title: Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease.
abstract: Evidence supports use of teleconsultation for improving patient access to dermatology. However, little is known about the quality of rapidly expanding direct-to-consumer (DTC) telemedicine websites and smartphone apps diagnosing and treating skin disease.
  
  
  
  To assess the performance of DTC teledermatology services.
  
  
  
  Simulated patients submitted a series of structured dermatologic cases with photographs, including neoplastic, inflammatory, and infectious conditions, using regional and national DTC telemedicine websites and smartphone apps offering services to California residents.
  
  
  
  Choice of clinician, transparency of credentials, clinician location, demographic and medical data requested, diagnoses given, treatments recommended or prescribed, adverse effects discussed, care coordination.
  
  
  
  We received responses for 62 clinical encounters from 16 DTC telemedicine websites from February 4 to March 11, 2016. None asked for identification or raised concerns about pseudonym use or falsified photographs. During most encounters (42 [68%]), patients were assigned a clinician without any choice. Only 16 (26%) disclosed information about clinician licensure, and some used internationally based physicians without California licenses. Few collected the name of an existing primary care physician (14 [23%]) or offered to send records (6 [10%]). A diagnosis or likely diagnosis was proffered in 48 encounters (77%). Prescription medications were ordered in 31 of 48 diagnosed cases (65%), and relevant adverse effects or pregnancy risks were disclosed in a minority (10 of 31 [32%] and 6 of 14 [43%], respectively). 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. Major diagnoses were repeatedly missed, including secondary syphilis, eczema herpeticum, gram-negative folliculitis, and polycystic ovarian syndrome. Regardless of the diagnoses given, treatments prescribed were sometimes at odds with existing guidelines.
  
  
  
  Telemedicine has potential to expand access to high-value health care. 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. We offer several suggestions to improve the quality of DTC telemedicine websites and apps and avoid further growth of fragmented, low-quality care.
authors.affiliation: Department of Dermatology, and Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco School of Medicine, San Francisco.
authors.forename: Jack S
authors.initials: JS
authors.lastname: Resneck
authors.affiliation: University of California, San Francisco School of Medicine, San Francisco.
authors.forename: Michael
authors.initials: M
authors.lastname: Abrouk
authors.affiliation: University of California, San Francisco School of Medicine, San Francisco.
authors.forename: Meredith
authors.initials: M
authors.lastname: Steuer
authors.affiliation: University of California, San Francisco School of Medicine, San Francisco.
authors.forename: Andrew
authors.initials: A
authors.lastname: Tam
authors.affiliation: University of California, San Francisco School of Medicine, San Francisco.
authors.forename: Adam
authors.initials: A
authors.lastname: Yen
authors.affiliation: Pasadena Premier Dermatology, Pasadena, California.
authors.forename: Ivy
authors.initials: I
authors.lastname: Lee
authors.affiliation: Department of Dermatology, University of Pennsylvania, Philadelphia.
authors.forename: Carrie L
authors.initials: CL
authors.lastname: Kovarik
authors.affiliation: Department of Dermatology, University of Missouri, Columbia.
authors.forename: Karen E
authors.initials: KE
authors.lastname: Edison
mesh_terms: D000328:Adult; D003266:Continuity of Patient Care / Q000592:standards; D000075202:Contraindications; D003625:Data Collection / Q000592:standards; D000072085:Dermatologists / Q000331:legislation & jurisprudence / Q000592:standards; D003880:Dermatology / Q000592:standards*; D003951:Diagnostic Errors; D030881:Disclosure; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D020407:Internet; D008007:Licensure, Medical; D008297:Male; D008487:Medical History Taking / Q000592:standards; D008875:Middle Aged; D063731:Mobile Applications; D057240:Patient Preference; D016544:Patient Simulation; D055553:Prescription Drugs / Q000009:adverse effects / Q000627:therapeutic use; D011787:Quality of Health Care; D012871:Skin Diseases / Q000175:diagnosis* / Q000188:drug therapy; D017216:Telemedicine / Q000191:economics / Q000592:standards*; D055815:Young Adult
chemical_list: D055553:Prescription Drugs