A study looking at telehealth diagnosis of skin conditions—a rapidly expanding field thanks to the ubiquity of smartphones—is raising serious concerns about the quality and accuracy of these services, especially in direct-to-consumer (DTC) delivery models.

Led by Jack Resneck, MD, of UC-San Francisco, the study’s authors go so far as to conclude that it’s probably unwise for payers to continue expanding coverage of DTC teledermatology.

Until improvements are made, they write, “patients risk using healthcare services that lack transparency, choice, thoroughness, diagnostic and therapeutic quality, and care coordination.”

Their study report posted online May 15 in JAMA Dermatology.

Resneck and colleagues had simulated patients submit photos of confirmed neoplastic, inflammatory and infectious conditions to regional and national DTC telemedicine websites and smartphone apps offering services to California residents.

The team received responses for 62 clinical encounters from 16 DTC telemedicine outfits from Feb. 4 to March 11 of this year.

Among their more troubling findings on quality:

• No provider asked for identification or raised concerns about pseudonym use or falsified photographs.
• Only 16 (26 percent) disclosed information about clinician licensure, and some used internationally based physicians without California licenses.
• Just 14 (23 percent) collected the name of an existing primary care physician, while only six (10 percent) offered to send records.
• Prescription medications were ordered in 31 of 48 diagnosed cases (65 percent), and relevant adverse effects were disclosed in only 10 (32 percent).

As for accuracy, the researchers found the DTC providers made several correct diagnoses in clinical scenarios where photographs alone were adequate; however, when additional history elements were important—basic things like fever, unusual hair growth and missed menstrual periods—the providers “regularly failed to ask simple relevant questions and diagnostic performance was poor,” report Resneck et al.

Further, major diagnoses were repeatedly missed. These included secondary syphilis, eczema herpeticum and polycystic ovarian syndrome, and, regardless of the diagnoses given, treatments prescribed “were sometimes at odds with existing guidelines.”

Resneck and colleagues acknowledge several limitations, not least their inability to ascertain whether, or to what degree, dermatologists seeing patients in person would have done better than the DTC teledermatologists evaluated in the study.

In their discussion, extrapolating their findings beyond dermatology, they express their hope that studies such as theirs “will help DTC telemedicine companies and participating clinicians improve their services so that patients seeking these newer channels of care delivery can receive transparent, ethically provided, coordinated, high-quality care.

“In the meantime, we also hope that policymakers, regulators and payers will find ways to identify and encourage telemedicine services that abide by these principles, while discouraging the growth of DTC telemedicine websites and apps that provide fragmented, low-quality care.”

The study has drawn coverage from the mainstream press, including a feature article in the Wall Street Journal.