Telemedicine has proven to be a godsend in its ability to extend health care services to underserved patients in remote locations. It’s also ideally equipped to deal with certain specific forms of health care. However, a recent dermatologic study indicates that it may not be an appropriate tool for all medical disciplines. The study also reveals that not all telemedicine providers are created equal in terms of the quality of the care that they provide.
In a study previewed online in advance of publication in “JAMA Dermatology,” a team of dermatology researchers reveals that online telemedicine providers misdiagnosed a number of serious skin conditions and also prescribed potent medications without thoroughly investigating their patients’ medical histories.
16 Websites Contacted
Researchers, posing as patients with skin problems, made contact with 16 direct-to-consumer (DTC) telemedicine websites, all of which offered services to California residents. These “patients” reported that they were suffering from a variety of dermatologic conditions, including infectious, inflammatory, and neoplastic skin disorders. They documented these conditions with photographs of skin lesions and other signs of skin disorders.
Of the 16 telemedicine providers, nine were devoted exclusively to dermatologic services, according to an article posted at MobiHealthNews.com. These nine were DermatologistOnCall, Dermcheck, DermLink, Direct Dermatology, FirstDerm, SkyMD, Spruce, Virtual Acne, and YoDerm. The remaining seven telemedicine providers offer general telemedicine services and they were AmWell, First Opinion, HealthTap Prime, MD Live, MeMD, Teladoc, and Virtuwell.
62 Clinical Encounters
In all, members of the research team received responses from 62 clinical encounters with clinicians at the 16 telemedicine sites. In 42 of those encounters, clinicians were arbitrarily assigned to patients, giving the latter no choice in the matter. In only 16 of the encounters were patients provided with any information about the clinician’s licensure.
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The research team’s simulated patients were asked to identify their primary care physician in only 14 of the 62 encounters and were offered an opportunity to have relevant information forwarded to their PCP in only six encounters. In 48 encounters, patients were provided with a diagnosis or likely diagnosis, and among those cases where a diagnosis was proffered, the DTC clinicians ordered prescription medications in 31 cases — or 65 percent. However, relevant information about the ordered drugs’ adverse side effects was provided in only 10 cases. Information about the pregnancy risks of these medications was provided in only six of the 14 cases where pregnancy was a factor.
Many Diagnoses Were Correct
The research team reports that clinicians at DTC websites made several correct diagnoses in cases where the photographic evidence was sufficient to draw such conclusions. However, in cases where photographic evidence was insufficient and corroborative information about the patient’s medical history was critical, DTC clinicians often failed to ask relevant questions, and diagnoses were more often off the mark.
Researchers report that major diagnoses were repeatedly missed, particularly in cases involving eczema herpeticum, gram-negative folliculitis, polycystic ovarian syndrome, and secondary syphilis. Regardless of the accuracy of the diagnoses offered, clinicians sometimes prescribed treatments that were at odds with existing guidelines.
11 of 14 Spot Skin Cancer
To their credit, 11 of the 14 clinicians who were shown photos of nodular melanoma, an aggressive and potentially deadly form of skin cancer, advised the consulting patient to see a doctor in person. However, three of the 14 clinicians advised the patient that the condition was almost certainly benign.
More unsettling was the performance of telemedicine providers in diagnosing a young woman with polycystic ovarian syndrome, an endocrine gland disorder that’s accompanied by hormonal symptoms such as acne and facial hair. Of the 12 DTC clinicians consulted on this case, none was able to correctly diagnose the disorder, which requires hormonal therapies.
Dermatologist Jack Resneck, M.D., lead author of the study, told the Wall Street Journal that many of the clinicians “failed to ask simple, relevant questions of patients about their symptoms, leading them to repeatedly miss important diagnoses.”
Basic Follow-Up Questions Missing
Dr. Resneck said that researchers were unable to determine whether the clinicians would have performed better had they seen the patients in person. He noted that “the usual give-and-take that occurs between a physician and a patient wasn’t happening during these electronic consultations. The clinicians weren’t asking basic follow-up questions.”
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Asked to comment on the study’s findings, Ateev Mehrotra, M.D., an associate professor of health care policy and medicine at Harvard Medical School, told the Wall Street Journal that the study “identifies a number of egregious quality issues that raise significant concern.” He pointed out, however, that other studies have found comparable quality issues with in-person visits as well. He added that because many dermatologists refuse to accept Medicaid patients, the low-cost telemedicine services — averaging $35 to $95 per encounter — may be all that some patients can afford.
Quality of Diagnosis Questioned
In the conclusion to their study, the dermatology research team acknowledges that telemedicine has the potential “to expand access to high-value health care. Our findings, however, raise concerns about the quality of skin disease diagnosis and treatment provided by many direct-to-consumer telemedicine websites.”
The researchers suggest that the current expansion of health care coverage for such services may be premature. “Until improvements are made, patients risk using health care services that lack transparency, choice, thoroughness, diagnostic and therapeutic quality, and care coordination.”
Acknowledging that quality control is a critical issue in the rapidly expanding arena of telemedicine services, Jonathan Linkous, CEO of the American Telemedicine Association, told the Wall Street Journal that his organization established an accreditation program in 2015. The purpose of the program, he said, was to raise the standard of care offered by telemedicine providers. Although nearly 500 telemedicine companies had applied for accreditation as of mid-May 2016, only seven had been approved up to that time, said Linkous.
ACP Position Paper
In a position paper published in the November 17, 2015, issue of “Annals of Internal Medicine,” the American College of Physicians spells out its recommendations for the appropriate use of telemedicine’s technologies. On the plus side, the ACP paper notes that telemedicine has the potential to improve health outcomes, reduce medical costs, expand patient access to health care, and enhance patient-physician collaboration. Against those potential benefits must be weighed some of the risks and challenges associated with the practice of telemedicine.
High on the list of risks and challenges cited by the ACP paper are the absence of an in-person physical examination, issues surrounding the establishment of a relationship between patient and provider, and variations in state practice and licensing regulations.
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