No matter what you may read, direct-to-consumer telehealth is not telemedicine.
To be clear, direct-to-consumer (D2C) telehealth generally involves a company that charges consumers a fee to speak to physicians on the phone. The physician questions the consumer about symptoms and comes to a diagnosis. It's naïve to think that people are merely calling to receive medical advice from a doctor - they've spent the money, and they want a prescription, usually for an antibiotic. It's important to understand the difference because too many people use D2C to argue for more permissive prescribing rules couched in terms of providing greater access to healthcare. I am not making up the classification, although for brevity I've shortened it to D2C.
Historically, telehealth was often used interchangeably with telemedicine when they both meant approximately the same thing or as an umbrella term for connected care that includes remote patient monitoring (passive at a person's home or active in the intensive care unit), the storing and forwarding of radiological images and telemedicine. An article titled "Physician telemedicine services could grow with new policies" continues to blur the distinction. Compounding the identity problem is that the American Telemedicine Association (ATA) has resisted a name change, and yet caters to both telemedicine and D2C telehealth companies and their interests.
Some would argue that D2C telehealth companies would not exist if they didn't fill a need. It's difficult to argue against that if you've ever had to deal with a screaming child's earache at 2 a.m. Health problems have a way of occurring in the middle of the night or on weekends, or so it seems. Rarely are common complaints serious, but we've come to demand an expedient way to handle them. Few people have never visited an urgent care center or emergency room or taken advantage of a 24-hour pharmacy. An increasing number of adult Americans no longer have a primary care provider because they stay healthy. For them, consulting a doctor is inconvenient because it requires an actual visit.
For the most part, an interaction - whether in person, via telemedicine or on the phone – between a patient and a physician can be beneficial. The sticking point is the issuance of a prescription medication to a previously unknown person who the doctor has never examined and for which the doctor has no access to the medical record. And here's where telemedicine differs from telehealth. During a telemedicine visit, the patient is seen by the provider. A patient presenter is with the patient in most cases, and follows the directions of the remote provider in placing a stethoscope or exam camera on the patient's body, providing both sounds and images. The remote provider also has the benefit of an array of other medical devices to gather patient information not available to a D2C telehealth physician.
Another distinction between telemedicine and D2C telehealth is that telemedicine consultations are often with medical specialists like cardiologists, dermatologists and pulmonologists. These often occur when the patient is in an underserved rural community and the specialist is in a large urban area. The distance makes it difficult to make and keep appointments otherwise. D2C telehealth, on the other hand, best deals with minor primary care issues over the phone. If deemed to be a more serious health concern, the patient is told to make an appointment with a specialist or to proceed to a hospital emergency room.
A decade ago, most state medical boards, with some exceptions, called the issuance of prescriptions without an in-person physical exam unprofessional conduct and dealt with it pretty harshly by disciplining physicians. In fact, Congress passed the Ryan Haight Act in 2008, requiring establishment of the patient-provider relationship before a prescription can be written. It prohibits dispensing controlled substances via the Internet without a "valid prescription." The act defines telemedicine as the practice of medicine by a practitioner who is at a location remote from the patient and is communicating with the patient or health professional treating the patient via a telecommunication system so long as the patient "is being treated by, and physically located in, a hospital or clinic" or "while the patient is being treated by, and in the physical presence of, a practitioner." The law was in response to physicians who, hired by Internet pharmacies to review the answers to online questionnaires, issued prescriptions based solely on the answers. There was no way for the prescribing physician to check the "patient's" veracity.
In the past few years, with the support of the American Medical Association and the Federation of State Medical Boards, an electronic examination via telemedicine (not telehealth) has become acceptable in about 20 states. Now, under pressure from the public, the ATA and lawmakers, medical boards in a number of states have relaxed their standards to allow D2C telehealth companies to operate, and others are considering doing the same. The latest to succumb to this trend is the Alabama Board of Medical Examiners, which recently suspended its rule requiring first-time visits between a patient and physician to be in person.
We used to place an intangible value on a personal relationship with a doctor. Technology has allowed us to maintain that with telemedicine, not D2C telehealth.
Editor's note: This article first appeared on GlobalMed's blog site.
Roger Downey is the communications manager for GlobalMed, a Scottsdale, Ariz.-based telemedicine design, manufacturing and marketing firm. He is a broadcast news veteran, having worked as a news anchor/reporter in Phoenix for 25 years and serving as the media relations officer for the Arizona Medical Board, the regulatory agency for MDs in the state. He is a board member of the Arizona Partnership Implementing Patient Safety (APIPS), a non-profit organization composed of physicians, nurses, hospital and government agency representatives, pharmacists and insurance carriers. He is also a member of the American Telemedicine Association Pediatric Special Interest Group.
