Researchers Question Accuracy of Remote Dermatology Care

Website doctors miss major diagnoses

Researchers posing as patients with skin problems sought help from direct-to-consumer (DTC) telemedicine websites––with troubling results, according to a study published in JAMA Dermatology. Some of the online doctors misdiagnosed syphilis, herpes, and skin cancer, and some prescribed medications without asking key questions about patients’ medical histories or warning of potential adverse effects, the researchers found. Two sites linked users with overseas doctors who weren’t licensed to practice where the patients were located, as required by state law.

A research team led by the University of California–San Francisco School of Medicine submitted a series of structured dermatological cases with photographs, including neoplastic, inflammatory, and infectious conditions, using regional and national DTC telemedicine websites and smartphone apps that offered services to California residents. The study involved seven general-medicine websites and nine sites devoted to dermatology issues. The online visits generally cost $35 to $95.

The researchers received responses for 62 clinical encounters from 16 DTC telemedicine websites from February 4 to March 11, 2016. None of the responses asked for identification or raised concerns about the use of pseudonyms or falsified photographs. During most of the encounters (42 [68%]), the simulated patients were assigned a clinician without any choice. Only 16 (26%) responses disclosed information about clinician licensure, and some used internationally based physicians without California licenses. Few collected the name of an existing primary care physician (14 [23%]) or offered to send records (6 [10%]).

A diagnosis or likely diagnosis was proffered in 48 encounters (77%), and prescription medications were ordered in 31 (65%) of these cases. Relevant adverse effects or pregnancy risks were disclosed in only a few cases (10/31 [32%] and 6/14 [43%], respectively).

Most important, the researchers found that major diagnoses were repeatedly missed, including secondary syphilis, eczema herpeticum, gram-negative folliculitis, and polycystic ovarian syndrome. Moreover, regardless of the diagnoses given, the prescribed treatments were sometimes at odds with existing guidelines.

Although DTC dermatology websites routinely post disclaimers that they do “not provide health care services” and do “not create a physician–patient relationship,” the researchers found that these sites do offer clinical diagnoses and make specific treatment recommendations (without sending prescriptions to pharmacies).

The researchers concluded that their findings raise doubts about the quality of skin-disease diagnosis and treatment being provided by DTC telemedicine websites and apps.

“The substantial investment of health plans in providing enrollees with insurance-covered access to these DTC telemedicine websites, as well as rapidly expanding availability for patients willing to pay out of pocket over the internet, may be premature,” the researchers write. “The problem may be exacerbated by several health plans’ willingness to pay large national DTC telemedicine providers while excluding asynchronous telemedicine provided by a patient’s existing specialists.”

In a Wall Street Journal interview, Jonathan Linkous, chief executive officer of the American Telemedicine Association, acknowledged that there is a need for quality control in the growing field of virtual medical consultations. The organization began an accreditation program last year to set higher standards; only seven telemedicine companies have been approved to date, although nearly 500 applied.

Sources: JAMA Dermatology; May 15, 2016; and Wall Street Journal; May 15, 2016.