Dr. Iltifat Husain’s physician take is at the end of this article
Although telemedicine services have the potential to extend clinical care to hard-to-reach communities, a recent study published in JAMA Dermatology raises concerns about the quality of that care.
When Jack Resneck and colleagues submitted simulated patients with structured dermatologic cases, including photographs, to direct to consumer (DTC) telemedicine web sites and smartphone apps in California, they received 62 responses from 16 services. Among their findings: “Websites made several correct diagnoses in clinical scenarios where photographs alone were adequate, but when basic additional history elements (eg, fever, hypertrichosis, oligomenorrhea) were important, they regularly failed to ask simple relevant questions and diagnostic performance was poor.” Among the missed diagnoses: Secondary syphilis, eczema herpeticum, gram negative folliculitis, and polycystic ovarian syndrome.
The investigators also found that few of the physicians bothered to query patients about their primary care provider (23%) or were interested in sending a record of the telemed encounter to others (10%). Some services used internationally-based physicians without California licenses. Resneck et al concluded “Ongoing expansion of health plan coverage of these services may be premature. Until improvements are made, patients risk using health care services that lack transparency, choice, thoroughness, diagnostic and therapeutic quality, and care coordination.”
Based on their findings, the researchers recommended several best practices for DTC telemedicine services to follow, including disclosure of clinicians’ licensure, credentials, and their location. They also advised the services to 1) obtain proof of identity of patients looking for care, 2) collect at least each patient’s history of the present illness, review of systems, medication list, and drug allergies, 3) perform laboratory studies in settings in which an in-person physician would have relied on those studies, and 4) provide diagnoses and treatments that are based on evidence-based guidelines.
Dr. Iltifat Husain’s take:
This JAMA Dermatology study raises some serious concerns about who the actual provider performing the telemedicine diagnosing are. This overall space isn’t well vetted or regulated, and requires patients to have a high fund of healthcare knowledge to receive appropriate advice and care. Most worrisome to me were some of the huge diagnostic misses — such as secondary syphilis. These are patients that would potentially delay getting second opinions due to reassurance from a telemedicine visit that could lead to disastrous consequences. Obviously, a primary care physician or any physician could have missed some of these diagnoses. However, traditionally there are clear repercussions in place when a miss happens or at least feedback to the physician to help prevent the mistake happening again.
