Although telemedicine is a promising avenue to improve health care access and patient satisfaction and to reduce costs, many concerns have been raised about the quality of health care provided.
The Federation of State Medical Boards, state boards, and other physician organizations have expressed concern regarding the quality of DTC telemedicine. 14,15 The concerns with DTC telemedicine are driven by the lack of in-person physical exam, limited access to medical records, lack of follow-up, and barriers to diagnostic testing. Together these limitations may lead to poor quality of care, misdiagnosis, or higher rates of follow-up visits. Telephone visits have been flagged as particularly concerning given that such encounters involve no visual cues to assist with diagnosis. 16
Assessments of the quality of DTC telemedicine to date are limited. Follow-up visits have been used as a rough proxy for quality. The logic is that higher rates of early follow-up after DTC telemedicine visits would suggest high rates of misdiagnosis and poor quality. Follow-up visits can occur at any site: emergency department, physician office, or DTC telemedicine companies. Studies have found that follow-up rates are similar among in-person office visits and DTC synchronous telemedicine visits 6 as well as e-visits. 17
Another method of assessing quality has been to compare antibiotic prescribing across settings. For example, one study investigated antibiotic and broad-spectrum antibiotic prescribing rates for Teladoc and physician's offices, finding that the fraction of acute respiratory infection (ARI) visits at which an antibiotic was prescribed was similar for Teladoc (58%) and physician offices (55%). When antibiotics were prescribed, Teladoc physicians were more likely to prescribe a broad-spectrum antibiotic for ARI visits (86%) compared to 56% at the physician offices. 18 One assessment of e-visits in a health system found that antibiotic prescribing for sinusitis treatment was higher during e-visits than during physician office visits. 17 Another study highlighted that the training of the clinician may be an important factor; e-visits provided by nurse practitioners were associated with higher rates of prescribing medications than e-visits provided by physicians. 19 One limitation of these studies is that they assess the quality of antibiotic prescribing based on the diagnosis provided by the clinician; the underlying assumption is that the diagnosis is correct.
One method for assessing diagnostic accuracy and adherence to guidelines is to use secret shoppers. In a recent study, researchers used 67 trained standardized patients who presented to DTC telemedicine companies with the following six common acute illnesses: ankle pain, streptococcal pharyngitis, viral pharyngitis, acute rhinosinusitis, low back pain, and recurrent female urinary tract infection. 20 Conditions were misdiagnosed in 24% of visits and adherence to guidelines was only 54%. Although such rates are concerning, it is unclear how they compare to equivalent in-person visits. Given the ongoing debate on telephone visits, it was notable that there was no difference in quality between audio-only and video visits. Perhaps most importantly, the study also described significant variation in quality across the eight DTC telemedicine companies. Other research that studies the “average” DTC telemedicine misses this key point.
One consistent theme in evaluations is that DTC telemedicine clinicians are less likely to order tests. This is to be expected given the additional logistical hurdles in ordering a test. For example, whereas ordering a strep test in a physician office is relatively simple, in a DTC telemedicine encounter, the clinician must identify where the patient can get the test, follow up with the results, and then set up another interaction to discuss the results with the patient. Given this complexity, some DTC companies do not have the ability to order tests. If a test is needed, the patient is told to visit their primary care provider. Whether this lower rate of testing is “good” or “bad” depends on the clinical scenario: for instance, lower rates of testing in patients with back pain likely indicate higher-quality care because these tests are normally overused. 21 However, for conditions such as streptococcal pharyngitis or urinary tract infections lower rates of testing more likely indicate lower-quality care. 17
In summary, studies assessing DTC telemedicine quality have been mixed. Some evidence supports that the care is equivalent to in-person care, whereas other research raises concern about the overuse of broad-spectrum antibiotics and misdiagnosis. Because lower rates of testing are consistently found with DTC telemedicine, there needs to be greater attention on how to facilitate appropriate testing. Finally, the care provided across DTC telemedicine providers is variable; some providers are providing higher quality care than others.
DTC telemedicine visits are clearly lower cost than an equivalent in-person visit. One study found total costs (including prescriptions and testing) of $161 for DTC telemedicine visits and $219 for in-person primary care visits. 22 Thus, if patients substituted higher-cost physician office or emergency department visits with DTC telemedicine visits, there could be substantial savings.
The key to cost savings from DTC telemedicine therefore is substitution. However, it is also possible for DTC telemedicine visits to raise costs if they increase health care utilization by lowering the threshold for when patients seek care. A recent study quantified the relative fraction of DTC telemedicine visits that represented substitution versus new utilization. It found that 12% of DTC telemedicine visits were substitution and 88% represent new utilization. The net impact was an increase in health care spending. 23
Patients who use DTC telemedicine tend to be both younger and healthier than the rest of the population. 6 More than one-third of e-visits are scheduled for the weekend and holidays, likely due to convenience. 6 The impact of DTC telemedicine on improving access to underserved communities remains poorly studied. One evaluation of Teladoc visits surprisingly found that users were not more likely to live in a rural community or a community with a shortage of clinicians. 21