Many Consumer Telemedicine Sites Put Skin Disease Patients at Risk, Says UCSF Dermatologist
Direct-to-consumer commercial telemedicine sites remotely treating patients for skin disease engaged in practices that put patients’ health and safety at risk, according to a study led by Jack S. Resneck, Jr., MD, professor and vice chair of dermatology at UC San Francisco.
“The results were deeply disappointing,” said Resneck of the study of 62 clinical encounters from 16 telehealth sites serving consumers in California. “We found a lack of transparency and patient choice, and a downright careless attitude toward prescribing medications without disclosing side effects or risks, including pregnancy risks. There were avoidable misdiagnoses, a lack of necessary follow-up, and very little interest in communicating or coordinating with patients’ regular healthcare providers.”
These practices are especially disturbing, Resneck said, because telemedicine itself has the potential to provide high quality care. “We’ve seen fantastic outcomes over the years with teleconsultation, where a referring clinician sends a patient’s history and images to a remote dermatologist for recommendations to safely and effectively manage skin conditions,” he noted. “However, that’s not the kind of telemedicine being provided by these commercial direct-to-consumer sites.”
Resneck cited an estimate of 1.25 million visits to consumer telehealth sites in the United States in 2015. “Use of these sites is rapidly increasing, which makes these results all the more important,” he said. “Ironically, however, many major insurance companies are paying for visits to these large commercial sites while refusing to cover follow-up telehealth visits for patients with their own doctors who know them well.”
For the study, research team members assumed identities as fictional patients and submitted simulated dermatologic cases to the sites. They uploaded photographs they claimed were of their own skin eruptions or lesions, mostly obtained from publicly available online search engines. Registering with the sites as uninsured, they paid fees, mostly ranging from $40 to $100, using debit cards in the names of the fictional patients.
The researchers found that none of the 16 telehealth sites asked for proof of patients’ identities or questioned the sources of the photographs. Only 26 percent of sites disclosed information about their practitioners’ medical licenses. “This is shockingly low,” said Resneck. “Patients deserve to know who is providing their care and what their qualifications are. Is the person giving diagnoses and prescriptions a doctor, a physician assistant, a nurse practitioner or none of the above? What is their specialty? Are they board certified?” In some instances, he noted, cases were even sent to overseas clinicians who were not licensed in the United States. “As far as we can tell, these overseas doctors were practicing medicine without a license,” Resneck said.
In 68 percent of cases, patients were arbitrarily assigned a clinician from a variety of specialty backgrounds without being given a choice. “It’s important for patients to have some choice in who takes care of them,” said Resneck. “When you go to a medical office in person for a skin disease, you usually get some say in whether you see a dermatologist, a primary care doctor, an obstetrician or a nurse practitioner.”
A diagnosis was offered in 77 percent of cases. There were several serious misdiagnoses. In one case where a patient said he suspected psoriasis but uploaded pictures of syphilis, all but one of the responding sites recommended or prescribed psoriasis medications. A case of acne caused by polycystic ovarian syndrome, a predictor of infertility and diabetes, was missed by every responding site, since none inquired about the patient’s excess facial hair or irregular periods. Resneck noted that the sites did somewhat better with two diagnoses that could be made from photographs alone, without much medical history needed.
“One reason for these misdiagnoses was that the clinicians went by the patient’s brief submitted history and photos and did not ask any relevant follow-up questions,” said Resneck. “When you walk into your doctor’s office, you usually have a conversation. Typically, the doctor asks you some questions—have you had any respiratory symptoms in the past few weeks? Any fevers? You might mention something important that didn’t occur to you at first which could be very helpful in making a diagnosis. That sort of give-and-take certainly could happen in direct-to-consumer telemedicine, but it was not being replicated in these virtual encounters.”
Patients were given prescriptions in 65 percent of diagnosed cases, but were informed about risks, benefits and potential side effects in only one third of those instances. Women who were prescribed drugs that could pose a risk during pregnancy were advised of those risks only 43 percent of the time. “To me, this is a really careless and potentially dangerous way to go about prescribing medication,” said Resneck. “These sites are prescribing oral antibiotics, systemic steroids and other drugs without enough discussion of treatment options, risks and side effects.”
Finally, sites collected the names of patients’ primary care providers in only 23 percent of cases, and offered to send results to their regular providers in only 10 percent of cases.
“Overall, I’m a tremendous supporter of telehealth,” said Resneck. “I think it has great potential to improve access to high quality health care. But for that to happen, care has to be coordinated between clinicians, and that’s not happening here. Patients are getting care from faraway clinicians who are not sharing records with their local medical teams—leading to fragmented and uncoordinated care for patients. And when patients end up needing in-person care if their condition worsens, or they have a medication side-effect, those distant clinicians often don’t have local contacts, and are unable to facilitate needed appointments. That’s why telemedicine is best performed by physicians and team members who are part of practices or regional systems in which patients already receive care.”
Resneck said that while the study dealt only with dermatologic complaints, “some of the concerning practices we saw are likely to affect other kinds of telehealth patients as well. For issues such as transparency, choice, care coordination, and informed consent for medication side effects, I don’t have any reason to believe that the experience would be any different for a patient with a sore throat instead of a rash.”
The authors recommend that consumer telehealth sites follow a number of best practices, including regularly disclosing their clinicians’ licensures, credentials and locations; obtaining proof of patients’ identities; collecting medical histories and training clinicians to ask appropriate follow-up questions; disclosing risks, benefits and pregnancy concerns for medications before prescribing them; and collecting information about patients’ primary care providers and sharing medical records with those providers.
“Basically, we think that telehealth sites should follow the same set of best practices that any ethical health care professional is expected to follow,” said Resneck. “Otherwise, the current poor performance of these direct-to-consumer providers risks ruining the great potential of telehealth to improve access to quality care for patients.”
Co-authors are Michael Abrouk, Meredith Steuer, MMS, Andrew Tam and Adam Yen of UCSF; Ivy Lee, MD, of Pasadena Premier Dermatology, Pasadena, CA; Carrie L. Kovarik, MD, of the University of Pennsylvania; and Karen E. Edison, MD, of the University of Missouri.
The study was supported by funds from the American Academy of Dermatology Association.
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