Teleconsultation simply is the use of live video to see patients remotely, and represents the origins of telemedicine. The initial telemedicine trials as we know them today, and the basis for many large telemedicine programs started with live video clinics done at remote and typically rural settings [1]. When video teleconferencing became suitable for healthcare, patients could be seen at a distance with suitable fidelity. The rationale behind this was access to healthcare, as many times patients were not able to drive or could not afford to drive or driving was not an option due to geography, such as clinics in remote Alaska, rural America, or during inclement weather. In other words, telemedicine grew up and developed into teleconsultations.

Today, two of the largest programs in North America are based on teleconsultations-Avera and the Ontario Telemedicine Network [2, 3]. The most northern aspects of the province of Ontario are not accessible by road, and therefore telemedicine is naturally fit especially for subspecialty care.

The other reason why teleconsultation became a favorable method of practicing telemedicine is because providers did not have to travel. Physicians in essence run a small business, and therefore have to travel to access different patient referral basins. Travel meant less time in clinic, fewer patients booked, and fewer procedures performed. Therefore, the “windshield time” is the wasted time and inefficient and also not cost-effective. Telemedicine created a high degree of efficiency and began to cut down on provider travel and was thus more cost-effective.

Inflammatory bowel disease (IBD) adds a third dimension beyond geography and provider travel. Patients suffering with IBD have multiple confabulating factors that make travel impossible or difficult, and make urban clinics inaccessible. For one thing, patients with IBD can have disabling diarrhea, urgency to move the bowels, incomplete evacuation, and in cases of ulcerative colitis (UC) have to move their bowels multiple times an hour. Patients may stop eating the day before just to drive the clinic. Therefore, travel is not just about geography and provider convenience, but it is complicated by bowel function and inability to access toilets. Nausea and vomiting in the case of severe IBD are likewise disabling. Patients can also have difficulty taking extensive time off work as IBD can lead to medical absences, traveling a half day for clinic means more personal time off (PTO). Patients can have difficulties finding childcare. Patients can have difficulties paying for tolls, parking, and meals when traveling. In total, there is a fundamental assumption in healthcare that travelling is something that patients will do, and the setting of IBD this is not the case, and therefore patients may skip clinic visits, and lose access to healthcare. Teleconsultations represent a solution to these challenges.

The last reason why teleconsultations are valuable for patients with IBD is that the most complex patients demand subspecialty medical homes, the multiple subcomponents of the medical home are not readily available in real time or in typical face-to-face medicine. The ability to provide teleconsultations to complete the array of medical home participants/components is a significant advance in healthcare via technology and more specifically telemedicine.

Teleconsultation is a live two-way audio video conference between a physician and a patient and nurse who are at a remote location. Traditionally, the subspecialist physician is in urban location/tertiary hospital. The patient and nurse are typically located in a rural health care facility and most commonly a rural hospital. As technology evolves, and video broadband becomes a commodity, these classic locations are being expanded to include medical office buildings, the home, mobile applications , and rural nonhospital locations. The expense of setting up video connectivity and the hardware end-points described below meant that the traditional urban doctor and rural patient/nurse was the model. Regardless, this is a doctor to nurse and patient live video conference.

The nurse at the remote location will place the patient in a room, they will gather information, such as a medical list/vital signs and send it via fax or scan or electronic health record (EHR) to the urban physician. During this process vital signs are taken, initial questions are answered, and if this is the patient’s first time for telemedicine an overview is provided. The urban doctor will connect video in a point-to-point fashion using live video teleconferencing and will speak to both the nurse and the patient together.

The interaction with the nurse and patient answers basic and then more patient centric questions akin to a routine face-to-face encounter. The physician will have a dialogue with the patient and complete the history of present illness, confirm the chief complaint, and dive into significant details about the past medical history, past surgical history, family history, social history, and lifestyle factors. During this process the patient can ask questions, provide information, and if the family is in the room they will interact with the telemedicine physician in the same fashion as in person. By the end of this process, the subjective component of the examination is completed.

The next part of the examination is the objective part whereby the nurse examines the patient’s serving as a proxy for the urban physician. Traditionalists describe the art of medicine as laying hands on the patient, in this new model of care the objective examination is the art of telemedicine. The urban physician observes carefully as the nurse examines the patient and describes the findings. Lymph nodes, tenderness of the abdomen, peripheral edema, and the expression of pus from wounds can all be described and simultaneously observed. There is an art to this that is learned through experience and careful attention. Video fidelity is critical during this process, because a grainy or frozen picture may significantly negatively impact the observation.

To augment this component of the objective examination, digital medical peripherals can be attached to the rural endpoint. This can include a digital stethoscope that will listen to high-pitched bowel sounds in the setting of a Crohn’s obstruction, or a high definition wound camera to capture a peripheral lesion, such as pyoderma or note the drainage from a recent surgical incision. Other peripherals can include a laryngoscope looking for mouth ulcers, a blood pressure cuff, and an EKG that could provide a preoperative cardiac clearance. These medical peripherals are rapidly advancing and reaching a commoditize price that makes their prevalence larger, and hence the capabilities of the rural telemedicine clinics more sophisticated [4].

In most teleconsultation clinics physicians have access to radiology and laboratory data to complete the examination of the patient. Just like a face-to-face visit, physicians will consider the aggregated sum of data and then render an opinion. A clear assessment and plan is generated and given to the patient and the nurse at the remote location. A treatment plan can include ePrescribing to the patient’s pharmacy, ordering additional diagnostic studies, such as a computerized tomography (CT) scan at the remote hospital, or it may involve discussing surgical options for more complicated cases. A comprehensive and effective examination is thus completed.

One of the main limitations of this process is examination of the patient’s abdomen and the rectal examination. Subtle findings of fullness from a nest of Crohn’s fistulas in the right lower quadrant, lateral tenderness on the rectal examination from an early fistula, or lateralizing colitis secondary to inflammation are subtle findings that may not be fully appreciated when you dissociate the expert watching the exam from the hands conducting an examination. This is why in many situations having an expert handle teleconsultation especially in more complex cases is an absolute necessity. Experts typically can pick up on very subtle findings by watching the nurse conduct examination. This also highlights the importance of the remote nurse who is conducting the examination. In almost all cases, the urban physician has the ability to discuss how they examine patients and the types of patients they expect to see with the remote nurse ahead of time. Many rural telemedicine clinics strive to use nurses who have specific skill sets in tele-examination so they can convey the necessary information. When nurses examine the patients, they typically speak aloud about what they are feeling, hearing, and seeing. This is a change from typical face-to-face visits, as physicians do not typically speak out loud and describe the data they are generating and accruing in real time.