Direct-to-Consumer Telemedicine

doi:10.1016/j.jaip.2019.06.027

The Journal of Allergy and Clinical Immunology: In Practice

Volume 7, Issue 8, November–December 2019, Pages 2546-2552

https://doi.org/10.1016/j.jaip.2019.06.027 Get rights and content

The telemedicine industry and adoption of services have grown exponentially in the last 5 years, and the market is expected to reach more than $130 billion by 2025. Most US health institutions and hospital systems are currently using some form of telehealth, and more than 90% of health care executives surveyed across the United States have virtual care on their roadmap for growth. Telemedicine has been proposed as a way to expand the reach of allergy services and allow more patients to manage their disease with an allergy specialist. Technology can help address fragmentation of allergy care, which is currently provided in multiple clinical settings beyond the allergist's office including in primary care, pulmonary, dermatology, ear, nose, and throat, urgent care, and the emergency room. Remote monitoring, specialist second opinions, and synchronous and asynchronous encounters offer opportunities to streamline routine care, especially as smart hardware such as digital inhalers hit the market and reimbursement for telehealth services evolve. To date, allergy care has been a significant area of interest for direct-to-consumer telemedicine solutions, although the care has mainly been offered by nonallergists. Quality assurance and adherence to evidence-based standards, particularly in the self-pay direct-to-consumer space, warrant attention.

Section snippets

Defining Direct-to-Consumer Telemedicine

The term “direct to consumer” (DTC) in the health care industry has historically referred to marketing strategies deployed by pharmaceutical companies to advertise directly to patients. More recently, it has been used to define health care products and services that are marketed directly to and initiated by a patient as opposed to access that is made available only through a provider. Examples include access to 24/7 physician services via talk, phone, and text, interactive mobile health

DTC Telemedicine Modalities

There are 2 types of DTC telemedicine: synchronous and asynchronous (Table I). Synchronous telemedicine involves real-time 2-way video conferencing, chat rooms, or audio-only encounters, whereas asynchronous telemedicine, also referred to as “store and forward,” involves information transferred between patient and provider over hours or days. This can be achieved via secure text messaging or email and may include audio, images, or other multimedia files. If indicated, prescriptions may be

Current DTC Telemedicine Use Trends in America

Overall, telemedicine use is growing rapidly. Among privately insured and Medicare Advantage enrollees in a large, private US health plan, telemedicine use grew at a compound annual growth rate of 52% from 2005 to 2017.⁹ In the same population, primary care telemedicine grew at an annual compound rate of 36% and increased sharply in 2016, when access to DTC telemedicine increased.9, 10, 11 Teladoc alone reported that its visits increased 53% from 2016 to 2017, for a total of more than 1.46

The DTC Telemedicine Landscape: High-Growth Areas

The most well-known DTC telemedicine market is dominated by for-profit companies, which are often venture capital–funded or publicly exchanged. Synchronous video visits continue to grow exponentially year over year. Coverage for these services is often offered through health plans or an employer, with anywhere from a $0 to standard co-pay, although self-pay-per-visit options are also available at an average of $79.3, 16 In addition, up to 75% of providers and health systems now offer some

Patient Satisfaction

Overall, patients report high levels of satisfaction with DTC telemedicine encounters. For synchronous encounters through Online Care Group with providers with whom patients had no previous relationship, a recent study found that 85% of patients were satisfied with the provider.¹⁴ Prescription receipt and coupon use were associated with the highest odds of patient satisfaction, highlighting convenience and cost as drivers.46, 47 In a pilot study of synchronous versus in-person encounters in an

Quality Assurance

To practice telemedicine, a physician is required to be licensed in the state where the patient is located.⁵⁰ The Interstate Medical Licensure Compact has made it easier for physicians to get medical licenses outside of their state of primary licensure; however, multistate licensure requirements still remain a major barrier to adoption.⁵¹ Guidelines for clinical telemedicine encounters have been proposed by the American Telemedicine Association. It recommends that several quality review metrics

Barriers to Adoption

Barriers to adoption of DTC telemedicine include issues related to technology, reimbursement, licensure, training, and quality (Table II).⁷

Technology limitations are a key barrier to adoption for patients, providers, and hospital systems. Patients may lack the technology or infrastructure to use telemedicine, or may simply be in the habit of seeing a provider in person. Patients also cite a preference to see their own provider who may not have telemedicine capabilities.⁴⁸ For providers, there

Allergist Role in DTC Telemedicine

The allergy specialty is prime for telemedicine because patients are generally healthy, frequently visit their provider, and have a range of conditions that lend themselves through treatment via video or asynchronous modalities (ie, store and forward images). For example, assessment of environmental triggers is made feasible via telemedicine as is the ability to evaluate a reaction in real time. The latter is of increasing importance as sublingal immunotherapy gains popularity in the United

Future Direction/Trends

As telemedicine becomes more mainstream and is adopted by hospital systems and provider groups, and as reimbursement models evolve, it will be interesting to see where DTC telemedicine solutions live.

On one hand, the technology exists to enable providers and hospital systems to address gaps in care in a way that integrates with the existing health care ecosystem. On the other hand, if the self-pay DTC telemedicine industry continues to see tailwinds and billion-dollar valuations, health care

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Cited by (29)

Provision of Food Allergy Care in the United Kingdom and United States: Current Issues and Future Directions
2023, Journal of Allergy and Clinical Immunology: In Practice
Food allergy (FA) is a growing issue worldwide. The United Kingdom and United States are high-income, industrialized countries with reported increases in FA prevalence over the past few decades. This review compares delivery of FA care in the United Kingdom and United States and each country’s response to the heightened demand and disparities for FA services. In the United Kingdom, allergy specialists are scarce and general practitioners (GPs) provide most allergy care. Whereas the United States has more allergists per capita than the United Kingdom, there is still a shortage of allergy services owing to the greater reliance on specialist care for FA in America and wide geographic variation in access to allergist services. Currently, generalists in these countries lack the specialty training and equipment to diagnose and manage FA optimally. Moving forward, the United Kingdom aims to enhance training for GPs so they may provide better quality frontline allergy care. In addition, the United Kingdom is implementing a new tier of semi-specialized GPs and increasing cross-center collaboration through clinical networks. The United Kingdom and United States aim to increase the number of FA specialists, which is critical at a time of rapidly expanding management options for allergic and immunologic diseases requiring clinical expertise and shared decision-making to select appropriate therapies. While these countries aim to grow their supply of quality FA services actively, further efforts to build clinical networks and perhaps recruit international medical graduates and expand telehealth services are necessary to reduce disparities in access to care. For the United Kingdom in particular, increasing quality services will require additional support from the leadership of the centralized National Health Service, which remains challenging.
Deployment of an Interventional Radiology Telemedicine Program During the COVID-19 Pandemic: Initial Experience With 10,056 Visits
2022, Journal of the American College of Radiology
Citation Excerpt :
There are also potential economic benefits to patients, related to less time away from work and travel expenses associated with attending appointments. Conversely, there are some who believe telemedicine should be a temporary solution for the duration of the public health emergency, citing issue surround quality and fragmentation of medical care [27]. However, based on provider and patient experiences to date, it is clear that telemedicine will almost certainly play an increasing role in health care delivery during the pandemic and beyond.
To evaluate the clinical, operational, and financial effects of using telemedicine services in an academic interventional radiology setting during the coronavirus disease 2019 pandemic and to identify potential barriers to equitable telemedicine access for patients.
Evaluation and management (E&M) data over a 104-week period from September 2019 to August 2021 were reviewed. Data related to the visits were recorded including visit type, billing provider, patient demographic information, Current Procedural Terminology code charged, and reimbursement received. The ZIP code pertaining to the patient’s primary residence was matched with median household income from the US Census Bureau.
In all, 14,754 E&M encounters were performed over the study period, of which 10,056 were conducted using telemedicine. Twenty-two percent of visits were performed with interactive video; the remainder were performed using audio only. Female patients were more likely than male patients to use interactive video visits for telemedicine encounters (23.7% versus 20.4%, P < .001). Patients availing of video visits (mean age, 58.1 years, SD = 14.0) were also significantly younger than those patients who used audio-only (telephone) encounters (mean age, 62.5 years, SD = 13.3). Patients with private insurance and those living in neighborhoods with higher median household income were more likely to avail of interactive video visits (P < .001). Professional E&M monthly revenue was between 23.3% and 53.2% of peak prepandemic levels (mean 37.7%).
Telemedicine services allowed for rapid restoration of E&M encounter volumes over the study period. Further work is required to determine the potential implementation barriers to increasing the use of video visits.
Direct-to-Patient Teledermatology During COVID-19 Lockdown in a Health District in Madrid, Spain: The EVIDE-19 Pilot Study
2021, Actas Dermo-Sifiliograficas
Como consecuencia de la pandemia por la COVID-19 cesó la actividad dermatológica asistencial, por lo que iniciamos un estudio para evaluar la utilidad de la teledermatología (TD) directa entre paciente y dermatólogo a través de una App. El objetivo fue evaluar el impacto de esta herramienta para evitar consultas presenciales, así como describir los principales diagnósticos y la satisfacción de pacientes y médicos.
Estudio descriptivo prospectivo. Se incluyen pacientes nuevos que cumplen criterios de inclusión. Se realizó un análisis descriptivo de todas las variables mediante el programa estadístico SPSS.
De los 1.497 pacientes que aceptaron participar el 25% (n = 374) enviaron una consulta virtual con imagen. De entre ellos el 17% (n = 64) fueron dados de alta de forma directa para control por atención primaria. En un 85% (n = 318) de los pacientes se logra evitar la consulta presencial durante al menos 3 meses. Se emitió un diagnóstico en el 87,1% (n = 325) de los pacientes, siendo la confianza en el diagnóstico ≥ 7/10 en el 77,5% (n = 290). La calidad de la imagen fue suficiente en el 52,1%. La satisfacción del paciente fue de 4,5/5. Once de 16 dermatólogos consideraron la TD útil globalmente. La afección más frecuente fue la inflamatoria y melanocítica, siendo los diagnósticos más habituales nevus, acné y eccema.
La TD directa asíncrona es una herramienta eficaz para valorar pacientes nuevos, con un alto grado de satisfacción para médicos y pacientes. El desarrollo de un sistema de TD eficiente implica la integración de la imagen digital en los sistemas de información médicos.
Dermatologic care was halted because of the coronavirus disease 2019 pandemic, prompting us to study the usefulness of direct-to-patient teledermatology via a mobile application. We aimed to evaluate the service as a tool for avoiding face-to-face consultations, describe the main conditions diagnosed, and assess levels of patient and physician satisfaction.
Prospective descriptive study of new patients who met the inclusion criteria. Descriptive statistics for all variables were analyzed with SPSS.
Of the 1,497 patients who agreed to participate in the study, 25% (n = 374) sent an image to a consultant dermatologist through the mobile application. Sixty-four patients (17%) were discharged directly and referred to primary care for follow-up. A face-to-face consultation was avoided for at least 3 months in 85% of patients (n = 318); 87.1% (n = 325) received a diagnosis and the dermatologist's level of confidence in this diagnosis was 7 or higher in 77.5% of cases (n = 290). The quality of the images sent was considered sufficient in 52.1% of cases. Patients rated their satisfaction with a score of 4.5 out of 5. Eleven of the 16 dermatologists rated their satisfaction as good overall. The most common conditions were inflammatory and melanocytic lesions. The main diagnoses were nevi, acne, and eczema.
Direct-to-patient store-and-forward teledermatology is an effective means of evaluating new patients. Both clinicians and patients expressed high levels of satisfaction with the service. Systems enabling the addition of digital images to patient records are necessary to ensure the efficiency of teledermatology.
Patient satisfaction and utilization of telemedicine services in allergy: An institutional survey
2021, Journal of Allergy and Clinical Immunology: In Practice
Telemedicine for preoperative assessment during a COVID-19 pandemic: Recommendations for clinical care
2020, Best Practice and Research: Clinical Anaesthesiology
Citation Excerpt :
Telemedicine can help obtain a detailed medical history focusing on the primary condition, as well as help evaluate the presence of symptoms associated with COVID-19 [2–4]. Through close visual observation, the patient's general appearance and well-being can be evaluated, e.g., use of accessory respiratory muscles, presence of chills, confusion, and bluish lips or face [2,3,13,24]. The aim of these measures is to prevent further spread of COVID-19 by isolating those patients who have tested positive before disease transmission can occur [3,4,8,17,31].
Limiting the spread of the disease is key to controlling the COVID-19 pandemic. This includes identifying people who have been exposed to COVID-19, minimizing patient contact, and enforcing strict hygiene measures. To prevent healthcare systems from becoming overburdened, elective and non-urgent medical procedures and treatments have been postponed, and primary health care has broadened to include virtual appointments via telemedicine. Although telemedicine precludes the physical examination of a patient, it allows collection of a range of information prior to a patient's admission, and may therefore be used in preoperative assessment. This new tool can be used to evaluate the severity and progression of the main disease, other comorbidities, and the urgency of the surgical treatment as well as preferencing anesthetic procedures. It can also be used for effective screening and triaging of patients with suspected or established COVID-19, thereby protecting other patients, clinicians and communities alike.
Telemedicine for Allergy Services to Rural Communities
2019, Journal of Allergy and Clinical Immunology: In Practice
Citation Excerpt :
Synchronous TM can be divided into direct-to-consumer (DTC) and facilitated visits. Synchronous DTC encounters usually are initiated by patients on demand when they want to speak with a health care provider (see Table II and review by Elliott and Yopes in this issue).15 For that reason, this type of visit usually is not scheduled in advance because it requires a provider to be available on-call.
Telemedicine (TM) involves the use of technology to provide medical services to patients who live at a distance. It can be used asynchronously for interpretation of test results (spirometry, skin tests imaging studies), and for communication of information when the simultaneous presence of provider and patient is unnecessary. Synchronous encounters can either be unscheduled and initiated on demand by patients or be facilitated substitutes for in-person visits. The latter results in asthma outcomes that are as good as those for in-person visits while reducing the cost and inconvenience of travel from rural communities to urban centers. Facilitated visits can be done in the ambulatory and emergency department settings, and they can be used for inpatient consults when allergy specialists are not readily available. Both patients and providers experience high degrees of satisfaction with this type of visit. In addition, virtual visits performed using TM are cost-effective. TM offers a solution to the shortage of specialty care that is present in rural communities.

View all citing articles on Scopus

: Conflicts of interest: T. Elliott is a shareholder in Doctor On Demand, Inc, and an employee of Aetna. M. C. Yopes declares no relevant conflicts of interest.

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Review and Feature ArticleDirect-to-Consumer Telemedicine

Section snippets

Defining Direct-to-Consumer Telemedicine

DTC Telemedicine Modalities

Current DTC Telemedicine Use Trends in America

The DTC Telemedicine Landscape: High-Growth Areas

Patient Satisfaction

Quality Assurance

Barriers to Adoption

Allergist Role in DTC Telemedicine

Future Direction/Trends

Acad Pediatr

J Allergy Clin Immunol Pract

Healthc (Amst)

Reimagining healthcare marketing: direct-to-consumer approach

Foreward from Acting Administrator of the Health Resources and Services Administration (HRSA) and Associate Administrator of the Federal Office of Rural Health Policy (FORHP), U.S. Department of Health and Human Services

J Healthcare Poor Underserved

Patient preferences for direct-to-consumer telemedicine services: a nationwide survey

BMC Health Serv Res

Teladoc announces third quarter 2018 financial results

Doctor On Demand reaches 1M virtual visits milestone

NYU Langone Health launches new technology platform to transform digital patient experience