1. Rhoads, Sarah J. DNP, PhD, APRN

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Immediate gratification has become our new norm. Consumers demand instant access to information, products, and healthcare, and our ever-evolving virtual world enables them to meet many of their needs through a few, simple keystrokes or clicks. In a field riddled with lengthy wait times, complicated information, and general inaccessibility, how exactly does healthcare adapt to this new way of thinking?

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As a child, I remember watching Star Trek's Dr. "Bones" McCoy and Nurse Chapel use their tricorders to analyze patients' conditions. At the time, such a diagnosis-determining technology seemed as fictional as traveling to distant planets. However, today's reality is beginning to make science fiction obsolete, with the emergence of handheld devices that monitor vital signs and screen for various medical conditions.1


The good and the bad

Wearable devices and smartphone apps empower patients to participate in their health maintenance. For example, there are numerous apps that encourage individuals to lose weight, among hundreds of other health monitoring and promotion techniques. As with any technology, sometimes the person remains engaged for an extended period of time; however, the novelty often wears off after a few months and use decreases. Motivated patients may even bring their data to their nurse to examine and interpret. What do we do with this app-generated patient data? In most cases, the data are stand-alone and don't integrate with the electronic medical record (EMR). Moreover, nurses may wonder why we want to upload the data; after all, what purpose do all of these readings serve? This isn't an easily answered question and may have different answers for different types of data or patients.


There are some apps and websites that connect individuals with a healthcare provider or specialist, and many people are embracing this technology even if they pay out of pocket for the fee. For example, there are dermatology apps that allow individuals to virtually visit a dermatologist from their home for slightly more than a specialty visit copay. When used and integrated into the healthcare system, this can be an effective use of technology and time. However, if the care provided doesn't integrate into the consumer's healthcare system, caution is warranted because, at present, there are no standards related to communication between a virtual healthcare specialist and the patient's primary care provider. Additionally, virtual, or telemedical, care must be held to the same standard as that of in-person care regarding quality and outcomes.


In a recently published study, researchers examined 16 different direct-to-consumer dermatology apps and websites that used photographs for diagnosis, excluding interactive video (two-way audio and video) consultations.2 The research team created simulated patient profiles, imitating a person with a specific condition by using known photographs or images of cancers, syphilis, and other diseases. The team used these simulated patient profiles to register to be virtually seen by a provider for 62 different clinical visits. The findings of this study have caused much discussion within the telehealth community.


In brief, none of the 16 apps and websites asked for any type of identification from the patient, some of the providers weren't licensed to provide care in the state where the patient lived, and rarely did the app or website offer to send records to the patient's primary care provider. The majority of patients seen were offered a diagnosis and a prescription medication, but proper counseling wasn't provided in the majority of the visits regarding adverse reactions or pregnancy risks and the prescribed medication didn't follow evidence-based guidelines for management of the diagnosis. In many instances, the providers made the correct diagnosis with a clear photo of an easily identifiable condition; however, when further subjective data were needed to aid in the diagnosis, the patients weren't asked relevant questions and, therefore, were given an incorrect diagnosis.


The most alarming aspect of the study was the misdiagnosis of major conditions, such as secondary syphilis. In only 1 of the 62 encounters did a provider suggest local follow-up for further testing, assessment, and evaluation. If a condition that's seen virtually needs a biopsy or further diagnostic testing, the ability to make a referral should be present. This study raises several questions related to direct-to-consumer care. Although a virtual visit is very convenient, the expected standard of care should still be met.


Informed patients

With so many clinical diagnostic services emerging on the app market, there's little doubt that a patient will ask his or her nurse's advice regarding this care. Having faced these questions myself many times, here's the advice I give my patients regarding direct-to-consumer sites:


1. If your primary care provider or health system has an app or website that allows for direct-to-consumer care, use that one first. This ensures continuity of care and the visit to be recorded in your EMR so that your primary care provider can have a record of the visit.


2. If your primary care provider's office allows for interactive video visits with specialty providers, explore that option. Being able to virtually see the specialist in the primary care provider's office promotes continuity and comanagement of care. Although not in the comfort of your home, this virtual visit allows for lab draws, specimen collection, and any other necessary hands-on testing.


3. Examine the app or consulting website for provider credentials, paying special attention to whether the provider is licensed in the state in which you live. In the absence of an applicable state medical license, avoid such a consultation for myriad reasons, including liability, authority, and legality. A board-certified provider in the desired specialty is preferred. Moreover, you should select apps and websites that allow the ability to review and select your preferred provider. If this isn't possible, then you're subjecting your health to the luck of the draw.


4. Use an app or website that has the ability for two-way audio and video communication using a smartphone or web camera. Diagnosis of a medical condition often requires verbal, as well as visual, information. Live, interactive video allows you to interact with the virtual provider in real time just as you would in the office setting, providing opportunities to offer subjective explanations and answers that a photo or written description can't easily capture.


5. Make sure that the records of the visit are sent to your primary care provider. In the absence of this service, a record of the visit should be available for download so you may present such information directly to your provider.


6. Be sure to ask the provider questions as you would during a regular, in-person visit.


7. Ask the provider if there's any follow-up needed after the virtual visit.


8. Examine the security features of the app or website. The last thing you want is for your secure information to be hacked. HIPAA compliance applies just as strongly to a virtual visit as it does to an in-person visit.


9. If medication is prescribed, be sure to ask about adverse reactions, the correct way to take the medication, and if there are any risks related to breastfeeding and pregnancy (if applicable). Be certain to disclose any other medications you're currently taking to avoid adverse drug interactions.



Quality comes first

As healthcare providers, technology is an additional tool we can use to reach our patients and assist in their care. However, in the interest of making a quick profit, there are and will continue to be apps and websites that don't put the patient's medical and privacy needs first. Moreover, in the absence of enforceable best practices in the virtual world, there are apps and websites that individuals may think are providing quality care when, in reality, they aren't. A virtual visit should mirror the quality, privacy, and responsibility seen in any face-to-face visit. As technology continues to improve and evolve, virtual care will be further utilized by healthcare providers and consumers. We must continue to explore the best way to use this technology while ensuring that our patients receive the best care possible.




1. Hsieh P. 8 Star Trek technologies moving from science fiction to science fact. [Context Link]


2. Resneck JS Jr, Abrouk M, Steuer M, et al. Choice, transparency, coordination, and quality among direct-to-consumer telemedicine websites and apps treating skin disease. JAMA Dermatol. [e-pub May 15, 2016] [Context Link]