Teledermatology Study Raises Misdiagnosis Concerns

A study looking at 16 direct-to-consumer teledermatology websites found that treatment recommendations sometimes contradicted guidelines, incorrect diagnoses were made, and prescriptions frequently lacked disclosure about possible adverse effects and pregnancy risks, according to an article in JAMA Dermatology.

Jack S. Resneck, Jr., M.D., of the University of California, San Francisco, and the paper’s coauthors used study personnel posing as fake patients to submit six dermatologic cases with photographs, including neoplastic, inflammatory and infectious conditions, to regional and national DTC telemedicine websites and smartphone apps offering services to California residents.

Photographs submitted were mostly obtained from publicly available online image search engines. Study patients claimed to be uninsured and paid fees using Visa gift debit cards. No false government-issued identification cards or numbers were given.

Even though direct-to-consumer teledermatology (DTC) is growing quickly and large DTC services are contracting with major health plans to provide telecare, relatively little is known about the quality of these services.

None of the websites asked for identification or raised concern about pseudonym use or falsified photographs.

“Patients” were assigned a clinician without any choice in 68 percent of the encounters. 26 percent disclosed information about clinician licensure; and some used internationally based physicians without California licenses.

Quality Doubts Raised

One major limitation to this study, the article points out, is that the authors were unable to assess whether clinicians seeing these patients in traditional in-person encounters would have performed any better. Also, the websites did actually make several correct diagnoses in cases where photographs alone were adequate but when additional history was needed they often failed to ask simple, relevant questions.

“Telemedicine has potential to expand access, and the medical literature is filled with examples of telehealth systems providing quality care. Our findings, however, raise doubts about the quality of skin disease diagnosis and treatment being provided by a variety of DTC telemedicine websites and apps. … We believe that DTC telemedicine can be used effectively, but it is best performed by physicians and team members who are part of practices or regional systems in which patients already receive care,” the authors conclude.

A diagnosis or a likely diagnoses was given in 77 percent of cases. Prescriptions were ordered in 65 percent of these cases, and relevant adverse effects or pregnancy risks were disclosed in a minority of those.

Major diagnoses missed included secondary syphilis, eczema herpeticum, gram-negative folliculitis and polycystic ovarian syndrome.

Resneck JS, Jr, Abrouk M, Steuer M, et al.
Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease
JAMA Dermatol. Published online May 15, 2016. doi:10.1001/jamadermatol.2016.1774.

Image: Andy Blackledge/Flickr. Sculptor James Nathaniel Muir’s “Caduceus”