Many praise telemedicine as the next frontier in medicine, with the potential to increase access to care and decrease costs. However, a new study has found that these services may not always offer the best quality care.
The study comes from Dr. Jack S. Resneck, Jr. of the University California, San Francisco School of Medicine and other researchers. The study authors published their results in the journal JAMA Dermatology May 15th. With the rise in telemedicine use, the researchers wanted to examine the quality of care from teledermatology services.
Many consumers are turning to direct-to-consumer (DTC) telemedicine websites and smartphone apps for quick and easily-accessible medical care. The DTC sites give consumers the opportunity for a remote medical visit, corresponding online and through photos with a dermatologist or other clinician to get a diagnosis for their skin disease as well as prescriptions and treatment advice. A large Medicaid managed care plan in California has offered coverage for teledermatology services since April 2012.
For their study, the researchers posed as patients with certain dermatology cases, using stock photographs. The cases covered inflammatory, infectious, and neoplastic conditions. The fake patients used sixteen different regional and national DTC websites and smartphone applications that serve people in the state of California, making notes on various aspects of their service. In February and March 2016, the researchers recorded information for 62 clinical encounters. Because of the study design, the researchers had to exclude the minority of sites that require a video encounter with the clinician.
The researchers discovered that although they were using fake names and information, none of the telemedicine websites asked them for identification or seemed to express any concern about whether the researchers were using a pseudonym. Although that worked out in the researchers’ favor, it could be a problem if patients were abusing the system.
The researchers discovered that 68 percent of patients were automatically assigned to a clinician, with no choice about who they would prefer to see, despite this choice being part of the medical code of ethics. Some of the clinicians were located internationally, although they were seeing patients located in the state of California. Only 26 percent of the telemedicine clinicians disclosed information about their licenses, and this lack of transparency could be a concern if patients believe they are seeing a fully-licensed dermatologist but are actually speaking to someone without a valid medical license.
Although it is important for a medical specialist to coordinate with a patient’s primary care physician, to help avoid overlap in care, prescription interactions, or other problems, the researchers found that only 23 percent of the clinicians asked for the primary care physician’s name and only 10 percent offered to send medical records to that physician. In addition to not coordinating with the primary care physician, these remote sites would likely not have local contact information to refer a patient to an in-person appointment for further care and follow-up.
The clinicians seemed to offer a medical diagnosis in most of the cases, with 77 percent offering a diagnosis and 65 percent offering a prescription for the medical problem. However, the researchers had doubts about the quality of these diagnoses and prescribed treatments, with many of the treatments not following standard guidelines. In cases where simply seeing a skin problem made it easy to diagnose, the telemedicine sites did seem to get the diagnosis right. However, when other information was relevant, such as whether the patient had a fever, most of the clinicians failed to ask the additional relevant questions, missing the correct diagnosis. Many of the clinicians failed to diagnose problems such as secondary syphilis, polycystic ovarian syndrome, eczema herpeticum, and gram negative folliculitis, medical problems which go beyond a simple skin condition. In one particular case, the photograph and patient information seemed to fit with a syphilis diagnosis, but the fake patient told the clinician he thought he had psoriasis. The clinician agreed with the psoriasis diagnosis and prescribed the patient psoriasis medication, missing a serious medical problem.
When the telemedicine clinicians prescribed a medication, only about a third of them explained possible risks and side effects to the patients. When the patient was a woman of childbearing age, few of the clinicians mentioned risks related to pregnancy.
The researchers do seem to see the value of telemedicine. The technology could help patients in remote areas more easily access a specialist, and telemedicine can also help patients save time by seeing a doctor in their own home. However, the researchers suggest some standards that telemedicine websites should adopt to provide the best quality care. These include disclosing clinician license information, matching clinicians with patients in the same state, and giving patients a choice about who to see; getting proof of patient identity and collecting medical information such as current medication, history, and a full review of symptoms; following existing medical guidelines when making a diagnosis and suggesting treatment, and training clinicians to ask appropriate follow-up questions; discussing medication risks and pregnancy concerns with the patients; following up with the patient’s primary care physician and maintaining relationships with local specialists to refer patients or for follow-up; and monitor their quality of care. By adopting higher standards, telemedicine could indeed be a powerful tool for the future of medical care.
According to the American Telemedicine Association (ATA), 200 networks and 3,500 sites service the U.S., with more than a million online consultations expected this year. The group began an accreditation program last year, and of 500 companies that applied for the accreditation, only seven have been approved.