Lessons for Managing Complex Conditions Remotely

Lessons for Managing Complex Conditions Remotely
Thyrotoxicosis offers a case study in practicing specialty telemedicine.

Telemedicine is pushing into unprecedented clinical areas. Providers across disciplines are diagnosing and developing care plans remotely for even complex conditions that require imaging and laboratory draws.

As endocrinologists, Michelle Griffith, M.D., and Howard Baum, M.D., of Vanderbilt University Medical Center have years of experience with remote care. We connected with them to discuss their experience with best practices in telemedicine for complex conditions.

Current Pandemic Response

Discover: Do you have any concerns about the current spike in telemedicine?

Griffith: The spike we are seeing feels appropriate for the situation. Long term, we need more thought into what remote diagnoses are appropriate. We don’t want to create a situation where we’re seeing most patients via telehealth and bringing half of them back into the clinic later. That would be a significant overutilization problem.

We encourage providers across specialties to consider what they are comfortable seeing via telemedicine and create protocols.

Baum: We’ve advocated for telemedicine in endocrinology for a long time and encourage it for specialties that lend themselves to it. The problem historically has been that providers were not substantially reimbursed.

Lessons from Thyrotoxicosis

Discover: You recently published a case report with Lindsay Bischoff, M.D., medical director of the Vanderbilt Thyroid Center, describing thyrotoxicosis management via telemedicine. Why was this important?

Griffith: We saw this article as a way to open the discussion in our own endocrine literature. There are extensive data on diabetes telemedicine. There aren’t a lot of published clinical data on endocrinology telemedicine. There are not even many descriptive papers like this article.

Baum: We also wanted to speak to everyone’s common experience. Thyroid disease is the second most common condition outside of diabetes that endocrinologists deal with. Hyperthyroidism is also not extraordinarily straightforward. There are patients that can be quite ill, so it is a condition where there might be reluctance to use a telemedicine approach.

“Hyperthyroidism is also not extraordinarily straightforward. There are patients that can be quite ill, so it is a condition where there might be reluctance to use a telemedicine approach.”

Discover: What is the bottom line for handling complex cases like the one you described?

Griffith: We described ways providers might think about ensuring safety and doing as thorough an evaluation as possible. That starts with gathering any existing office notes and laboratory values before the initial visit. On video, the patient can assist in some elements of the exam, like grossly determining thyroid tenderness. You can also note gross findings of orbitopathy. You do have to be aware of things like cardiac compromise in these patients, but this can be done remotely with help from adequate histories.

Baum: Plus, you don’t need to do the entire patient interaction remotely. Some specialists may prefer an initial office visit for new thyrotoxic patients and to manage subsequent follow-up visits via telemedicine. There are going to be circumstances where you just have to see the patient. You may need to order radiology services or antibody testing to determine disease etiology.

Patient Perspective

Discover: What are you learning from your patients?

Baum: Right now, we all may be compromising a bit and seeing certain patients remotely when we’d prefer more face-to-face visits. Some patients are uncomfortable with a remote interaction in principle, or they don’t have the equipment or skillset to participate. At larger institutions, security and compliance safeguards can make it a more challenging technical interaction than they are used to.

Griffith: In the case of our 30-year-old thyrotoxicosis patient, she was able to go to an affiliated laboratory near her home without putting herself at undue risk. We placed all orders electronically and ultimately were able to successfully diagnose and treat Graves disease remotely.

Imaging Challenges

Discover: What are the issues with obtaining reliable imaging?

Griffith: While laboratory values are generally pretty consistent between testing sites, imaging is not always comparable. It can be really operator dependent. Imaging quality also varies based on volume performed at a center.

While we’ve been liberal with that during the pandemic, and describe imaging workarounds in our paper, when we think about long-term telemedicine, we need more interoperability between radiology systems. That would make it easier for us to lay eyes on remote imaging without having to wait for disks that are literally mailed to us. That’s an addressable factor.

Guideline Updates

Discover: What needs to happen at the national level?

Baum: All of our published guidelines, and training, are based on face-to-face interactions with the patient. It begs the question, what is the appropriate way to use and modify existing guidelines when interacting with the patient via telemedicine?

“It begs the question, what is the appropriate way to use and modify existing guidelines when interacting with the patient via telemedicine?”

With our case report, we started to identify some agreed upon principles. The decisions regarding what patient visit is appropriate for telemedicine is based strictly on an individual patient’s situation. I hope we get to a point where the pandemic is no longer a deciding factor.