Mark Matulaitis holds out his arms so the Parkinson's specialist can check his tremors. But this is no doctor's office: Matulaitis sits in his rural home as a neurologist a few hundred miles (kilometers) away examines him via the camera in his laptop.
Welcome to the virtual house call, the latest twist on telemedicine. It's increasingly getting attention as a way to conveniently diagnose simple maladies, such as whether that runny nose and cough is a cold or the flu. One company even offers a smartphone app that lets tech-savvy consumers connect to a doctor for $49 a visit.
Now patient groups and technology advocates are pushing to expand the digital care to people with complex chronic diseases that make a doctor's trip more than just an inconvenience.
"Why can't we provide care to people wherever they are?" asks Dr. Ray Dorsey, a neurologist at the University of Rochester Medical Center who is leading a national study of video visits for Parkinson's patients and sees broader appeal.
"Think of taking your mom with Alzheimer's to a big urban medical center. Just getting through the parking lot they're disoriented," he adds. "That's the standard of care but is it what we should be doing?"
Among the hurdles: While Medicare covers some forms of telehealth, it doesn't typically pay for in-home video exams. Plus, doctors who practice by video-chat must be licensed in whatever states their long-distance patients live. Some states restrict the kind of care and prescribing available via telemedicine.
About 40 percent of Parkinson's patients don't see a specialist, in part because they live too far away, even though research suggests those who do fare better, according to the Parkinson's Action Network.
When Matulaitis first was diagnosed in 2011, his wife had to take a day off work to drive him more than two hours to a Parkinson's clinic. Once he was stabilized on medication, Dorsey enrolled the man in a pilot study of video house calls. Set-up was simple: The doctor emailed a link to video software designed for patient privacy.
He's thrilled with the care.
"It's just the same as if you've ever done Facetime on an iPhone," explained Matulaitis, 59, who continues his virtual checkups with Dorsey a few times a year. "It allows the doctor to see the patient at a point where they are at their best."
Telemedicine is broader than a Skype-like doctor visit. For years, doctors have delivered different forms of care remotely, from the old-fashioned phone call to at-home monitors that measure someone's blood pressure and beam the information to a clinic. Hospitals routinely set up on-site video consultations with specialists.
But the virtual house call is gaining interest. Some insurers offer versions, such as Wellpoint Inc.'s LiveHealth Online service. Telemedicine provider American Well is making headlines with its direct-to-consumer service, offered in 44 states. Psychiatrists are exploring mental health follow-up counseling from the privacy of a patient's home computer.
New guidelines from the Federation of State Medical Boards say telemedicine can be OK without a prior in-person visit, a change expected to influence licensing regulations in a number of states, said federation president Dr. Humayun Chaudhry. The guidelines hold virtual visits to the same standards as an office visit, including a full medical history and informed consent, and say patients should be able to choose among participating doctors. The group also is finalizing a plan to make it easier for doctors to practice across state lines.
But does a virtual exam translate into better outcomes for the chronically ill?
"There's an evidence gap that needs to be filled," said Romana Hasnain-Wynia of the Patient-Centered Outcomes Research Institute, an agency created under the new health care law to study which medical treatments and procedures work best.
With a $1.7 million grant from PCORI, Dorsey's study is randomly assigning about 200 Parkinson's patients from around the country to receive either their usual care or added virtual checkups from a specialist. His pilot studies have suggested telemedicine allows needed care such as medication adjustments while saving patients time.
As for people seeking even a seemingly simple diagnosis, there are other questions such as how to avoid overprescribing antibiotics. Yes, a smartphone camera may spot signs of strep throat. But national guidelines urge a strep test before giving antibiotics, to be sure a virus isn't to blame.
"You have to be a touch more thoughtful when you're talking about new patient relationships," said Dr. Joseph Kvedar of the Center for Connected Health, a division of Boston's Partners Healthcare. But he predicts at-home infection tests one day could supplement telehealth.
Then there's cost. The key is whether telehealth replaces doctor visits or adds to them, Dr. Ateev Mehrotra of Harvard and the RAND Corp., said in recent testimony for a House Energy and Commerce subcommittee that is studying how to enhance telemedicine.
"Telehealth may be too convenient," said Mehrotra, urging that it be implemented in a cost-effective way that provides high-quality care.