bad, forms part of the interaction surrounding the medical consultation. Trust, confidentiality, privacy, honesty, and respect are some of the many hallmarks of the patient–doctor relationship. These are formed over time. This is particularly helpful for patients and physicians who have met before a telehealth consultation; as it is very likely a great deal of small talk and nonverbal communication has taken place, and laid the foundation for these hallmarks of the patient-physician relationship, and are essential for good medical care.
Trust is one of the foundational elements of the traditional patient–doctor relationship. A patient’s trust is earned by their physician, but influenced by many things, from the tangible—like the office, its cleanliness, its organization, the seats in the waiting room—to the intangible—like the atmosphere in the practice, and how other staff made them feel. If telehealth is offered in a distilled form, as though transactional and feeling hurried, this will affect how a patient perceives their doctor and how they perceive the care they receive. And of course, there are elements which the doctor is not in control of, which will affect how they are perceived by patients—the technology used to power the telehealth consult. Unfamiliar equipment, unreliable internet connections, unsure if their camera is on, or distrusting of whether some connected device is recording every word they say, or that targeted and personalized adverts will soon reflect the contents of what was intended to be a very private discussion with their physician, can contribute to patients distrusting their physician.
Almost 25 years ago, a study of internal medicine consults demonstrated that ∼1 in 3 brought up new medical concerns at the end of the visit ( ). Another study found that patients were less likely to bring up new concerns when the visit ends with follow-up appointments versus being asked if they have any other concerns ( ). It is also worth considering that in some contexts, patients prefer to have a family member accompany them to doctors’ appointments, and in many face-to-face consults, many will be used to multiple family members, even multiple generations of a family accompanying the patient. While the role of family members as interpreters has been called into question, as they may prioritize their own agenda ( ), their roles in providing emotional support, aiding in mobility, and decision-making, is not ( ), and consultation models, virtual or in person, should include patients companions or family members whom they wish present for the consultation. Technology should work to enable this, and systems designed and instituted to account for these important factors.
The broad categories of tools for conducting a telehealth consult include virtual phone lines, web-portals, virtual chat platforms and other mobile applications, and will be discussed further below ( Fig. 6.1 ).
There are companies that provide a “virtual phone” service, which allows one to have an entirely separate HIPAA compliant 2nd line, on their exisiting mobile phone. These services are essentially a virtual 2nd line, with a distinct and separate phone number, but on your primary device. Advantages of this approach include that you do not have to have a second device, that you can set aside “business hours” for your virtual number outside of which you will not be disturbed, and that patients have another option for greater connectivity with their urologist. This could be a disadvantage if this is being used as an additional point for a variety of incoming communications, which could be unfiltered and not triaged. In smaller practices, such a system would be best used in place of other messaging options, rather than in addition to them as it could just add to what is often already a very onerous workload.
Online patient web portal
Many existing electronic medical record (EMR) providers have integrated an online patient web portal to their offerings ( Fig. 6.2 ). These allow patients an alternative to contacting the physician or their office to receive results, or reminders of what was planned, or was discussed at a prior consultation: they are like a digital front desk. There are many versions of these portals from existing EMR providers. It is possible to create one’s own custom and bespoke patient web portal, and the optionality and customization, are therefore almost limited by the regulations and the risk tolerance of the provider offering the service. The MyChart offering from EPIC or the HealtheLife from Cerner are two very commonly used web-based patient portals that enable various degrees of interaction and engagement between patients and providers. There is plenty of rhetoric extolling the values of patient portals, but in my experience, most patients currently do not derive immense benefit from these as they currently exist. I do believe that there is a generational component to this, both in terms of the understanding of the patients and the providers, but also meaningful interaction is difficult to imbue through existing patient portals that I have experienced. Much of the benefits will come in empowering patients to more meaningfully engage with their own health, but for the majority of people, managing their health is not an everyday reality right now. While I am an advocate and proponent of telehealth, a reality check is required; most people, even those with digital devices designed for these specific purposes, do not know their current blood pressure, the variability in their pulse, or even their respiratory rate and body temperature. When most patients don’t know or care to know their most basic vital signs, why would we expect them to fastidiously monitor anything else about their health? There are many important tools and useful components to help improve patient care, and while they must be developed further, we as a profession must help better engage patients with their health from an earlier stage, so that they do care as much about their biological function, as they do about the content of their social media feed, or the release date of content from a subscription streaming service.