Direct to Consumer Telehealth: Throwing The Baby Out With The Bathwater

I would like to acknowledge the contributions of Catherine Schuster Bruce in this post. Catherine is a University of Bristol Medical Graduate who recently spent two months on placement with Partners Connected Health prior to starting work at the Royal London Hospital, London.
Missed diagnosis. No Diagnosis. Dodgy Clinicians… There’s been a lot of hand wringing around direct-to-consumer (DTC) telehealth. Recently, more alarms went off in the wake of a Wall Street Journal article, outlining the results of a study posted online in JAMA Dermatology that assessed the quality of DTC teledermatology.
Specifically, this study aimed to test the quality of 16 DTC teledermatology services in California. They created surrogate ‘personas’ that presented as potential real-life patients seeking a teledermatology consult. Factors assessed included clinician choice; clinician location; type of data the clinic requested; the diagnoses given; the treatment prescribed or recommended; whether adverse medication effects were discussed; and whether the care was coordinated with the patient’s own physician.
Although the study did not use real patients, it raised some legitimate concerns about these online services. For example, the researchers were not able to verify American Board of Medical Specialities (ABMS) certification for all listed domestic physicians, and some websites did not even offer a consultation with a licensed, board-certified dermatologist. In addition, only 11% offered to send records to a current member of the patient’s clinical team, highlighting growing concern over lack of communication between primary care providers and DTC telemedicine services.  This issue was raised in a survey by Fogel et al that was published in the Journal of Telemedicine and Telecare, and in policy documents from the American Medical Association.

The study also raised concern with respect to diagnostic accuracy. However, these claims may be overstated, as the study authors were unable to assess whether clinicians seeing these patients in traditional face-to-face encounters would have performed better. Arguably, we should aim for a standard of care that is the same, whether you are seen in person or via telehealth. Although there is robust literature showing comparable agreement between face-to-face clinicians and tele-clinicians, the studies have not been extended to DTC services.  This line of research needs to be pursued because, in the DTC environment, a clinician is dealing with less information than either face-to-face encounters or traditional telehealth encounters.  The empiric question is how much information is enough to render an accurate diagnosis and prompt an effective therapeutic strategy.

But, let’s pause and try to put all of this in perspective. Today there are a number of mobile and web-based DTC teledermatology services — some linking  volunteer physicians to underserved clinics and organizations, and other dermatology websites and independent providers that offer consumers a dermatologist’s opinion without ever meeting in person. At the same time, there are also numerous companies, such as American Well and Teledoc, that offer telehealth consultations to employer groups and insurers as a member benefit. For a defined list of non-acute conditions, you can tune in and get a consult from a provider you’ve never met before.  Walgreens and CVS offer these services too.
In 2015, visits to DTC telemedicine websites reached 1.25 million individuals, and more than one million visits are expected this year, according the American Telemedicine Association (ATA).  As these web-based services proliferate, there is apprehension over a lack of regulation, quality control and clinical standards. In fact, in a recent JAMA Viewpoint, my colleagues Stephen Agboola and David Bates and I raised concerns about telehealth and patient safety.

Medicine is a profession, and various forms of regulation – licensing, credentialing, granting of privileges — are in place to assure that those providing services to patients are legitimate professionals who will, as Hippocrates put forth, ‘above all do no harm.’ While most advocates have long agreed that state licensing of providers creates artificial barriers for telehealth, most also agree that unfettered, unregulated growth of DTC telehealth is probably not a good idea.
Some efforts are underway.  For instance, the ATA offers an accreditation process for direct-to-consumer telehealth.  This is an important start, but probably not enough.
The illustrative case from the JAMA Dermatology study is a teledermatology ‘patient’ feigning symptoms of secondary syphilis. This condition looks a lot like other more common, benign skin rashes and is rare, so I suspect it gets missed in many healthcare settings. That said, if the doctor thinks of it, s/he should order the test.  Of course, ordering a test requires sending the patient to some brick-and-mortar facility, all but negating the value of the online consultation.  When the online provider is faced with a patient with what appears to be a common condition easily treated with a prescription cream, the temptation could be too great to treat without recommending the blood test, thus supporting the business model of online consultation.
There are some things to work out, but there is good to be had by encouraging the thoughtful growth of DTC telehealth. For example, we need more patient-focused regulation and further study. We should also determine which symptoms are properly suited to online diagnosis versus the need for in-person care.
It is time that medical professionals tackle direct-to-consumer telehealth in a thoughtful way.  Today, virtually every other service is delivered online these days.  Do we really think healthcare is so different?  Although it is a threat to traditional brick-and mortar healthcare, to dismiss telemedicine without further study is short-sighted. Those offering DTC telehealth services have an obligation here as well.  It seems apparent that these online services are faced with a dilemma: provide the sort of convenient care that consumers demand or admit defeat.
What other challenges — and opportunities — do you see in advancing telehealth services?