This is our telemedicine…

Quality of primary telemedicine consultations of patients and their legal representatives

Sofia Simenyura, XX2 century

Exactly a year ago, businessmen from medicine noticeably revived: The telemedicine Law has finally come into force in Russia. And if earlier remote consultations were legal only in the format of "doctor – doctor", then, starting in January 2018, doctors were given the right to conduct consultations using the phone and the Internet and for patients. The go-ahead of lawmakers immediately activated companies wishing to "stake out" a place in this market, because there is something to share. Already, experts are talking about the amount of 3 billion rubles a year with a projected growth of 20% per year. And by 2022, it is expected that every fifth Russian will use telemedicine services on a permanent basis (data – "Mobile Medical Technologies").

But behind the fierce competition, one of the most serious issues remained in the shadows – the quality of remote consultations provided. Today there is not a single service that monitors the professional level of online admission of telemedicine doctors. This is a serious omission, especially bearing in mind the desire of market players to see telemedicine consultations in the programs of state guarantees of free medical care to citizens. That's why the team of the "Center for Diagnostics and Telemedicine Moscow Department of Health" I decided to evaluate the quality of primary remote consultations offered to patients by the largest Russian companies already working in the field of telemedicine.

For this purpose, the most well-known telemedicine services in Russia were selected: Yandex.Health, MMT (Online Doctor), Doctor Smart, DocDoc, Telemed Help and Doctor at Work. According to experts, today only one "Yandex.Health" across the country conducts about 10 thousand teleconsultations per month (Data vc.ru ).

The competence of doctors working on these platforms was assessed with the help of simulated patients, who were specially trained actors. Testing with standardized patients is the "gold standard" accepted worldwide. In addition, in the USA and Great Britain has accumulated a lot of experience, which allowed us to compile a clear list of indications for which primary telemedicine consultations can and should be carried out. And, of course, a telemedicine doctor should play an important role in quickly determining the severity of the patient's condition and quickly redirecting him for further treatment and rehabilitation. Especially if the case is life threatening.

So, based on international experience and the Russian legislative framework, researchers based on the real medical history of the patient of the therapeutic department of the Moscow emergency hospital have developed a "legend" of the simulated patient. At the same time, clear triggers were included in the descriptions, which were supposed to be tips for consulting doctors. Of course, provided they comply with the rules of the classical patient survey – a basic medical skill that is taught at the Department of Propaedeutics. And taking into account the features of a remote consultation, a thorough, algorithmized process of interviewing a patient should be the most important tool of a "correspondence" medical appointment. This is the only way a telemedicine doctor will be able to make a preliminary diagnosis, make a conclusion and give correct recommendations. That's what came out of it.

The simulated patient is a 45–year-old male with an increased body weight and a family history of myocardial infarction and hypertension. At the same time, he does not hide his long smoking experience (25 years of 1.5 packs of cigarettes a day) and calls a managerial position in the company his place of work. The reason for the patient's treatment was severe pain in the epigastrium. But, according to legend, a month before that, he had been thoroughly treated for peptic ulcer disease and, as a hint to doctors, constantly emphasized that the pain he was experiencing was not similar to the previous exacerbation of peptic ulcer disease.

For technical reasons, two services ("Telemed Help" and "Doctor at Work") immediately dropped out of testing. The payment and registration system is not debugged on their platforms, and the patient simply could not overcome this barrier and sign up for an online consultation. Therefore, the researchers were able to evaluate the quality of telemedicine consultations only in the services "MMT (Online Doctor)", Doctor Smart, "Yandex.Health" and DocDoc. In the first two – via audio communication, in the third and fourth, the patient communicated with the doctor via text chat.

The first serious mistake was made immediately. Doctors "MMT (Online Doctor)", "Yandex.Health" and DocDoc started the consultation "blindly", armed only with the name of the patient: none of them found out the reason for seeking medical help, anthropological data and other primary input. Only the doctor Doctor Smart offered to fill out a form to collect complaints. Also, all doctors were extremely negligent in collecting data such as hereditary and allergic anamnesis, the presence of bad habits and other equally important details of the patient's life, which logically led to serious omissions in further diagnosis.

The simulated patient complained of abdominal pain. This symptom accompanies many pathological conditions and requires careful and multi-stage questioning to form a diagnostic concept. Suspicions about the presence of risks from the cardiovascular system should have immediately arisen when finding out the presence of excess body weight, significant smoking experience, burdened family history and constant stress loads (managerial position) – a clinical case from a textbook. However, the doctors of all tested services limited themselves only to collecting anamnesis of the disease and, as a result, none of them suggested acute coronary syndrome of gastralgic form – a life-threatening condition that requires emergency hospitalization.

In fairness, it should be noted that the partial collection of the life history was still carried out by the Yandex.Health service. True, the doctor limited himself to clarifying the fact of smoking to confirm the hypothesis of an exacerbation of peptic ulcer or gastritis, but nevertheless drew attention to the patient's insistent instructions that the pain of the past exacerbation of gastric ulcer is not similar to the pain syndrome, which was the reason for seeking teleconsultation. Accordingly, they were given recommendations about calling an ambulance to exclude not only the pathology of the gastrointestinal tract (gastrointestinal tract), but also ischemic changes from the heart. Doctors of the MMT (Online Doctor) and DocDoc services also gave recommendations on calling an ambulance team, but only to exclude surgical pathology. That is, the cardiological risks remained "behind the scenes". Service Doctor Doctor Smart offered standard therapy for exacerbation of gastric ulcer. They are recommended: a full-time doctor's appointment for examination, a second consultation after five days to assess the patient's condition and certain treatment in case of positive results of the proposed diagnostic tests.

So, the doctors of the three services – albeit for different reasons – recommended seeking emergency medical care. However, the fact of a successful call, monitoring of the patient's condition, and even more so the fact of the arrival of the team and successful hospitalization was not monitored. Moreover, given that the diagnosis was initially made incorrectly, and the recommendation to call an ambulance was not given as an emergency, in such a situation, it is possible to predict that the patient ignores the received recommendation to call an ambulance and, as a result, the patient's condition worsens, up to a fatal outcome.

It is important to understand that in case of an emergency or urgent situation, a representative of the telemedicine service is obliged to organize and monitor the patient's receipt of the necessary assistance. This is accepted according to the international standard. To do this, the responsible employees of the services and medical consultants should have protocols of interaction with rescue and emergency medical services for all regions and territories whose patients apply to the service for primary teleconsultations. This practice has not been introduced in Russia. But, you must agree, the absence of relevant provisions in regulatory documents should not be the reason for negligence. A person's life is in the hands of a telemedicine service and a consulting doctor.

What happened in the dry residue? During the initial telemedicine consultation of the simulated patient, not a single doctor, not a single service conducted a full-fledged inquiry. The correct diagnosis was made by only one doctor. And then with a caveat. Three suggested to the patient to call an ambulance without understanding that the patient is in a pre-infarction state. No doctor gave the patient preventive recommendations.

This fact underlines the need for scrupulous methodological work, careful preparation of survey scripts and, of course, creating conditions for the development of medical continuity when recommending treatment in an ambulance.

Researchers in no case stigmatize the above-mentioned doctors of certain services. This work is just an attempt to identify the weaknesses of telemedicine companies, to suggest what and in what direction it is worth working on and how exactly to improve the quality of telemedicine services provided.

To be continued…

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