RESEARCH Case report

.................................................................................................................................

Q Telemedicine can help to ensure that patients

receive timely medical care
Eva Blozik, Irène E Wildeisen, Philipp Fueglistaler and Jan von Overbeck
Swiss Center for Telemedicine Medgate, Basel, Switzerland

Summary
We describe a case illustrating that telephone consultations can help to lower the psychological threshold for accessing
medical care in people who are not aware of the seriousness of their symptoms, or who might otherwise be reluctant
to access face-to-face care. A 69-year-old male patient called a teleconsultation service at the weekend because of acute
fever. The patient was scheduled to have a hip replacement and the usual pre-operative check-up done the day before
had been normal. However, a careful medical history taken during the teleconsultation revealed potentially serious
symptoms. We therefore referred the patient to the emergency room immediately with the suspicion of severe infection,
possibly due to colon cancer. The patient was subsequently diagnosed with septicaemia and adenocarcinoma of the
sigmoid. This demonstrates that teleconsultation is not only a powerful tool for triage and diagnosis, but can also help
to reduce delay in diagnosing severe diseases in primary health care.

Introduction those whose health insurers have a service contract with us,
.............................................................. which currently includes well over half of the Swiss
population. There are no additional costs for the individual
Telephone consultations (teleconsultations) have caller, as the fees for our services are not passed on directly.7
increasingly been used as a means of health-care delivery.1,2
A good working definition of teleconsultations is ‘the
process where calls from people with a health-care problem
are received, assessed and managed by giving advice or by Case report
referral to a more appropriate service’.3 One of the main
..............................................................
purposes for introducing such services is to help callers
The 69-year-old patient’s wife called the Swiss Center for
manage their own health problems, which in turn reduces
Telemedicine on a Saturday evening because her husband
unnecessary use of other health-care providers and the
was experiencing freezing, chills and sweating. The couple
associated costs.4,5 It has been shown that teleconsultation
did not want to bother their general practitioner during the
services reduce the number of immediate visits to
weekend and both felt that the symptoms were not serious.
physicians without causing adverse events such as
However, they wanted reassurance from a doctor.
subsequent hospitalisations, visits to emergency
The patient was scheduled for hip replacement the
departments or deaths.6
following week and had undergone a preoperative check-up
As well as reducing unnecessary physician visits,
the day before the call. This check-up included a physical
teleconsultation services can help to identify patients with
examination, a chest X-ray and an electrocardiogram, none
serious medical problems, and ensure they receive timely
of which revealed any contraindications for elective surgery.
acute care, even if this was not the initial intention of the
The only pathological finding was a slight anaemia
patient.6 We report a case illustrating this in an out-of-hours
(haemoglobin 128 g/l, reference values 140 –180 g/l). The
teleconsultation performed at a large teleconsultation
patient was told that there was no immediate need for
centre in Switzerland (Swiss Center for Telemedicine
intervention or further diagnosis, but that his red blood cell
Medgate). This centre provides up to 400 medical
count should be monitored.
teleconsultations per day, covering a wide spectrum of
The teleconsultation was performed by a physician with
medical questions from acute health problems to health
several years of experience in internal and general medicine,
behaviour questions. Our services are freely available to all
but without a specialty qualification. As an essential part of
the consultation, a detailed and structured medical history
Accepted 8 September 2011 was taken. This revealed further important information,
Correspondence: Dr. med. Eva Blozik, Swiss Center for Telemedicine Medgate,
Gellertstr. 19, 4020 Basel, Switzerland (Fax: þ41 61 377 88 40; including the fact that the patient had lost 5 kg in weight
Email: eva.blozik@medgate.ch) during the past two months without dieting. Given this

Journal of Telemedicine and Telecare 2012; 18: 119– 121 DOI: 10.1258/jtt.2011.110812
E Blozik et al. Case report – timely medical care
medical history, including age, weight loss, fever and
anaemia, one of the differential diagnoses was a potential
malignancy, such as a colon carcinoma in combination
with a Streptococcus bovis infection.8,9
Since this clinical picture was indicative of a serious
pathology, the physician at the centre for telemedicine
advised the patient to go to the emergency room
immediately. The in-patient diagnostic evaluation
performed there revealed a systemic inflammatory response
syndrome, and a CT scan did indeed show a colonic focus
suggestive of cancer. Furthermore, after colonoscopy and a
biopsy, an adenocarcinoma of the sigmoid colon was
diagnosed. Antibiotic therapy was commenced immediately
after admission. Once the signs of inflammation decreased,
the patient underwent colon resection and he was
discharged from the hospital in good health.
Discussion
..............................................................
Our case report illustrates that even when patients receive
highly specialised medical care, health problems pertaining
to other medical disciplines may be missed. Teleconsultation
services cover a broad range of medical disciplines from a
general practice perspective, and are therefore well positioned
to identify problems a specialist might overlook. Obviously
telemedical diagnosis and treatment have inherent
limitations, but telemedical triage and screening clearly have
the potential to help improve quality and efficiency by
transferring the patient to the appropriate point of care
without delay. In the present case, if telemedicine had not
been used, the patient might have undergone the scheduled
hip replacement, his colon cancer might eventually have
been diagnosed, and he might have been at very high risk of
life-threatening complications due to sepsis.
This case also demonstrates that teleconsultation services
can lower the psychological and physical barriers
preventing people in need from accessing medical care.
Previous studies have identified a number of such barriers,
such as the doctor’s lack of responsiveness to patient
concerns, medical bills, transportation and reluctance to
drive.10 Calling a telemedical service centre is relatively
anonymous, requires no travel, and has reduced waiting
times compared to face-to-face consultations. Patients may
prefer to access this type of medical care when they are
reluctant to ‘disturb’ their primary care giver, request
physical care, or when they seek a second medical opinion.
This is of particular significance when the cause of their
reluctance is underestimation of the seriousness of their
symptoms. These persons might not request medical care in
time if teleconsultation services are not available.2,11 In the
present case, the couple did not wish to disturb their own
doctor at the weekend, but were willing to call the
telemedicine centre for a teleconsultation, at which point
the seriousness of the situation was immediately recognized
and the necessary steps were taken.
120
We also observe that in some instances, the medical
history can be a more sensitive diagnostic tool than
laboratory and imaging procedures. Even though our
patient had undergone an extensive preoperative check-up
the day before which did not detect any contraindications
for surgery, there was a clear need for immediate referral to
emergency care. This was identified purely on the basis of
careful, comprehensive medical history-taking. In the
majority of cases, this is the only diagnostic tool available to
physicians working by telephone. It is therefore crucial that
training of physicians working over the phone focuses on
good medical history taking.12
The economic effects of teleconsultation services are
challenging to measure. It has been shown that about 50% of
calls can be managed without having to refer the caller
elsewhere.6 These are situations in which assessment shows
that home-care measures are appropriate. Following careful
selection and counselling, the patients are able to manage
their health problem on their own.7 Referring persons to
face-to-face encounters who would not have sought physical
medical care may initially increase the number of physician
visits and hospital admissions. However, the underlying
hypothesis is that the overall costs of care will decrease, as the
proportion of avoidable serious and expensive outcomes,
such as the need for intensive care, will be reduced.2,5,6
In conclusion, medical teleconsultation services may not
only avoid unnecessary physician visits, but may also
facilitate access to appropriate medical care for persons at
medical risk who would otherwise not seek treatment in the
appropriate time interval. By reducing the threshold
discouraging patients from accessing care, teleconsultations
can prevent further harm due to delayed medical support,
and may even lower costs by reducing the risk of
complications. In order to investigate this hypothesis,
systematic analyses of the economic effects are needed.
Acknowledgements: We are grateful to the Department of
Orthopedics, Zieglerspital, Spital Netz Bern, Switzerland, for
transfer of the clinical reports.
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