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Direct-to-consumer telemedicine websites: Caveat emptor, a prediction, and proposal

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By Warren R. Heymann, MD
July 17, 2016

Two weeks ago, I experienced pain extending from my right groin to my buttock to the degree that I almost could not bear weight. I felt as though I was 90, and if anyone saw my gait, they would have reached that conclusion. If there were an app for my iPhone to take an image of my hip, I would have used it. What did I do? What everybody else does — I Googled “hip and groin pain,” went to the Mayo Clinic site addressing the issue. I learned that the distribution of discomfort was likely due to tendons around the hip, rather than the joint itself. I followed their advice of resting (in my case not exercising for a couple of days) and taking ibuprofen. Within a few days it all resolved — I extend my thanks to the Mayo Clinic!

Jack Resneck Jr et al evaluated 62 clinical encounters for 16 direct-to-consumer (DTC) websites. (One is “YoDerm” for acne only. I thought it would be from Philly, but the web address says California!) The simulated diagnoses included polycystic ovary disease, secondary syphilis, nodular melanoma and seborrheic keratosis, eczema herpeticum, and stasis dermatitis. In no cases was patient identification verified, only 26% disclosed information about clinician licensure, only 23% asked for the name of the primary care physician, and only 10% offered to send a record of the encounter. A diagnosis was rendered in 77% with 65% of patients receiving a prescription; potential adverse reactions were discussed in only 32% and pregnancy risks in 43%. Although several diagnoses were made correctly when the images were adequate, if the “give and take” of a regular live encounter would have been beneficial, this venue often failed to ask rudimentary questions, resulting in poor diagnostic performance. The authors concluded that while telemedicine has the potential for expanding access to “high value” health care, until improvements are made (in transparency, choice, thoroughness, diagnostic and therapeutic quality, and care coordination), the widespread implementation of these services may be premature. They state: “We believe that DTC telemedicine can be used effectively, but is best performed by physicians and team members who are part of practices or regional systems in which patients already receive care” (1).

This study has justifiably received ample press, most notably in the New York Times article “Skin Problem? Websites May Offer Poor Care” (by Nicholas Bakalar, May 18th, 2016). I recommend that you read it AND the comments about the article.

While possibly too premature to have widespread implementation, the proverbial train has left the station. The only advice I can give people is caveat emptor.

Prediction: When all is sorted out, insurers will insist on a teledermatology visit first (for ridiculously low reimbursement) before approving or paying for a live visit. You will see live patients in two circumstances — failure to improve (not even cryosurgery unless topical chemotherapy is tried first) or if a procedure is required. I also anticipate that one of the “quality measures” will be giving patients a response within 30 minutes, 24/7. Oy vey ist mir!

Proposal: Our group is about to embark on using telemedicine once our EMR releases its teledermatology program. We will be using this ONLY for existing patients. While I am comfortable with the process (I looked at the beta version at the AAD), I am very fearful about reimbursement. I really do not believe that most encounters will take just a few minutes. Some might (a seborrheic keratosis in a patient worried about melanoma), but what about a purpuric rash in a transplant patient? The standard evaluation and management fees cannot apply here. It’s time to take a lesson from the lawyers and bill for time only. I propose a base fee of $50 for up to a 5 minute consult, and $5 per minute thereafter. (A 15-minute visit would be $100, 30 minutes $175, etc.). Honestly, though, after a full day of live patients, I’d rather go home and have dinner with my wife, Ronnie.

1. Resneck JS Jr, et al. Choice, transparency, coordination, and quality among direct-to-consumer telemedicine websites and apps treating skin disease. JAMA Dermatology 2016; 152: 768-775.

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