Small study pokes holes in direct to consumer dermatology telemedicine services

By Aditi Pai
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Direct to consumer dermatology telemedicine services are lacking in a number of areas, including transparency, diagnostic and therapeutic quality, and thoroughness, according to a small study published in JAMA Dermatology.

Researchers who worked on the study were from the University of California San Francisco School of Medicine, Pasadena Premier Dermatology, University of Pennsylvania Department of Dermatology, and University of Missouri Department of Dermatology.

“Telemedicine has potential to expand access to high-value health care,” researchers wrote in the abstract. “Our findings, however, raise concerns about the quality of skin disease diagnosis and treatment provided by many DTC telemedicine websites. 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.”

Researchers submitted a total of 62 simulated dermatologic patient cases to 16 direct to consumer telemedicine websites that offered services to California residents and mentioned skin disease among treated conditions. Nine of the websites focused solely on dermatology, including DermatologistOnCall, Dermcheck, DermLink, Direct Dermatology, FirstDerm, SkyMD, Spruce, Virtual Acne, and YoDerm. Another seven were general telemedicine services. These included AmWell, First Opinion, HealthTap Prime, MD Live, MeMD, Teladoc, and Virtuwell.

There were six simulated dermatologic cases that included patient demographics, history of present illness, review of symptoms, and three photographs that researchers took from publicly available image search engines. Researchers used the telemedicine services between February 4 and March 11 of this year. When they were given the choice of a clinician, researchers prioritized a dermatologist, followed by a primary care physician, other physician, nurse practitioner, and then physician assistant.

After analyzing data from the telemedicine visits, researchers found that 77 percent of the cases received either a diagnosis or likely diagnosis and in 68 percent of the cases, services assigned patients to a clinician without giving patients a choice. 

Services offered users prescriptions in 65 percent of the diagnosed cases, but in 32 percent of the cases where users received a prescription, relevant adverse effects were not disclosed. And in 43 percent pregnancy risks weren’t disclosed.

Just 26 percent of the services disclosed information to patients about clinician licensure. Some of these services even used a physician based outside the US who didn’t have a California license. Some 23 percent of the services collected the name of the user’s primary care physician and even fewer, 10 percent, offered to send records to the user’s primary care physician.

Clinicians who spoke with patients via the telemedicine services also repeatedly missed major diagnoses, including secondary syphilis, eczema herpeticum, gram-negative folliculitis, and polycystic ovarian syndrome.

“When implemented appropriately, DTC telemedicine websites can improve access to quality care for patients facing geographic, mobility, or financial constraints,” researchers wrote in the study. “While a large body of evidence supports the use of teleconsultation for skin disease between a referring clinician and dermatologist, our study raises significant concerns about the rapidly expanding use of direct-to-consumer telemedicine.”