Virtual ER not yet Reality.

In Editorial by Edmund Kwok3 Comments

I was recently asked for an opinion on an article that was published on LinkedIn, boasting “the virtual ER is here today, saving time and money“. Could this really be true? When a patient is facing a medical emergency, can he/she really access an emergency room virtually, without the wait while lowering overall cost to the system at the same time?

Sounds too good to be true.

As someone who works in a tertiary care emergency department, I was highly intrigued in this too-good-to-be-true solution, and decided to dig deeper. The “Virtual ER” as touted by the article refers to a company in the US called Stat Doctors. It basically offers its clients a 24/7 videoconferencing service that connects them to a Board-certified ER physician for a “live” consultation. For $50 a pop, a patient can expect to be connected to a doctor within 10 minutes – a brief period during which the physician can review the patient’s online medical records and background. After a Skype-like interaction, the physician can then provide medical advice and/or direct a prescription to the local pharmacy for pick-up.

This is not the equivalent of an ER visit.

There is absolutely no way any physician can diagnose or rule-out true medical emergencies based solely on a video-conferencing interaction. No vital signs? No auscultation of the heart or lungs? No examination of end-organ perfusion? No ECGs? No bloodwork? No xrays or imaging?

Contrary to its title, the article admits that this service is best reserved for non-emergencies such as “asthma, cold, pink eye, sports injuries…and many more“. The problem is that each of those presenting complaints has a potential to be a true medical emergency…and in many cases a physician cannot tell the difference without a full physical exam +/- investigations. Asthma severity is very much ascertained by vital signs, auscultation of the lungs, and clinical exam; a cold can actually be a pneumonia that needs to be teased out by a combination of exam and/or xray findings; vision-threatening glaucoma requiring measurement of intraocular pressure can be masquerading as pink eye; and many fractures (and complications!) can only be acutely diagnosed or ruled out by a thorough examination.

“Virtual ER” is quite a misleading title, and advertising it as such will only fuel the already rampant misguided expectations of what ERs are for. Quite frankly, I fear it will likely lead to increased overall cost to the healthcare system (even if it meant lower cost for some individual patients). They should really rename it “Virtual Chat with a Doctor“, or more accurately “Play Guess the Diagnosis without Vital Signs or thorough Physical Exam“.

Their argument for decreased costs is also over-simplified and likely incorrect. It is certainly true that many visits to the ER are non-emergencies; but once again, that is in hindsight after assessment and treatment. Those who decide to physically visit an ER are probably worried that they may have an actual emergency. Without the aid of vital signs, physical exam, or simple diagnostic tests like ECGs etc., I imagine many of these virtual ER visits would be advised to visit/follow-up with an actual ER or doctor’s office. And in such cases, not only is there an added $50 cost just to be told to go to the ER anyways, but wasted time for both the patient and the physician.

In fact, I’d much rather have family doctors staffing this 24/7 quick-chat service to cover office off-hours, and have the Board-certified ER specialists working the real ERs. In a publicly funded healthcare system like Canada’s, it would definitely be a waste of healthcare dollars to pull Emergency Medicine specialists away from real ER shifts and have them answering Skype calls.

Now, just because this concept is too immature at this point to fulfill its promise, I do believe there is much potential in the future. Imagine if the company can somehow introduce accurate vital sign measurements into its system (e.g. a blood pressure cuff, thermometer, etc., hooked up to the patient’s computer that transmit real-time monitoring, similar to this), or maybe even more complex diagnostics like ECGs (check out this iPhone peripheral). Technology for high quality images transmitted via videoconferencing are a good start towards approximating an actual physical examination, but even in fields that rely heavily on visual diagnosis there are problems with accuracy (see the controversy around apps for skin lesions).

Bottom line, we are still quite far from having a real virtual ER. The addition of video-conferencing capabilities can certainly augment current strategies such as TeleHealth that are aimed at providing non-urgent medical advice outside usual family doctors’ office hours. At the present time though, services like Stat Doctors really only cater towards a very select group of relatively healthy patients with very, very minor complaints.

(Addendum: On the other hand, at 50-bucks a pop for each quick Skype-like consult, not a bad business model in a private healthcare system…)

Edmund Kwok

Edmund Kwok

Emergency Medicine. Quality Improvement. Patient Safety. Change Management. Healthcare Administration.

Frontdoor 2 Healthcare

Frontdoor2Healthcare, founded by Dr. Edmund Kwok in 2012, provides editorial and commentary on issues affecting Canadian healthcare from the emergency department’s “front door” perspective. Frontdoor posts allow for open sharing of the diverse opinions and perspectives of emergency physicians from across the country.

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