I have the pleasure of teaching the Telemedicine Certificate Program at the New York Institute of Technology’s College of Osteopathic Medicine at Arkansas State University, in Jonesboro Arkansas. Interestingly, despite the fact that these young student doctors grew up with tablets and cell phones in hand, they do not inherently believe a telemedicine exam can be as comprehensive as an in-person exam. In an effort to make my case, I use the concept of the S.O.A.P. note.
S.O.A.P. is an acronym that refers to how physicians document their progress notes. It stands for Subjective, Objective, Assessment and Plan. This age-old way of documenting allows for a systematic way of capturing important patient data. It also now serves as the way these students validate the role of telemedicine.
1. The Subjective History
Beginning with the Subjective portion of the documentation, the presenting complaint of the patient and circumstances under which it occurs is collected. The Subjective history taking is completely conversational and does not require any hands on to complete. It does however include observations made by the physician as to the body language and non-verbal cues of the patient. I stress to my students the importance of using technology that provides a mutually clear image with excellent audio, in the same way I encourage proper communication skills and body language with the in-person visit.
2. The Objective Exam
The objective portion of the exam includes the hands-on processes that take place during a patient encounter. The physical examination begins with vital signs, and includes three core components: auscultation (listening), visualization (looking) and palpation (touching). Vital signs are straight forward as long as the patient is in a clinical environment where they can be accurately transmitted or the patient uses a reliable device that collects vital signs and then transmits the data to the receiving physician. Digital stethoscopes and high-definition exam cameras make auscultation and visualization often times superior to the traditional in-person exam despite the distance between the patient and their physician.
The palpatory component is really the only true barrier that separates the telemedicine exam from the in-person exam. However, even this gap can be successfully bridged by having a qualified assistant at the patient’s bedside. This facilitator could be a medical assistant, nurse, PA/NP or even another physician depending on the complexity of what needs to be performed. This concept is often met by resistance from not only the medical students, but also seasoned physicians that are uncomfortable with the idea of someone else doing the exam. Skeptics tend to forget that many of the decisions made by physicians, for their patients, are often predicated on information obtained by phone from a nurse at the bedside. And in the case of a phone call, there is no ability to directly observe the patient exam or participate with digital devices.
3. Assessment and Plan
The two remaining components of the S.O.A.P. note are the Assessment and the Plan. The Assessment and Plan are a review of the physician findings and a conversation about the management. During this portion of the exam the physician makes recommendations, refers for additional testing, prescribes medications and discusses next steps. All of which can easily be done remotely with today’s electronic health records and telemedicine platforms.
I want to be very clear that having a patient and physician together in the same room is the highest standard of care. However, the realities of time and distance make this impossible for millions of Americans. Telemedicine is a way to bridge this gap and it’s time to embrace the opportunities that telemedicine can provide for the physician, patient and their family.