Study finds gaps in DTC teledermatology quality

MINNEAPOLIS – Missed diagnoses, lack of care coordination, and security concerns were among the gaps in care that appeared when research personnel with simulated skin problems used direct-to-consumer (DTC) sites for telemedicine consults in a recently published study that highlighted potential drawbacks of this technology.

While telemedicine “has potential to expand access, and the medical literature is filled with examples of telehealth systems providing quality care,” the authors of the study concluded, their results “raise doubts about the quality of skin disease diagnosis and treatment being provided by a variety of DTC telemedicine websites and apps” (JAMA Dermatol. 2016;152[7]:768-775).

Dr. Karen Edison

Karen Edison, MD, a dermatologist and telemedicine pioneer, shared results of the study that addressed the quality of DTC teledermatology, a rapidly growing market, at the annual meeting of the Society for Pediatric Dermatology. The DTC telemedicine care model provides direct patient access to providers through a web portal or app, without referrals from a primary physician or via insurance or managed care.

Dr. Edison, chair of the department of dermatology at the University of Missouri–Columbia, a study coauthor with over 20 years of teledermatology experience, said that she herself has recently begun seeing established patients live via video conferencing, with several successful “e-visit” experiences over the last several months.

In addition, she has about 3 years’ experience in“store-and-forward” teledermatology, where notes and relevant clinical images from an office visit are forwarded to a specialist, who then initiates a clinician-to-clinician consult to provide expertise in difficult cases or when resources are lacking. Live interactive and store-and-forward teledermatology have both been shown to be reliable for diagnosis and management, based on a “large body of evidence,” said Dr. Edison, citing a 2015 American Telemedicine Association statement.

However, the reliability of DTC care has been less well studied, she pointed out.

In an interview, Jack Resneck Jr., MD, the study’s lead author, agreed. “Physicians by our nature are innovators and will embrace new technologies whose quality and value are proven, but DTC telehealth isn’t there yet,” said Dr. Resneck, professor and vice-chair of dermatology, at the University of California, San Francisco.

Dr. Jack Resneck Jr.

To simulate a realistic patient experience and assess aspects of quality of care in DTC teledermatology, he, Dr. Edison, and their coinvestigators devised a study that had study personnel pose as patients to seek care for one of six skin conditions. They limited e-visits to websites or apps that offered services to California residents and excluded sites that required an interactive video visit, or that served patients insured by a particular insurance company or by a particular brick-and-mortar health care organization.

The “patients” initially submitted a universal history of present illness for a given condition, and had up to three photos available for submission. They also had supplemental medical history and review of systems information available that they would provide only if prompted by the provider.

A total of 16 telemedicine sites received a total of 62 submissions from the study personnel. Security issues arose almost immediately, Dr. Edison said at the meeting. “No site asked for photo ID or attempted to confirm identity,” and no site attempted to verify the authenticity of the submitted photos.

Twenty-seven of the providers were dermatologists, and an additional eight were internal medicine or family practice physicians. The remainder came from a variety of specialties. Six visits were conducted by seven nonphysician providers (three physician assistants from dermatology settings, and four nondermatology nurse practitioners).

When it came to the actual patient encounter, only one in three clinicians asked for a review of previous symptoms or a pertinent review of systems. “None asked relevant follow-up questions,” Dr. Edison said. Just under half of the providers asked female patients whether they could be pregnant or were lactating. Of the 14 encounters where pregnancy category C or higher drugs were prescribed, six providers (43%) discussed pregnancy risk.

For four of the simulated patient encounters, clinicians diagnosed a skin condition without asking for any photographs. No patients were referred for laboratory testing.

One of the cases was a 28-year-old woman who described a long history of inflammatory acne; the additional information, which no site requested, was that the patient also had hypertrichosis and irregular menses, as well as a mother with diabetes. This history would have led to a polycystic ovarian syndrome (PCOS) diagnosis, had it been elicited.

This was one of many such instances, and, in addition to PCOS, major diagnoses were missed, including secondary syphilis, eczema herpeticum, and gram-negative folliculitis.