The physical exam splits into parts, and each goes remote at its own pace

Dr. Aditi U. Joshi has done roughly 25,000 telehealth visits. Her main lesson from them is that the physical exam was never a single task. She told Healthcare IT News managing editor Bill Siwicki that it combines several distinct ways of collecting information, and each of those pieces shifts to remote care at its own pace.

Joshi is an emergency physician and the founder and CEO of digital-health consulting firm Ardexia. She was one of three physicians in the outlet's October 12 feature, the first of a two-part series on how much of the exam can leave the room. Her verdict splits in two. For a subset of conditions, remote assessment is closer than most people assume. For everything else, it is farther off than the marketing suggests.

That split gives a virtual care leader a more workable question than "can exams go virtual?" It becomes a sorting job: which components travel, which devices make them possible, and how the encounter gets written down.

What a camera and a guided patient can do

Dr. Cynthia Horner, chief medical officer at telemedicine company Amwell, argued in the feature that once clinicians stop trying to recreate the exam room through a webcam, a meaningful share of the exam already works remotely. A clinician who observes the patient and gives directions can assess speech, gait, mental status, coordination, range of motion, respiratory effort, general appearance and many skin findings. Patients can measure their own temperature, weight, blood pressure, heart rate and oxygen saturation.

Connected devices push further, Horner said: digital auscultation, otoscopy and views of the throat or skin. At-home tests and remote patient monitoring add glucose readings, urinalysis and infectious-disease results.

Ingenium Digital Health, a telehealth consultancy, has set out a similar map in its Telehealth Tuesday series, drawing on chief clinical officer Dr. Matt Faiman. The series starts from an awkward fact. Video visits see heavy use in behavioral health and specialty care, yet most primary care providers still largely avoid them. Ingenium lists the usual causes (unfriendly technology, workflows not built for video, no training in "webside manners," no ready support) and adds one more: the belief that a physical exam over video is impossible.

Its answer walks the classic exam sequence step by step. Inspection carries over almost untouched: can the patient finish a full sentence, are they coughing, does their face show pain? Palpation becomes something the patient performs under instruction.

Faiman's examples include describing a neck lymph node as feeling like a grape, a marble or a golf ball; pressing each of four abdominal quadrants to find tenderness; jumping three times as a screen for conditions such as appendicitis or cholecystitis; and counting a radial or carotid pulse aloud so the clinician hears the rhythm. An irregular or rapid pattern, in Ingenium's account, may point to an underlying cardiac issue.

There is a softer case for doing the guided exam at all. Faiman's comparison is poison ivy: the diagnosis is often obvious at a glance, yet clinicians still listen to the heart and lungs because patients expect it. Ingenium argues that walking patients through a virtual exam brings the same credibility and reassurance, plus clinical value. That suggests part of the exam's job on video is relational, which would matter for a primary care group whose clinicians doubt the format.

The home kit and its human variable

The Healthcare IT News feature argues that a few low-cost, readily available peripheral devices let clinicians and patients gather most of the information a live, face-to-face visit would produce. Its sketch of a reasonable, cost-effective setup is short:

• Digital blood pressure cuff
• Portable pulse oximeter
• Thermometer
• Spirometer
• Scale

Dr. Blake J. Lesselroth, vice chair and professor of medical informatics at the University of Oklahoma School of Community Medicine at OU-Tulsa and an adjunct professor of health informatics at the University of Victoria in British Columbia, said these tools add a lot because they produce reasonably objective biometric data. He chose "reasonably" on purpose. The quality depends on the operator, and the operator is the patient. Blood pressure, his example, can read falsely high if the patient talks or crosses their legs during the measurement.

Every home reading is only as good as the patient taking it.

Volume pushes the other way. Joshi pointed out that for chronic disease management, a week of home blood pressure readings or continuous glucose data shows something one office reading never could. Set beside Lesselroth's warning, the tradeoff becomes clear: the home gives up control over technique and gains repetition the clinic cannot match.

Setting is part of technique too. PlushCare, a virtual care provider, notes that the environment affects the quality of a physical exam and advises completing one in a quiet, comfortable place. For a remote visit, the patient picks that room.

Heart sounds and decision rules over video

Most people assume auscultation is the one component that requires a clinician in the room. Lesselroth's teaching work suggests otherwise. He argued in the feature that many portable technologies are now mature enough for a clinician to reproduce very sophisticated face-to-face exams, and digital stethoscopes were his example.

In medical simulations, medical and physician assistant students performed cardiopulmonary exams on standardized patients, and medical assistants positioned digital stethoscope diaphragms on the patients' chests and backs. The sound was turned into a digital signal and sent to the students over videoconferencing software. Recorded pathologic sounds were used to recreate specific clinical scenarios. According to Lesselroth, the students mostly managed to perform the cardiopulmonary exam and reach a provisional diagnosis.

The setting was simulated, a point the feature makes itself. Lesselroth added that clinical studies have shown practitioners can identify pathologic heart and lung sounds as easily as if they were in the same room as the patient. For a program planner, that turns auscultation from a wall into a hardware and staffing question. Even the simulation needed someone on the patient's side placing the diaphragm.

Guided exams take clinical decision rules into the living room. The feature's example is an ankle injury. The clinician asks the patient to show whether they can bear weight and take four steps, then guides them to find and press specific areas of bony tenderness. The patient's hands do the palpating, but the clinician's structure decides which findings count, the same division of labor Faiman describes for the abdomen.

The chart has to show the gaps

Federal telehealth guidance from the Department of Health and Human Services is specific about documentation. Clinicians should record their observations, what the patient did on their own (taking a blood pressure with personal equipment, for example), what the patient could not do because the equipment wasn't at home, and anything else needed for coding and billing. The same guidance says telehealth may be used to conduct several types of physical exams, listing ear, nose and throat, skin, abdominal, cardiopulmonary, neurological and musculoskeletal exams.

That third item is the easy one to overlook. A note that says no cuff or stethoscope was available tells the next clinician, and the coder, exactly where the exam stopped.

The HHS page also tells clinicians what to watch for during the visit: tone of voice, body language and unusual signs such as skin discoloration or an unsteady gait. It tells them to explain clearly everything they want the patient to do. That is the guided exam's core step, written into federal guidance.

Colorado builds a spine exam it can bill

Healio's Orthopedics Today reported in April 2020 that CMS had expanded Medicare telehealth coverage during the COVID-19 pandemic. Looser rules from CMS and some insurers let University of Colorado physicians convert clinics to virtual appointments. Dr. Vikas V. Patel, executive vice chair of orthopedic surgery, said the university already had a telehealth program, but it was rarely used and hard to run, less because of the technology than because of legal issues.

Once remote visits started, Patel said, the team found it could not do a full physical exam well, especially for spine conditions that require assessing strength and sensation. With little research to draw on, Patel, Dr. Nolan M. Wessell and colleagues built a structured virtual spine exam. Wessell said they identified the motor and sensory exams a good evaluation needs and adapted them, starting with a visual assessment before moving to the upper and lower extremities.

The exam itself is simple: watching the patient walk, testing leg strength with squats and arm strength with biceps curls and overhead lifts, and having patients run their own light-touch sensation checks on both upper and lower extremities. Patel said the design was "not super difficult"; the work was capturing as much of the office exam as they could.

Patel said the goal was an exam they could bill for and show to be as effective, or close to it, as an in-person visit. Wessell reported an overwhelmingly positive response from both physicians and patients. The Colorado team built for billing and validation from the start, which is the kind of record HHS's coding-and-billing line asks the note to support.

Where hands still win, and where it stops mattering

The Colorado case also marks the limit of the argument. A clinician's hands on a weak limb, or real sensory testing, still beat a squat on camera, which is why Joshi's "farther than the marketing suggests" applies to most of the exam beyond her subset. Ingenium makes a related point from the other side: when the next step for abdominal pain is an ultrasound anyway, where the first look happened matters less, and the right move when a remote exam falls short is to escalate or refer.

Ingenium adds that with today's diagnostic tests, the physical exam is almost never the only basis for a diagnosis and treatment plan. Read that way, a gap in the remote exam is often a triage decision, not a dead end.

PlushCare says that for generally healthy people, yearly preventive screenings are slowly taking the place of the traditional annual physical. It counts health tests, such as blood tests and recommended cancer screenings, as the most important part of an annual visit. By its account, nearly all of the most strongly recommended yearly screenings a patient would get in person at a doctor's office can move to a virtual visit.

It names two exceptions: Pap smears for cervical cancer and mammograms. Pap smears are typically sent to obstetrician-gynecologists, and mammograms always go to imaging centers rather than being performed in the primary care physician's office. If that holds, the parts of the exam that still require an in-person visit are ones primary care already refers out.