While a large body of evidence supports the use of store-and-forward teleconsultation for skin conditions, significant concerns exist over the emerging use of direct-to-consumer (DTC) telemedicine, according to a May 15, 2016 study in JAMA Dermatology. In 2015 the number of visits to DTC telemedicine websites reached 1.25 million, the authors said, and large DTC services are increasingly partnering with health plans. The authors constructed six simulated dermatologic cases, preparing patient demographics and medical history for each, and then used publicly available photos from online searches to display the simulated conditions. Posing as patients, study personnel told DTC websites offering services to California residents that they were uninsured and paid with Visa gift debit cards. In all, 62 cases on 16 DTC websites were included. Not one telemedicine provider asked for identification or raised concerns about whether a pseudonym or fake photograph was being used. The DTC websites made diagnoses in 77% of the cases and ordered prescription medications in 65% of those. Relevant adverse effects or pregnancy risk were disclosed less than half the time (in 10 of 31 cases and 6 of 14 cases, respectively). When the photographs alone were adequate, such as when they showed stasis dermatitis or melanoma, the DTC providers tended to make correct diagnoses, the authors said. When the diagnosis required knowledge of additional history elements, such as oligomenorrhea, hypertrichosis, or fever, the providers "regularly failed to ask simple relevant questions and diagnostic performance was poor." Major diagnoses that the DTC providers missed included secondary syphilis, eczema herpeticum, gram-negative folliculitis, and polycystic ovarian syndrome. Some websites offered patients a choice of clinicians; however, 68% did not. Websites disclosed information about clinician licensure in just 16 (26%) of the encounters. Some of the sites used internationally based physicians without California licensure, and though a website claimed all its physicians were "board-certified dermatologists," the authors could not find evidence these physicians were licensed in California. Just 23% of the DTC providers asked for the names of the patient's primary care physician, and only 10% offered to provide medical records to existing clinicians, an omission that the authors said would likely worsen care fragmentation.

HRC Recommends: Telemedicine use continues to grow and branch out in unique ways. When used well, it can improve communication between practitioners and their patients; however, if telemedicine is used without care, communication can become muddled or erroneous. Risk managers should understand how telemedicine is being used at their organization; incorporate telemedicine into patient safety (e.g., incident reporting) and quality improvement systems; address liability issues; and ensure that appropriate credentialing and privileging policies, clinical and regulatory guidance, electronic security protocols, and record retention policies are in place and are being followed. Healthcare organizations may wish to examine outcomes, care quality, patient satisfaction, and resource usage for telemedicine compared with other modalities.