What is the best evidence for physical exam components via telehealth

Posted on July 1, 2020 by Madalon Burnett

Summary

An excellent review article on this topic exists (1). Many components of the physical exam do not have any direct empiric evidence, and so the healthcare provider must evaluate for themselves whether their exam is gathering the information they need. There are several resources that have been made available online to support physicians in learning to perform a physical exam via telemedicine. 

I.   Vitals

  • Over-the-counter devices and smartwatches exist that can monitor blood pressure, respiration, temperature, pulse oximetry, weight, pulse rate and general appearance. Further studies to evaluate the efficacy of these devices compared with an in-office physical examination are required but they appear to be a feasible approach to measuring vital signs (1)

II.   Eyes

  • Extraocular movements, eyelids, sclera, cornea and epicanthic folds can be examined using a smartphone camera (1)
  • Virtual monitoring can be used to monitor glaucoma safely (1)
  • There is not sufficient evidence to compare smartphone based ocular imaging to regular eye exams by an eye care practitioner (2)

III.   Ear, nose, mouth, and throat

  • iPhone otoscope camera was shown to be unreliable compared with images obtained by a physician (1)
  • Smartphones speakers and microphones can be used for tympanometry and pneumatic otoscopy (1)
  • Physician review of otoscope images is comparable to in-person microscopic examination after surgical placement of tympanostomy tubes (3)
  • A prospective study with 62 patients found there was poor agreement between the in-person physical exam and telemedicine for evaluation of patients with sore throat (4)

IV.   Cardiovascular

  • Blood pressure, pulse rate and ECGs can be monitored using FDA approved devices. Smartwatches and smartphones can be used to monitor heart rate variability (1)
  • Regular ambulatory blood pressure measurement is superior to office blood pressure measurement (1)
  • Daily weight measurement can help with heart failure patients (1)
  • A digital stethoscope can allow parts of the cardiac exam to be done remotely if the stethoscope is available (1)
  • Data is inconclusive about the use of cardiac implants and defibrillators to provide data for managing heart failure patients remotely (1) 
  • Self applied continuous ECG patches can be used to diagnose atrial fibrillation (1)

V.   Respiratory

  • Telespirometry, teleoximetry, and COPD Assessment Test questions are available for telemedicine visits (1)
  • Electronic stethoscopes can be used to evaluate breath sounds (1)

VI.   Gastrointestinal

  • Symptom severity in ulcerative colitis can be assessed virtually (1)
  • Post-operative visits can be completed virtually (1)
  • In the future, it is likely that robotic capsule endoscopes can be used for virtual medicine (1)

VII.   Genitourinary

  • Follow up for urinary problems can be completed via telemedicine (1)

VIII.   Skin

  • Rashes and lesions can be evaluated provided a high quality image can be obtained (1)
  • Diabetic foot ulcers can be monitored by measuring the temperature difference between feet (1)

IX.   MSK

  • Basic tests such as range of motion, crepitus, and gait assessment can be done via camera. Resistance and special tests is more difficult to arrange via telemedicine (1).
  • Abel et al. found excellent agreement between measurements of motion and incision evaluation between telemedicine and outpatient visits for the first post-op knee arthroscopy assessment in adolescents (5)

X.   Neurologic

  • With good communication skills, a history and physical exam can be completed via telemedicine (1)
  • Standardized exams such as the MMSE can be done via telemedicine with reliable outcomes compared with an in-person exam (1)
  • Televisits for stroke patients have been used to evaluate patients in rural areas (1)

XI.   Psychiatric

  • Telemedicine is as effective as in-person care for patients with post-traumatic stress disorders (PTSD), anxiety, schizophrenia, depression and alcohol disorders (1).

XII.   Lymphatic

  • Telemedicine had moderate agreement with in-person visits on colouration of the palate and cervical lymphadenopathy for patients with pharyngitis (1)

XIII.   Infectious Diseases

  • Smartphones can be used to monitor wounds post-op for infection if the wound is in an area that the patient can photograph themselves (6)

XIV.   Extra Resources

  • A online course exists to teach doctors to perform the physical exam for a variety of specialties (7)
  • Stanford University offers a free video tutorial on virtual exams for upper respiratory infection, low back, and shoulder pain exams (8)
  • The American Academy of Allergy Asthma and Immunology published this video on how to conduct a physical exam via telehealth (9)
  • Cleveland Clinic published this video on performing a respiratory exam via telehealth (10)
  • The American Headache Society published this video on performing a neurologic exam via telehealth (11)

Questions? Comments? Does this need to be updated? Do you have valuable points to add ? Please email ask.reakt@ubc.ca.

References

  1. Ansary AM, Martinez JN, Scott JD. The virtual physical exam in the 21st century. Journal of Telemedicine and Telecare [Internet]. 2019 Nov 6 [cited 2020 Jun 24];1357633X1987833. Available from: https://medfam.umontreal.ca/wp-content/uploads/sites/16/2020/05/L-examen-physique-virtuel_Journal-of-Telemedicine-and-Telecare_2019.pdf
  2. Nagra M, Vianya-Estopa M, Wolffsohn JS. Could telehealth help eye care practitioners adapt contact lens services during the COVID-19 pandemic? Contact Lens and Anterior Eye [Internet]. 2020 Jun [cited 2020 Jun 28];43(3):204–7. Available from: https://www.contactlensjournal.com/article/S1367-0484(20)30075-8/fulltext
  3. A Comparison of In-Person Examination and Video Otoscope Imaging for Tympanostomy Tube Follow-Up | Telemedicine Journal and e-Health [Internet]. Mary Ann Liebert, Inc., publishers. 2020 [cited 2020 Jul 1]. Available from: https://www.liebertpub.com/doi/abs/10.1089/153056203772744653
  4. Akhtar M, Van Heukelom PG, Ahmed A, Tranter RD, White E, Shekem N, et al. Telemedicine Physical Examination Utilizing a Consumer Device Demonstrates Poor Concordance with In-Person Physical Examination in Emergency Department Patients with Sore Throat: A Prospective Blinded Study. Telemedicine and e-Health [Internet]. 2018 Oct [cited 2020 Jul 1];24(10):790–6. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6205037/
  5. ‌Aappublications.org. 2013 [cited 2020 Jun 24]. Available from: https://pediatrics.aappublications.org/content/141/1_MeetingAbstract/663 
  6. Coombes CE, Gregory ME. The Current and Future Use of Telemedicine in Infectious Diseases Practice. Current Infectious Disease Reports [Internet]. 2019 Oct 19 [cited 2020 Jun 28];21(11). Available from: https://www.healthrecoverysolutions.com/hubfs/March%202020%20Research%20/The%20Current%20and%20Future%20Use%20of%20Telemedicine%20in%20Infectious%20Diseases%20Practice.pdf
  7. Telemedicine: Conducting an Effective Physical Exam | SKMC Office of CME [Internet]. cme.jefferson.edu. [cited 2020 Jul 1]. Available from: https://cme.jefferson.edu/content/telemedicine-providers-conducting-effective-telehealth-physical-exam
  8. How to Administer a Virtual Physical Exam [Internet]. Department of Medicine<br>News. 2020 [cited 2020 Jul 1]. Available from: https://medicine.stanford.edu/news/current-news/standard-news/virtual-physical-exam.html
  9. ‌4AI4YOU [Internet]. YouTube. 2020 [cited 2020 Jul 1]. Available from: https://www.youtube.com/user/4AI4YOU
  10. ‌Clinic C. How to Conduct and Document a Respiratory Exam via Telehealth [Internet]. YouTube. 2020 [cited 2020 Jul 1]. Available from: https://www.youtube.com/watch?v=cjJb6Oeni0g
  11. ‌American Headache Society. Conducting a Telemedicine Neurologic Exam [Internet]. YouTube. 2020 [cited 2020 Jul 1]. Available from: https://www.youtube.com/watch?v=m4ntpFyZIv8

Disclaimer

The above is intended to serve as a rapidly-created, accessible source of information curated by medical students and healthcare professionals. It is for educational purposes only and is not a complete reference resource. It is not professional medical advice, and is not a substitute for the discretion, judgment, and duties of healthcare professionals. You are solely responsible for evaluating the information above.