Is a Medical Virtualist Specialty Necessary? Probably Not.

"We propose the concept of a new specialty representing the medical virtualist."A few days ago, an opinion piece in JAMA came to my attention. In it, Drs. Nochomovitz and Sharma called for a new medical specialty to be recognized: the medical virtualist.

As someone with a lot of experience in healthcare – years as a family physician, three terms on the MN State Board of Medical Practice, and my current role as Chief Medical Officer here at Zipnosis – I find this an interesting idea, but I’m unconvinced it’s necessary.

Why We Don’t Need “Virtualists”

First off, let’s talk about what virtual care (or telemedicine) is and is not. Virtual care isn’t a new type of healthcare, it’s a care delivery channel. This is an important distinction. The difference between healthcare services and technology that enables delivery of healthcare services is particularly vital when we look at tricky things like regulation. Typically, medical specialties are designated because of particular knowledge and skills needed for healthcare services, not the channel through which that care is delivered. We don’t have, for example, medical retailists who specialize in care delivery through retail clinics.

The biggest reason for steering clear of a “medical virtualist” specialty is simply that every care provider will need to have the skills and ability to provide healthcare services through online care delivery channels. The authors even recognize this, stating:

“Contemporary care is multidisciplinary, including nurses, medical students, nurse practitioners, physician assistants, pharmacists, social workers, nutritionists, counselors, and educators. All require formal training in virtual encounters to ensure a similar quality outcome as is expected for in-person care.”

I couldn’t agree more with this statement. Factors like healthcare consumerism, the shift to value-based care, and the need to address the quadruple aim will precipitate increased utilization and a growing need for healthcare providers to understand how to effectively deliver care online. It doesn’t, however, follow that a specialty is needed.

Further, their contention is that there will soon be a need for care providers to spend a majority of their time delivering care virtually. The trouble with this, though, is that there already are concierge medicine services, nurse lines, and telemedicine service companies that employ physicians, physician assistants, and nurse practitioners who work online full-time. Depending on the use case and mode of care, some hospitals and health systems may even have providers spending a good portion of their working week delivering care online or over the phone.

What We Do Need

Where Drs. Nochomovitz and Sharma really get things right is in their call for specific training – even certifications – for providers to support safe, effective online care delivery. The authors note:

“Physicians now spend variable amounts of time delivering care through a virtual medium without formal training. Training should include techniques in achieving good webside manner. Some components of a physical examination can be conducted virtually via patient or caregiver. Some commercial insurance carriers and institutional groups have developed training courses. [citation] These are neither associated with a medical specialty board or society consensus or oversight nor with an associated certification.”

Once again, I withhold support for a medical specialty board, but otherwise, I agree with the call for greater training and understanding of the specific skills needed to deliver care online. Up until recently, physicians and other care providers were trained exclusively on the medical and scientific elements of healthcare. Now, medical schools include courses on bedside manner and other “soft skills” that providers need to be effective in caring for patients. Many organizations, such as AAFP (of which I’m a member), offer and recommend training in areas like patient communication to support providers in their professional development.

Encouraging skill development in virtual care delivery would be a similar extension of the training medical professionals receive. The virtual care and telemedicine landscape currently has fewer options available, though that is changing with the AMA from last year stating its support for telemedicine training for medical students and residents. Most recently, the American Telemedicine Association partnered with the ClearHealth Quality Institute to develop and offer training and accreditation options in telemedicine.  

Moving care delivery forward through expanding virtual care is going to be increasingly critical for patients and providers. Drs. Nochomovitz and Sharma are clearly committed to forwarding the cause of virtual care. Their ideas for training and the core competencies that clinicians will need to effectively use virtual care to care for patients are well-thought out and comprehensive. However, for the reasons outlined above, I believe a medical specialty would be more of a distraction than a benefit to the healthcare landscape.

About the Author

Rebecca Hafner-Fogarty, Zipnosis Chief Medical Officer

Rebecca Hafner-Fogarty, MD, MBA, FAAFP

In addition to being a primary care physician and serving as Vice President of Policy and Strategy at Zipnosis, Dr. Hafner-Fogarty has extensive experience in medical regulation, having served on the MN Board of Medical Practice from 1998-2003, 2004-2010, and 2012-2016. She was board president in 2009 and has also been involved in medical regulatory activities at the national level.

Transforming Care in the Digital Age

Zipnosis Chief Clinical Officer Kevin Smith’s most recent article for Health IT Outcomes discusses how virtual care can make an impact on care quality. Responding to a study published in JAMA Ophthalmology, he notes that virtual care can help more effectively capture patient-reported symptom information and ensure EHR records are accurate. Read more.

Do You Have to Sacrifice Clinical Quality for Convenience?

People are busy these days. And making a trip to the doctor either eats into working hours or free time. That’s why patients are demanding alternatives to the ways they access care.

This demand has forced health systems to take a leap of faith and offer telemedicine services. Some of which are based on outsourced clinical support. But can health systems depend on outsourced telemedicine vendors to provide quality care that adheres to national best practices? Can patients be certain the diagnoses and treatments they receive are accurate and clinically adherent?

JAMA Study Finds Guideline Adherence in Live Video Visits Spotty

Capturing quality metrics for the telemedicine space has been tricky. But researchers at the University of California at San Francisco decided to try anyway. They evaluated the care provided by eight telemedicine vendors against national best practices. It should be noted that Zipnosis was not part of the study.

Results of this 2-year study were published in the May edition of JAMA Internal Medicine, and were not encouraging. Over the 599 virtual visits studied, adherence to national best practice protocols for care ranged from 34.4 to 66.1 percent. The variation range increased for treatment of viral pharyngitis and acute rhinosinusitis (sinusitis), with clinicians adhering to guidelines anywhere from 12.8 percent to 82.1 percent of the time.

So, what did all eight of the companies evaluated have in common? All were direct-to-consumer telemedicine providers that exclusively use synchronous – or live – video technology, apparently lacking the use of effective clinical decision support tools to ensure guideline adherence, to treat patients.

Convenience without Compromise

While the results of this study don’t bode well for outsourced and direct-to-consumer telemedicine vendors that rely primarily on video, high quality virtual care is within reach. An internal review of more than 1,700 asynchronous patient encounters through two major health systems for treatment of acute sinusitis on the Zipnosis platform had contrasting results to the JAMA study – a guideline adherence rate of 95 percent.

The backbone of this success is the adaptive online interview embedded within the Zipnosis platform, which guides patients through a structured interview grounded in evidence-based national best practices. Once the interview is complete, clinicians receive a comprehensive clinical note and are then guided through curated diagnosis and treatment options based on patient inputs – the final diagnosis is issued by a local provider, not an outsourced clinician.

The whole process leaves little room for error; harried clinicians won’t miss a question and organically designed clinical decision support means patients get the right care quickly and consistently. Best of all, since Zipnosis’ partners use their own clinicians, they can directly monitor and improve clinical quality without the hassle of working through a 3rd party clinical team.

Patients are demanding more convenient access to healthcare. The data is clear: Traditional, direct-to-consumer, outsourced telemedicine services that address patient convenience face challenges in the area of clinical quality. In the absence of a better alternative, this would be fine. But it is time to stop compromising and expect virtual care to improve access and quality at the same time. At least, that’s what we believe and are proving here at Zipnosis.