Study finds gaps in DTC teledermatology quality

Issues of transparency also arose: In two-thirds of the encounters, clinicians were assigned with no opportunity for patient input or choice. Licensure information was provided by about a quarter of providers overall. Of the U.S.-licensed physicians, just under half provided their board certification status. “Patient choice of their treating physician is part of our medical code of ethics, and we were surprised that these websites with multiple clinicians on staff assigned a clinician without patient choice in most encounters,” they added.

Telemedicine services provided the clinician’s geographic location in 61% of the encounters, and the investigators were able to identify the location of the clinician for 57 encounters. Of these, 35 were within the state of California, six were in India, and two were in Sweden; the rest were in other U.S. states. “Despite claims that they were not providing health care services, we believe that two DTC telemedicine websites headquartered in California but using foreign clinicians were engaged in the practice of medicine without a state license, as they clearly provided diagnoses and treatment recommendations,” they pointed out.

The geographic spread between patient and provider may have contributed to the lack of care coordination seen in the study, Dr. Resneck said in the interview, noting that most DTC providers “didn’t offer to send records to a patient’s existing local doctors.” When complications or follow-up care are needed, he added, “those distant clinicians often don’t have local contacts and are unable to facilitate needed appointments.”

In the study, the authors acknowledged a significant limitation of the study, their inability to “assess whether clinicians seeing these patients in traditional in-person encounters would have performed better on diagnostic accuracy.” However, they felt that their experience showed that the additional data that would have led to a correct diagnosis “typically emerge in the give-and-take of obtaining a history in the office setting.”

Telemedicine in all its forms can be expected to grow. At the meeting, Dr. Edison said that recently, the Stage 2 Meaningful Use requirement that at least 5% of a practice’s patients send a secure electronic message to their provider has been an impetus for increased adoption of teledermatology. And that can be a good thing. “Early access to our expertise saves patients from suffering, saves lives, and saves money,” she commented.

For Dr. Resneck, the early access should be part of the patient’s existing network of care, when possible, and he’s frustrated by the lack of continuity his study highlighted. “Many insurers are currently contracting with the fragmented DTC services we studied for their enrollees, while refusing to cover follow-up telehealth visits with a patient’s existing doctors, and that’s a problem,” he said.

Quality can’t be sacrificed for easy access, Dr. Edison agreed. “The same standard of care applies in teledermatology as in in-person health care,” she said.

Dr. Edison said that study personnel did not falsify their identities, and no prescriptions were actually filled. The visits were paid for by prepaid debit cards funded by the American Academy of Dermatology (study personnel claimed to be uninsured). Dr. Resneck serves on the board of the American Medical Association, and both Dr. Resneck and Dr. Edison serve on the AAD’s Telemedicine Task Force.

koakes@frontlinemedcom.com

On Twitter @karioakes