Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease
Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease
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DOI：
10.1001/jamadermatol.2016.1774
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发表时间：
2016-07-01
期刊：
影响因子：
10.9
通讯作者：
Edison, Karen E.
中科院分区：
文献类型：
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作者：
Resneck, Jack S.;Abrouk, Michael;Edison, Karen E.
重要证据支持使用远程会诊来改善患者获得皮肤科的机会。为了评估DTC远程皮肤病服务的表现，设计人员和参与者使用地区和国家DTC远程医疗网站和为加州居民提供服务的智能手机应用程序提交了一系列结构化皮肤病病例的照片，包括肿瘤、炎症和感染情况。MAIN结果和措施临床医生的选择，证书的透明度，临床医生的位置，人口统计和医疗数据要求，给出的诊断，建议或处方，讨论不良反应，结果从2016年2月4日至3月11日，我们从16个DTC远程医疗网站收到了62次临床会诊的回复。没有人要求提供身份证明，也没有人对使用假名或伪造照片表示担忧。在大多数会诊期间(42[68%])，患者被分配到临床医生，没有任何选择。只有16人(26%)披露了有关临床医生执照的信息，一些人在没有加州执照的情况下使用了国际医生。很少有人收集现有初级保健医生的名字(14[23%])或主动提供发送记录(6[10%])。诊断或可能的诊断在48例(77%)中被提供。在48例确诊病例中，31例(65%)开了处方药，少数患者发现了相关的不良反应或妊娠风险(分别为10/31[32%]和6/14[43%])。在仅有照片就足够的临床场景中，网站做出了几个正确的诊断，但当基本的附加病史因素(如发烧、多毛症、月经过少)很重要时，它们经常无法提出简单的相关问题，诊断性能很差。主要诊断一再被漏诊，包括二次梅毒、疱疹湿疹、革兰氏阴性毛囊炎和多囊卵巢综合征。无论诊断结果如何，开出的治疗有时与现有指南不一致。结论和相关性远程医疗有可能扩大获得高价值医疗保健的机会。然而，我们的发现引发了人们对许多DTC远程医疗网站提供的皮肤病诊断和治疗质量的担忧。目前正在扩大这些服务的健康计划覆盖范围可能为时过早。在取得改善之前，患者面临使用缺乏透明度、选择性、彻底性、诊断和治疗质量以及护理协调的卫生保健服务的风险。我们提出了几点建议，以提高DTC远程医疗网站和应用程序的质量，避免碎片化、低质量医疗服务的进一步增长。
IMPORTANCE 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.OBJECTIVE To assess the performance of DTC teledermatology services.DESIGN AND PARTICIPANTS 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.MAIN OUTCOMES AND MEASURES Choice of clinician, transparency of credentials, clinician location, demographic and medical data requested, diagnoses given, treatments recommended or prescribed, adverse effects discussed, care coordination.RESULTS 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.CONCLUSIONS AND RELEVANCE 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.