Patient treatment impacted by direct-to-consumer telemedicine

One subset of telehealth that has surged in recent years is the direct-to-consumer (DTC) telemedicine services. They offer anything from paediatric urgent care, to weight loss, to virtual medicinal cannabis services.

For many, these services provide a convenient and revolutionary approach to health care. However, many question whether comprehensive research and extensive studies are keeping pace with the swift development in this sector. Are patients receiving safe, effective and reliable health care and how would we know if they’re not?

The Australian direct-to-consumer telemedicine industry

A Perspective published in today’s Medical Journal of Australia asked these questions. General practitioner and an author of the Perspective Dr Darran Foo said that they want to make sure the patients are benefiting from these services.

“It’s not to say that the services don’t operate at a high level of safety and quality or don’t provide continuity of care,” Dr Foo told InSight+.

“I guess it’s more that these services are new, and they’re quite heterogenous and there really isn’t a way to tell whether or not it’s a good quality service just from looking at a website.”

Some of these concerns were highlighted when the Medical Board of Australia drafted up revised guidelines for telehealth consultations with patients (here).

In the industry responses, these services described how they have achieved positive patient outcomes, how they provide continuity of care, what safeguards and limitations are incorporated into their operating models and how they contribute to improved access to health care for patients in rural and remote areas.

It highlighted to Dr Foo how most of the current evidence about telemedicine services is anecdotal.

“Currently, it’s a lot of case reports, case studies, people coming out with what they’ve experienced, which is really important,” Dr Food said.

“But I think we need to get some robust data to inform the policy.

“If people are definitely increasing their health care utilisation, especially in rural regional areas, then there is a major problem and there needs to be something done to regulate that or potentially mitigate that harm.”

Telemedicine in rural and remote Australia

How people use these services in rural and remote areas is of particular concern to National Rural Health Alliance Chief Executive Susi Tegen. She said that these DTC telemedicine services are useful, but only if they add to, and aren’t instead of, existing locally delivered services.

“There’s an affordability aspect because many people in rural, regional and remote Australia have to travel further if the service doesn’t exist nearby, for specialist services in particular,” Ms Tegen said. 

However, she is concerned that some telemedicine services are replacing those that already exist locally.

“What concerns me the most is that it’s not building the capacity of the people we have and that we are training in the future,” Ms Tegen said.

“If you start to pick off some of the things that you can do quickly or are easy, you’re taking away from local care and reducing business from a local community pharmacy or a local allied health professional.”

“This is not a view against telehealth or digital health. I think all of those things have added significant value.”

She said these services needed to be coordinated.

“Australia prides itself in a connected health system, but with the prospect of supermarkets offering telehealth and medicines, there will be a disconnection of patient care,” Ms Tegen said.

“It’s very much like we're Americanising the Australian Health System. And I can tell you, America is not doing well in terms of the whole of patient health care.”

Ms Tegen is also concerned about how the lack of continuity of safe care can affect a person’s overall wellbeing in the long term. 

“It is no different from a patient ordering weight loss medicine overseas,” she said.

“This person may have other health issues but not declare those or the medications that they are taking. Who manages the side effects and issues that arise? A family doctor or multidisciplinary clinic would know because they have all the medications on file and access to their specialists who communicate with each other.”

DTC telemedicine services are also not offering treatment pathways, she said.

“I think if the whole-of-patient care is the ultimate goal, then companies entering the market should be working with local clinicians along the whole patient clinical journey,” she said.

“A diabetes educator working with the doctor, the podiatrist, and the team. 

“It should be a multidisciplinary model, not a one-off model where we can take part of the system out because it suits us to make a profit. Rural communities deserve better care.”

According to Dr Foo, DTC telemedicine services don’t have an obligation to consult with the person’s primary care doctor.

“At the moment there [aren’t] any requirements for them to send to their GP, although you’d expect it to be best practice,” Dr Foo said.

“Also, there aren’t any kind of requirements for them to upload records on My Health Record.

“The other major thing is a lot of these [DTC telemedicine] services operate as private services, so they don’t claim Medicare benefits or rebates. So there’s no visibility across the number of encounters or types of services rendered other than what’s reported by the companies themselves,” Dr Foo explained.

Finding the answers

Currently, we do not know how many patients use direct to consumer telemedicine services or what services they’re using.

“Who are all the patients that have used the services over a period of time?” Dr Foo asked.

“Can we look at all the people who live in rural region areas who use the services? Have they then ended up in hospital, have they ended up needing to see the GP more, have they ended up on more medicines they don’t necessarily needed and then resulting in harm? We don’t know the answers to these questions.”

The medical practitioners working in these services are bound to the same regulations as any other doctor. However, all the other ways the services operate are different.

“These models are really different to how a general practice would operate, for example … How do they impact the system as a whole?” he asked.

“How do they impact people’s use of the health care system down the track?”

The authors hope some comprehensive research will help to answer these questions to ultimately improve health care for all Australians.

Read the Perspective in the Medical Journal of Australia.