Incorrect diagnoses, inappropriate treatments, lack of information
about possible side effects and risks, and lack of transparency
about a doctor’s credentials were among the concerns raised in the
study of direct-to-consumer (DTC) teledermatology sites.
“I was deeply disappointed by the poor performance we observed,”
senior study author Dr. Jack S. Resneck, Jr. of the University of
California, San Francisco School of Medicine, told Reuters Health by
Resneck and colleagues note that DTC teledermatology is expanding
rapidly but has not been well studied. To test some of these sites,
the researchers posed as patients with skin-related symptoms.
The fake patients submitted photos of various cancerous,
inflammatory and infectious skin conditions to sites offering
services to California residents. They claimed to be uninsured and
paid fees using Visa gift debit cards, according to a report in JAMA
They received responses from 16 DTC sites for 62 online visits in
February and March of this year.
No sites asked for proof of identification or raised concerns about
the photos, which had mostly been downloaded from online search
engines. In two thirds of online visits, patients did not get a
choice of clinicians. Licensing information was provided in only
about a quarter of cases, and some of the sites used foreign
physicians without California licenses.
In less than a quarter of cases did the sites ask the name of the
patient’s primary care physician. In only 10 percent of cases did
they offer to send medical records.
A diagnosis was offered in 77 percent of cases. Although
prescription medications were ordered for 65 percent of diagnosed
cases, potential adverse effects were disclosed in only a third of
those cases, and pregnancy risks in 43 percent. In addition,
treatments were sometimes at odds with existing guidelines.
When a diagnosis could be made by photos alone, the sites made
several correct diagnoses. But when additional information was
needed—for example, other symptoms, such as fever or heavy
periods—sites “regularly failed to ask simple questions and
diagnostic performance was poor,” according to the researchers.
Major diagnoses such as syphilis, eczema, and poly cystic ovarian
syndrome were repeatedly missed, Resneck noted. One patient uploaded
photos of a syphilis rash and gave a medical history that fit with
syphilis, but she told the service she thought she had psoriasis.
“Most clinicians working for these DTC sites just agreed with the
self-diagnosis and prescribed psoriasis medications,” he said.
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Further, if patients end up needing in-person care because their
condition worsens or they have a medication side effect, many
teledermatology clinicians don’t have local contacts and can’t
facilitate an appointment.
“That’s why telemedicine is best performed by physicians and team
members who are part of practices or regional systems in which
patients already receive care,” Resneck stressed.
“I don’t want to see low-quality services put patients at risk and
ruin telemedicine for doctors who are using it to provide
high-quality care,” he added. “We had expected to see variation
among the different services, but the broad lack of choice,
transparency, quality, and care coordination is very concerning.”
Dr. Ateev Mehrotra of Harvard Medical School in Cambridge,
Massachusetts, added, “Teledermatology sites that don’t ask for
pictures or a medical history, and don’t ask about medications and
allergies, may not be as high quality as sites that do.”
He told Reuters Health, “While nothing can insure the quality of
care in person or on the Internet, the more information you’re asked
for and give, the easier it will be for a clinician to see the whole
picture and make an appropriate diagnosis.”
SOURCE: http://bit.ly/1srMuYU JAMA Dermatology, online May 15, 2016.
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