Study Assesses Direct-to-Consumer Teledermatology Services

A recent study published in JAMA Dermatology, utilized fake patients to assess the performance of direct-to-consumer (DTC) teledermatology websites. This study suggests incorrect diagnoses were made, treatment recommendations contradicted guidelines, and presciprdtions lacked disclosure about possible adverse effects and pregnancy risks.

This study continues the dialogue of wondering how effective direct-to-consumer services are in providing comprehensive and effective health care.

Jack S. Resneck, Jr., M.D., of the University of California, San Francisco, and coauthors used study personnel posing as patients to submit six dermatologic cases with photographs, including neoplastic, inflammatory and infectious conditions, to regional and national DTC telemedicine websites and smartphone apps offering services to California residents. The photographs were mostly obtained from publicly available online image search engines. Study patients claimed to be uninsured and paid fees using Visa gift debit cards; no study personnel provided any false government-issued identification cards or numbers.

The study received responses from 16 DTC websites for 62 clinical encounters for one month between February and March 2016. Dr. Carrie Kovarik, Associate Professor of Dermatology at the University of Pennsylvania and co-author of the study, reported:

  • None of the websites asked for identification or raised concern about pseudonym use or falsified photographs
  • During 68 percent of encounters, patients were assigned a clinician without any choice; 26 percent disclosed information about clinician licensure; and some used internationally based physicians without California licenses
  • 23 percent collected the name of an existing primary care physicians and 10 percent offered to send records
  • A diagnosis or a likely diagnoses was given in 77 percent of cases; prescriptions were ordered in 65 percent of these cases; and relevant adverse effects or pregnancy risks were disclosed in a minority of those
  • The websites made several correct diagnoses in cases where photographs alone were adequate but when additional history was needed they often failed to ask simple, relevant questions
  • Major diagnoses were missed including secondary syphilis, eczema herpeticum, gram-negative folliculitis and polycystic ovarian syndrome
  • Treatments prescribed were sometimes at odds with guidelines

The study found doctors from some of the 16 telemedicine sites contacted misdiagnosed skin cancer, syphilis and herpes. Some doctors prescribed medication without asking about basic medical history, the researchers found. None of the sites asked patients for identification or raised concerns about pseudonyms or falsified photographs, the study said. Few collected the name of an existing primary care physician or offered to send record, according to information provided in the JAMA Dermatology article.

Professionals in the field are calling this study “devious” and “hostile towards the industry”, questioning the intentions and the objectives of the study performed and the use of actors to play actual patients as a reliable source of information.

But Dr. Carrie Kovarik, says the results show we need to be holding Dermatologists utilizing telemedicine accountable.

“I’m not expecting people to hold telemedicine to a higher standard. I expect them to hold it to the same standard that they have in their offices,” Dr. Kovarik said. “We saw some sites doing wonderful work and we saw some sites using unlicensed international practitioners, and this has to stop.”

“Telemedicine has potential to expand access, and the medical literature is filled with examples of telehealth systems providing quality care. Our findings, however, raise doubts about the quality of skin disease diagnosis and treatment being provided by a variety of DTC telemedicine websites and apps. … We believe that DTC telemedicine can be used effectively, but it is best performed by physicians and team members who are part of practices or regional systems in which patients already receive care,” the authors conclude.

Click here for the full JAMA Dermatology study.

For more information on the market responses to this study click here. 

For additional coverage click here.

 

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