MINNEAPOLIS (FRONTLINE MEDICAL NEWS) – 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 ).

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.

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.

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 information 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.

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