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Telemedicine includes any healthcare interaction in which the patient and the practitioner are in separate locations. If I draw a picture of a rash on my foot and send it by carrier pigeon to my dermatologist, it could be considered telemedicine (although this is technically not a technological technique). What we’re practically talking about is electronic communication, usually in real-time, usually a video call, between a patient and a healthcare provider. It seems obvious we should be doing this all the time, and in fact telemedicine services are a rapidly expanding part of healthcare. There are certain advantages such as reduced travel and increased access. Not to mention reducing the risky parts of visiting a hospital, such as stress, nosocomial infections, and bad cafeteria food.

Obviously the information the practitioner can get is limited, which is the major downside. You can only see and hear so much, and as the SpaceX rockets at the bottom of the ocean will tell you, technology is still not perfect in 2019. Still, for a lot of issues, this can screen (pun credit sound BING!) conditions to see if an in-clinic visit is needed. As with any tool, there are advantages and disadvantages, and when used appropriately, telemedicine can be a useful tool. Many healthcare providers are incorporating telemedicine into their existing practices and finding it very useful.

There is a separate group of providers, however, known as Direct to Consumer (DTC) telemedicine. There are generally private, for-profit companies that allow a patient to initiate a consultation on their own. Basically, someone thinks they have a problem and they want to ask a doctor about it before they go into a clinic. So they go online, do a video call with a licensed practitioner, and get medical advice specific for their condition. It’s a great idea in general and has the potential to alleviate a lot of the strain on healthcare systems, as well as supporting patients who would have trouble getting into a clinic. DTC telemedicine is currently in a major boom period, as people turn toward to the internet for their health problems.

Here’s the catch: it appears that DTC companies may actually not be practicing the best medicine. A few recent studies (1,2,3) have assessed the quality of medicine between DTC companies and in-person treatments. They found that, for the same condition, antibiotics were more likely to be used inappropriately during DTC telemedicine consultations. They also found a lack of appropriate diagnostic testing. And this isn’t inappropriate in the wearing-socks-with-sandals kind of way, this is bad medicine. In another study, satisfaction with a telemedicine visit was highly correlated to receipt of a prescription.

This is obviously concerning since medicine already has a huge problem with antibiotic stewardship. There’s a possibility that the marketing that these companies do may be setting inappropriate expectations. It may be harder to convince someone that they don’t need medication, and that they do need to come into a clinic for testing, when that person is already expecting their problem to be fixed with a video call. In addition, DTC telemedicine, being independent from the patient’s medical system, often does not have access to the patient’s medical records which may decrease the quality of care they receive.

There is also mixed data on whether or not DTC services are actually good at reducing burdensome healthcare costs and increasing access to healthcare. It’s important to remember that telemedicine is not any one thing (okay, it’s probably not a carrier pigeon). There are so many variations and potential applications that it might be vastly superior to in-clinic visits for some purposes and vastly inferior for others. We need to keep studying it, and to make sure the companies and practitioners using it understand it’s limitations.

Conclusion: New technology usually comes with kinks

Telemedicine visits will probably become an essential part of healthcare as we figure out what the best uses are, but there is no doubt that there will unintended consequences where these electronic visits actually lead to worse outcomes. For-profit companies are capitalizing on the enormous demand for convenient medical care, and not always in perfect alignment with the best medical practices. Interestingly, another study which compared telemedicine versus in-clinic visits with the same healthcare providers, antibiotic stewardship was equivalent. There’s nothing inherently wrong with providing healthcare through a video call, but these findings suggest that the incentives around the practice model may interfere with the best medical practices. These services are probably under-regulated, and we are in the middle of the turbulence being created by these companies, healthcare providers, and government regulators.

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Posted by Greg Bishop

Greg Bishop is a veterinarian in Oregon who works mainly with dogs and cats. As a fan of the SBM blog, he sees the enormous amount of bad science and information in the field of veterinary medicine as an opportunity, not a problem! But also a problem.