Pros and Cons of Telehealth

Telehealth, the use of electronic information and telecommunication technologies to support long-distance clinical healthcare, patient and professional health education, and public health, offers numerous advantages but also comes with distinct challenges.

Pros of Telehealth:

1. Increased Accessibility and Convenience:
   • Geographic Barriers Removed: Bridges the gap for patients in rural or underserved areas who lack access to specialists or healthcare facilities, which is particularly relevant in a country like Kenya where healthcare access can be geographically skewed.
   • Reduced Travel Time and Costs: Eliminates the need for patients to commute, saving time, fuel, and reducing public transport costs, benefiting both patients and potentially the environment. This is a significant advantage for patients who might need to travel long distances to Kisumu’s major hospitals.
   • Improved Access for Vulnerable Populations: Benefits individuals with mobility issues, disabilities, chronic conditions, or those who find it difficult to leave home (e.g., immunocompromised, new mothers).
   • Reduced Wait Times: In some cases, telehealth can offer quicker access to appointments, potentially reducing long queues at clinics.
2. Continuity of Care and Chronic Disease Management:
   • Regular Monitoring: Facilitates frequent check-ins for chronic conditions (e.g., diabetes, hypertension, HIV management), allowing for timely adjustments to treatment plans.
   • Medication Management: Easier for providers to monitor medication adherence and side effects.
   • Follow-up Appointments: Simplifies follow-up visits post-surgery or acute illness, ensuring ongoing care without requiring a physical presence.
3. Cost-Effectiveness (for certain aspects):
   • Reduced Overhead: For providers, it can reduce clinic overheads (e.g., less need for large waiting areas, administrative staff for scheduling).
   • Lower Patient Costs: Patients save on transport, parking, and potentially time off work.
   • Efficiency: Can increase provider efficiency by reducing no-shows and allowing for more flexible scheduling.
4. Enhanced Patient Engagement and Education:
   • Comfort of Home: Patients may feel more comfortable discussing sensitive issues from their own environment.
   • Digital Tools: Platforms often include features for patient education, health tracking, and secure messaging, encouraging more active participation in their health.
5. Pandemic Preparedness and Emergency Response:
   • Reduced Exposure: Minimizes exposure to infectious diseases (e.g., during COVID-19, cholera outbreaks).
   • Crisis Response: Allows healthcare services to continue during disasters or public health emergencies when physical clinics may be inaccessible or overwhelmed.

Cons of Telehealth:

1. Limited Physical Examination:
   • Lack of Hands-On Assessment: Cannot perform palpation, auscultation, percussion, or direct visual inspection (e.g., observing gait, skin lesions requiring close inspection). This is the most significant limitation and can lead to missed diagnoses or incomplete assessments.
   • Reliance on Patient Self-Reporting: Diagnosis heavily relies on the patient’s ability to accurately describe symptoms, which can be subjective or incomplete.
2. Technological Barriers and Digital Divide:
   • Access to Devices/Internet: Not all patients, especially in lower-income communities or rural areas of Kenya, have reliable access to smartphones, computers, or stable internet connectivity.
   • Digital Literacy: Some patients, particularly the elderly or those with limited education, may lack the digital skills to navigate telehealth platforms.
   • Connectivity Issues: Poor internet connection can lead to dropped calls, poor video quality, and frustrating experiences for both parties.
   • Data Security and Privacy: Concerns about the security of patient data transmitted electronically, requiring robust encryption and compliance with privacy regulations (e.g., HIPAA principles, even if specific laws differ in Kenya).
3. Licensure and Regulatory Hurdles:
   • Cross-Jurisdictional Practice: Providers may face limitations on practicing across state or national borders, complicating care for patients who travel or live in different regions. In Kenya, this might involve clarity on cross-county practice.
   • Reimbursement Complexities: Varies by insurer and healthcare system, leading to confusion and potential non-coverage for certain services.
4. Continuity of Care Challenges:
   • Fragmented Care: Without careful coordination, telehealth can lead to fragmented care if patients see different providers for different issues without a central medical home.
   • Difficulty Building Rapport: Some patients and providers find it harder to establish a strong therapeutic relationship remotely compared to in-person interactions.
5. Emergencies and Acute Conditions:
   • Unsuitable for Emergencies: Telehealth is generally not suitable for medical emergencies (e.g., chest pain, severe bleeding, acute respiratory distress) where immediate physical intervention is required.
   • Limited Diagnostic Tools: Cannot conduct immediate lab tests, imaging, or specialized procedures.

How to Approach and Perform a Telehealth Assessment

Performing a telehealth assessment requires a structured approach to maximize efficacy and compensate for the absence of physical contact.

Before the Visit:

1. Technology Check:
   • Provider: Ensure reliable internet, charged device, good lighting, quiet and private background, and a secure telehealth platform.
   • Patient (Pre-call instructions): Advise patient to be in a quiet, private location with good lighting and stable internet. Instruct them on how to test their device’s audio/video.
2. Review Patient Records: Thoroughly review the patient’s medical history, current medications, previous visits, and any submitted forms or vital signs.
3. Prepare Questions and Tools: Have a mental or written checklist of specific questions for the presenting complaint. If a peripheral device (e.g., blood pressure cuff, glucometer) is relevant, ensure the patient has it and knows how to use it.

During the Visit:

1. Establish Rapport and Set Expectations:
   • Start with a warm greeting, eye contact (looking at the camera), and introduce yourself.
   • Confirm the patient’s identity and location.
   • Explain the process of the telehealth visit and its limitations (e.g., “I won’t be able to physically examine you, but we’ll talk through everything in detail”).
   • Confirm privacy and consent for the virtual visit.
2. Chief Complaint and History of Present Illness (HPI):
   • Allow the patient to fully articulate their chief complaint.
   • Use open-ended questions to gather a comprehensive HPI (OLD CARTS: Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Timing, Severity).
   • Ask targeted questions to compensate for the lack of physical examination (e.g., “Can you show me where the pain is?”, “Describe the color and consistency of the rash”).
3. Review of Systems (ROS):
   • Systematically go through relevant body systems, asking specific questions related to symptoms that might not be immediately obvious.
4. “Virtual” Physical Exam (Observation and Directed Self-Exam):
   • General Appearance: Observe overall demeanor, distress level, skin color, and breathing effort.
   • Directed Visual Inspection: Ask the patient to demonstrate or show areas of concern (e.g., “Can you move your arm this way?”, “Show me the back of your throat,” “Lift your shirt so I can see your abdomen”). Guide them on how to position the camera.
   • Functional Assessment: Ask about daily activities, mobility, and functional limitations.
   • Neurological (Limited): Assess speech clarity, facial symmetry, and gross motor movements (e.g., “Can you smile for me?”, “Lift both arms above your head”).
   • Vital Signs: Ask the patient to provide any recent vital signs they may have taken (temperature, blood pressure, pulse, weight) if they have the equipment.
5. Formulate Differential Diagnoses: Based on the subjective and objective (observed) data, develop a list of potential diagnoses.
6. Develop Treatment Plan:
   • Discuss the likely diagnosis with the patient.
   • Collaboratively develop a treatment plan, including medication prescriptions, lifestyle modifications, or follow-up actions.
   • Address patient questions and concerns.
7. Safety Planning and Follow-up:
   • Red Flags: Clearly instruct the patient on specific “red flag” symptoms that would necessitate an immediate in-person visit or emergency care.
   • Next Steps: Schedule follow-up appointments (telehealth or in-person) as needed.
   • Documentation: Document the telehealth visit thoroughly, including observations, patient-reported symptoms, and specific limitations of the virtual exam.

Limits to Telehealth

The limits to telehealth primarily stem from its inability to replicate a hands-on physical presence and the underlying technological requirements.

1. Inability to Perform a Comprehensive Physical Exam:
   • Cannot palpate masses, auscultate heart or lung sounds (without specialized remote stethoscopes), perform percussion, or assess reflexes.
   • Limited ability to assess subtle signs (e.g., skin turgor for dehydration, specific gait abnormalities, nuances of mental status requiring direct interaction).
   • Certain specialties (e.g., orthopedics, emergency medicine, complex wound care) are heavily reliant on physical examination and may not be suitable for initial telehealth consultations.
2. Reliance on Patient and Technology:
   • Patient Observation Skills: Depends on the patient’s ability to accurately observe, describe, and, if guided, demonstrate symptoms. Misinterpretation or lack of awareness can lead to diagnostic errors.
   • Technological Failures: Poor internet, device malfunction, or lack of digital literacy can render the visit impossible or ineffective.
   • Home Environment Limitations: Lighting, privacy, and background noise in the patient’s home can hinder effective communication and observation.
3. Urgent and Emergency Care:
   • Telehealth is generally unsuitable for conditions requiring immediate in-person assessment, diagnostic testing, or intervention (e.g., severe abdominal pain, chest pain, acute shortness of breath, trauma, uncontrolled bleeding, altered mental status).
   • It lacks the immediate diagnostic capabilities (e.g., labs, imaging) available in a physical clinic or hospital.
4. Sensitive Consultations:
   • While some patients prefer the privacy, others may find it difficult to discuss highly sensitive topics (e.g., sexual health, domestic violence, severe mental health crises) remotely without the established in-person rapport.
   • Ensuring privacy in the patient’s home environment (e.g., other family members overhearing) can be challenging.
5. Medication and Procedure Limitations:
   • Cannot directly administer injections, perform minor procedures, or conduct invasive diagnostic tests.
   • Prescribing controlled substances via telehealth often has strict regulations that vary by region.

Difference Between Provider’s and Patient’s Perspectives for a Successful Telehealth Visit

The definition of a “successful” telehealth visit can differ significantly between the provider and the patient, reflecting their unique needs and priorities.

Provider’s Perspective for a Successful Telehealth Visit:

1. Accurate Assessment and Diagnosis:
   • The primary goal is to gather sufficient information to form an accurate differential diagnosis and develop an appropriate treatment plan, despite the limitations of a remote exam.
   • Feeling confident in the clinical decision-making.
2. Efficient Workflow:
   • The visit proceeds smoothly without significant technical glitches, enabling the provider to see scheduled patients on time.
   • Seamless integration with electronic health records (EHR) for documentation and prescribing.