Direct to Consumer Telemedicine

From Clinfowiki
Revision as of 22:16, 25 April 2020 by Tlayng (Talk | contribs)

Jump to: navigation, search

Introduction

The direct to consumer (DTC) model of telemedicine differentiates itself from other forms of telehealth by allowing the patient to initiate the encounter. In other forms of telemedicine encounters, such as Telestroke or Teledermatology, a physician initiates the consultation. 24/7, on-demand access to a clinician - once thought to be a futuristic feat, is now readily available to patients, anywhere and anytime. Patients can enter the virtual front door of a number of private entities such as MDLive, Teladoc, or Dr. on Demand, or turn to a local healthcare system with a similar offering. The burgeoning sector of medicine, a $270 million industry in 2019, is expected to continue to grow past $320 million by 2025 as the industry becomes more mature.[1]

Delivering DTC Care

Further information about terminology and types of telemedicine visits and terminology can be found here.

Synchronous DTC Visits

Similar to other types of synchronous telemedicine, the patient initiates a live encounter with a clinician with audio or video conferencing. The widespread availability of computers, tablets, and cell phones with video capabilities enables this two-way interaction to reach the masses. The entities listed above (MDLive, Teladoc, Dr. on Demand) are all examples of companies specializing in synchronous direct to consumer visits.

Asynchronous DTC Visits

There is also a growing market for asynchronous telemedicine visits, where a structured interface leads a patient through questions to gather a medical history. Some of these systems rely on forms of artificial intelligence (AI) and branching logic to guide these patient encounters. This information can be synthesized to present the clinician with a suspected diagnosis, and even prepare a note. Bright.md is one such offering.[2] Whether these responses are always reviewed by a human can vary between different company offerings, as well as each state's requirements that govern telemedicine which vary from no requirement, to a video or phone consultation.[3]


A number of companies have applied this approach to specific medical conditions, such as:
  • hims - Erectile Dysfunction
  • hers - Birth Control, Skincare
  • roman - Erectile Dysfunction, Cold Sores
  • kick - Anxiety
  • LemonAid Health - Variety of Medical Conditions

Scope of Conditions

The constraints of a virtual visit with respect to physical exam, ability to accurately record vital signs, etc somewhat limit the types of conditions that are amenable to such evaluations. Almost all commercial DTC offerings describe their ability to address straightforward or simple, acute problems that bode well to such virtual evaluations such as:
  • Ear, Nose, and Throat complaints (allergies, pink eye, runny nose, sore throat, ear pain)
  • Skin complaints (rashes, small cuts, abrasions, insect bites)
  • Cold and Flu complaints (fever, cough, body aches)
  • GI complaints (upset stomach, diarrhea, nausea)
  • Urinary complaints (urgency, dysuria)
  • Musculoskeletal complaints (without preceding trauma)
  • Mild respiratory complaints (without increased work of breathing)
  • Urgent medication refills
An analysis of one pediatric telemedicine program described a similar scope of complaints, recording mostly skin complaints, URI symptoms, fevers, and GI issues. [4]
Table 1. Chief Complaints of the Patients Seen on Nemours CareConnect
Chief Complaints # of Calls, N(%), (N=1,000)
Skin-related symptoms 186 (18.7%)
URI Symptoms 174 (17.5%)
Fever 151 (15.2%)
GI-related Symptoms 97 (9.7%)
Hospital/ER Follow-Up 91 (9.1%)
Eye-related symptoms 79 (7.9%)
Ear-related symptoms 56 (5.6%)
Injury-related issues 25 (2.5%)
Asthma and breathing concerns 17 (1.7%)
Other 119 (12.0%)

DTC Telemedicine Concerns

While the benefits of telemedicine are often easily identifiable, there have also been concerns raised about whether this increase in convenience for the patient comes at the cost of lower-quality care. A JAMA editorial explores these issues, specifically with the aforementioned asynchronous types of visits, where the authors describe that questionnaire type offerings may not identify the best treatment for you, but only screen for those who should NOT be taking the medication being marketed.[5]

Quality

There have been a variety of methods to assess the quality of care delivered via telemedicine, including adherence to Healthcare Effectiveness Data and Information Set (HEDIS) measures[6], antibiotic prescribing[7], and "secret-shoppers."[8]

Follow-Up

Reimbursement

References

  1. At 4.3 % CAGR, Direct To Consumer Telehealth Services Market Size will reach 322.7 million USD by 2025. (2020, February 4). Retrieved April 25, 2020, from https://www.marketwatch.com/press-release/at-43-cagr-direct-to-consumer-telehealth-services-market-size-will-reach-3227-million-usd-by-2025-2020-02-04
  2. Bright.md raises $8M for AI-powered remote healthcare service with 'virtual physician assistant'. (n.d.). Retrieved April 25, 2020, from https://www.bright.md/news/bright-md-raises-8m-for-ai-powered-remote-healthcare-service-with-virtual-physician-assistant
  3. State Telehealth Laws & Reimbursement Policies, The Center for Connected Health Policy, https://www.cchpca.org/sites/default/files/2019-10/50%20State%20Telehalth%20Laws%20and%20Reibmursement%20Policies%20Report%20Fall%202019%20FINAL.pdf
  4. Vyas, S., Murren-Boezem, J., & Solo-Josephson, P. (2018). Analysis of a Pediatric Telemedicine Program. Telemedicine and e-Health, 24(12), 993–997. doi: 10.1089/tmj.2017.0281
  5. Jain, T., Lu, R. J., & Mehrotra, A. (2019). Prescriptions on Demand. Jama, 322(10), 925. doi: 10.1001/jama.2019.9889
  6. Uscher-Pines, L., Mulcahy, A., Cowling, D., Hunter, G., Burns, R., & Mehrotra, A. (2016). Access and Quality of Care in Direct-to-Consumer Telemedicine. Telemedicine and e-Health, 22(4), 282–287. doi: 10.1089/tmj.2015.0079
  7. Uscher-Pines, L., Mulcahy, A., Cowling, D., Hunter, G., Burns, R., & Mehrotra, A. (2015). Antibiotic Prescribing for Acute Respiratory Infections in Direct-to-Consumer Telemedicine Visits. JAMA Internal Medicine, 175(7), 1234. doi: 10.1001/jamainternmed.2015.2024
  8. Jain, T., Schwarz, E. B., & Mehrotra, A. (2019). A Study of Telecontraception. New England Journal of Medicine, 381(13), 1287–1288. doi: 10.1056/nejmc1907545

Submitted by Timothy Layng