Electronic Health Reporter

By Dr. Louis Krenn.

In rural America, patients often find themselves more than 30 minutes away from hospitals or care facilities, making it extremely difficult to receive consistent quality care. In fact, there are only 39 physicians per 100,000 people in most rural areas, and specialists are often few and far between. With the average rural area income being more than $9,000 less than the average household income in the U.S., there simply aren’t enough doctors or financial means to see a specialist in a rural setting. This leaves patients waiting three to six months to see a doctor with the appropriate expertise and can lead them to receive care from non-physician providers, who may not have the same clinical training that a physician has. As a practicing family physician in Springfield, Missouri, I experience these challenges almost daily and as technology advances I have found new ways to help my patients to significantly decrease their need for a specialist visit.

Some of the most common health issues I face as a primary care physician that fall outside of my normal scope are dermatological, cardiological or gastrointestinal. In urban areas, patients can easily make appointments at respective specialists, but in a rural area like my own, diagnosis and treatment is often left to the primary care physician. While seeing patients for regular scheduled appointments, I typically encounter 20 dermatological cases a week including conditions like eczema, psoriasis, warts and actinic keratosis.

Although these are common skin conditions, when I encounter these types of conditions I take my years of experience and try to assess to make a diagnosis and develop a treatment plan, even if I am not 100 percent certain of the specific condition. Thanks to technology, more and more tools are being developed that can help diagnose the conditions – whether common or more intricate – that primary care physicians may not be expertly trained on. These tools, known as clinical decision support tools, enable us to make more accurate diagnoses at the point of care.

Technology as an aide, not a replacement

When I talk to my colleagues about utilizing technology in our everyday practice, I commonly get pushback because there is fear that technology may put us out of a job. The truth is that clinical decision support tools are becoming essential tools for rural health care providers as the volume of available data increases alongside our responsibility to deliver value-based care. These tools are simply aiding us, not replacing us.

A tool I’ve been using for the past year, VisualDx, allows me to access thousands of medical images that I can use to compare to a patient’s skin rather than referring them to a dermatologist with a long wait time. By looking through multiple examples of the same condition on different body parts and on varying skin tones, I can accurately identify a patient’s condition and recommend a suitable treatment plan. This visual element allows me to be confident in each diagnosis and share my findings with my patients directly in the room.

Earning patient trust with technology use

When a patient comes in with a specialized health issue, they are often hesitant to trust that the diagnoses I’ve made are accurate due to a lack of expertise in a certain area. I recently had a parent bring in their child requesting a referral for dermatologist due to some bumps on her arms. In this case, I already knew the diagnosis as the rash had a very characteristic appearance of molluscum contagiosum. However, the patient’s parent was concerned that I was not knowledgeable enough in this area and was insistent upon a referral. In this case, I was able to use the tool to show her the diagnosis, the time frame that it usually lasted and the recommended treatment. This extra level of reassurance allowed the patient to trust my diagnosis and recognize that a referral was unnecessary.

I also had a patient with a pruritic rash that would not resolve with topical steroids. With VisualDx, I was able to narrow down the differential based on location, type of rash, and patient demographics. I was unable to make a final diagnosis so I decided to biopsy a representative sample. The path displayed a common skin condition known as a lichenoid eruption. I used this additional information along with photo evidence to identify one of the patient’s medications as the cause of the eruption and remove the offending medication. Having a visual tool that I can show to my patients provides them with the same sense of security and comfort that they would feel when visiting a specialist.

Ultimately, rural physicians need to be better equipped to handle health issues that lay outside of their specialties, but they can’t do it on their own. Clinical decision support tools are moving us in the right direction by serving as safeguard in the diagnosis process. For us, a patient’s trust is a top priority. With the help of these diagnostic tools, rural patients can feel comfortable bringing specialty issues to their primary care physician and can save time and money by avoiding an unnecessary referral.