Table 3.

Framework of Subspecialty Care Needs and Potential Telehealth Strategies

IDENTIFIED NEED	EXAMPLES	POTENTIAL STRATEGIES
Cognitive interpretation or advice	Discussion of management prior to referral; discussion of need for referral; questions regarding implementation of subspecialist recommendations; interval co-management of a patient with stable chronic illness	Telephone physician access line Electronic messaging/texting E-consultation
Example: “One that might be useful would be follow-up rheumatology. It's a long drive for an eight-minute visit.…[It]always seems like, jeez, I wish they could have just made it so that it was just in conversation [with me]: 'Here are all the labs, we got everything set up, I've had my hands on the patient, here's what I saw today,' and then let the rheumatologist decide [remotely], make choices about medications and progress and things like that.”
Specialized diagnostic study or procedures	Locally performed studies interpreted remotely, such as pulmonary function tests, echocardiograms, radiographic studies	Synchronous or asynchronous remote interpretation of studies
Example: “We use a telecardiology service with [pediatric tertiary medical center] where the echos [echocardiograms] and ekgs [electrocardiograms] are performed at our hospital but sent to [pediatric tertiary medical center] for interpretation, and if we have a question about the interpretation, we can always call them and get a response about why this interpretation or what this means.”
Remote assessment of patient by subspecialist	Visual examination (such as dermatologic examination); examination with remotely viewed images (such as tele-otoscopy); direct patient–subspecialist communication (such as telepsychiatry)	Live video telemedicine Store-and-forward patient images
Examples: “I think that probably most of the [medical] interviews can be done just as well by videoconferencing as in person. I don't like to say that it's never important to see someone in person…but I would think that medically, probably the majority could be accomplished that way.” “I think it would be really useful also in the field of dermatology.…‘I have this patient in the office, would you mind if I sent you this photo?’, or if we can use the telemedicine equipment to let you actually see the patient.
In-person interaction between patient and subspecialist	Specific examination, diagnostic, or therapeutic procedures requiring hands-on interaction Patient preference may also result in need for in-person encounter.	In-person visits Outreach/satellite clinic visit
Example: “Obviously any procedure-based specialty it would be pretty hard to do an endoscopy, liver biopsy, you know, trach aspirate, you know, so any time you get to the point where the patient needed a procedure, that's not going to happen by telemedicine.” “Well I guess all this surgical subspecialty stuff at this point is, you know, is that they've got to get their hands on, and the patients have to, if you're going to develop confidence in any procedures, they need to see them.”