Online MDs: Contenders or Pretenders

As early as November 2001, the increasing popularity of Internet consultations without a previous relationship between physician and patient was well recognized, enough that Swedish researchers conducted a study that lasted through January 2002 to “investigate how an Internet-based Ask the Doctor service without any preexisting doctor—patient relationship was used and evaluated by the enquirers.” Their findings, published in April 2006, show that such services are appreciated for their convenience and flexibility and the ability for users to reflect upon diagnoses, second opinions, and advice from a physician as opposed to attempting to remember conversations during a face-to-face meeting with a doctor.

Online Medical Consultation Services

Dozens of sites have popped up during the past six or seven years, and even earlier, offering advice (see Online Medical Consultation Services below), diagnoses, second opinions, and even prescriptions from doctors who never physically meet the person with whom they are consulting. Dale C. Alverson, MD, Medical Director of the Center for Telehealth and Cybermedicine Research at the University of New Mexico Health Sciences Center, and also board of directors member, Center for Telehealth , told MDNG that the popularity of such sites has risen “because of the gaps in access to services and the limited resources that we have to provide services. The tools of telehealth— the information communication technologies—offer opportunities to reach out to people who need services they can’t receive easily and also provide a way for healthcare professionals to virtually extend themselves to those people.” Further, the anonymity such sites offer to patients has also spurred their interest. “If you want Viagra or whatever it may be, and you don’t want to go to the doctor, that’s one way to get it. It’s a huge marketplace,” adds Rob Sprang, MD, Center for Telehealth & E-Health Law board of directors, and director of Kentucky TeleCare, University of Kentucky College of Medicine.

Included among these sites is YourDiagnosis, where individuals seeking health information provide answers to a comprehensive set of questions regarding weight, diet and other habits (smoking, alcohol intake, exercise, etc), immunizations, current medications and health supplements, current and previous family and personal health issues, presenting symptoms, and other factors. The information provided is aggregated to produce a thorough report that displays all replies entered, suggestions regarding what to do based on them, and the probability of certain diagnoses and their urgency.

Patients can then save their summary and, for $50, obtain comments on all aspects from a physician and ask a medical question to be answered by that physician. Users can also conveniently link right to the sister site YourNetDoctor, where questions can be asked of a general physician for $60. Similarly, Online Medical Diagnosis “a diagnosis and treatment program that uses medical specialists to accurately diagnose symptoms…with a program created by 1,500 specialist physicians”— and its sister site Online Medical Treatment Advisor—“a treatment program that uses medical specialists to accurately select the best and newest treatment for each patient, based on individual patient’s characteristics”—offer their services through a one-year subscription of $9.99.

Pretenders

Without regard to safety, it’s clear why patients would want to take advantage of the services provided by the above sites, but we can only speculate as to why a US oncologist would participate (please e-mail us at ccole@mdng.com if you participate, know someone who does, or have thoughts on the matter). Although Online Medical Diagnosis lists its associated physicians, no contact or affiliation information is provided, and when we searched for the individuals using Google and Yahoo, either no actual physician turned up or the name was so common that it would be difficult to determine who was the physician in question. Further, e-mail messages sent to the only site listing direct contact information for its doctor(s) and other staff were immediately bounced back, and calls to corporate numbers lead to unreturned voice mail messages and/or a bunch of “I don’t know, let me transfer you to…”

Given how difficult it is to actually contact any of the doctors working with these sites or look up the names of those that may be listed, it’s nearly—and likely purposely—impossible to confirm their legitimacy. “I can’t imagine that they are legitimate physicians,” said Sprang. “I realize there are doctors that may use the Internet for existing patients to help them renew prescriptions or make modifications to prescriptions, but anyone who associates with these blind Internet operations should have their medical license revoked. It’s unquestionably inappropriate.”

So, with a clear negative stigma surrounding them, why would an oncologist get involved with an online consulting or prescribing service? Aside from providing an easy way to make a buck without having to deal with coding, reimbursement, or typical office hours, oncologists who offer consultations and prescriptions online can take as long as they want to provide answers or information to patients, and can do so from the comforts of their own home should they so chose.

However, “Any physician who gets involved with this, I really have to question,” added Sprang. “There are a lot of legitimate physicians who are turning to the Internet to facilitate contact with physicians. It’s a brilliant application of the technology.” Sprang stresses the importance of differentiating between the legitimate practice of telemedicine—treating a patient who is actually viewed and heard via video teleconferencing technology—and the consultations and prescriptions provided by the services listed in the above sidebar.

Contenders

Other online physicians and oncologists include those who are using video teleconferencing to establish a relationship with a patient— just as they would with a patient who comes to their office, clinic, or hospital—and using secure e-mail messaging services and further video conferencing for follow-up (see our feature story from the American Telemedicine Association and our Day in the Life item in the Pulse section for more on this technology). “The premise is that if you use telehealth to provide service,” stated Dr. Alverson, “you should be able to provide that service in the same way you would establish a relationship with the patient face-to-face; that is, you do an adequate history, you make sure that an adequate physical is done—and that may require a third party. You should perform the examination in a way very similar to how you would if you were seeing the patient physically face-to-face. And that’s actually been a general policy that’s been developed through various national organizations, such as the Center for Telehealth & E-Health Law.”

Sprang feels such practice will “unquestionably” become preferred in the not-too-distant future. “Very few of us are able to live in a community that has access to all of the medical services that you could ever need,” he explained. Telemedicine “is the only way that I can see that we can make sure that you are not penalized for living in a medically underserved area, whether a rural area or in downtown urban areas because of financial constraints.” He notes that the idea of medically underserved populations is often mistakenly only associated with rural areas (see our feature on remote health for more on this). “If you live in downtown Lexington and don’t have a car, you’re medically underserved,” he added. “You’d have to walk all the way across town to get to a doctor’s office; a young mom with a young baby for instance just can’t do that.”

In either case, rural or urban, Dr. Alverson explained to MDNG that because many people can’t actually make the trip to the office or clinic—regardless of how close it may be—“many healthcare professionals are beginning to adopt and integrate telehealth, because it allows them to more effectively and consistently provide service to patients.” Primary care providers can now use telehealth to “allow their patients to more easily get oncology services; a primary care provider in a rural community can now offer the ability for the patient to get that service more quickly, more easily when they need it. Oncologists can follow-up with their patients more effectively as well. There’s more and more evidence, particularly in areas of chronic disease and the aging population, that more expedient access to care can be offered through these tools of telehealth, which is improving the health of the people served. There are some good examples of that, even in the home environment, with diseases like cancer and congestive heart failure, in which it’s being shown that problems are being picked up sooner.” He added that because patient management can be rearranged with telehealth, patients are able to remain out of the hospital, improving quality of life and saving the healthcare system money, because the patients aren’t requiring more extensive critical care services.

However convenient and cost-effective providing medical services via telehealth may be, oncologists who do so are faced with additional legal and ethical issues that may hamper their ability to “contend” with the “traditional” oncologist who sees patients only physically, face-to-face. “Modern medical concerns with telemedicine and robotics practiced across national and other jurisdictional boundaries engage the historical, complex area of law called conflict of laws,” wrote Dickens BM and Cook RJ in the July 2005 issue of the International Journal of Gynecology . Does a practitioner licensed in one jurisdiction and treating a patient in another violate the laws in that other jurisdiction? If that practitioner violates a contract or treats the patient negligently, does the practitioner incur liability in his jurisdiction, the patient’s, or both? What if treatment that is lawful in the practitioner’s jurisdiction isn’t lawful in the patient’s? Is that a crime? These questions have yet to be answered definitively, according to a June 2006 Journal of Telemedicine and Telecare article. However, the author writes that “it is also the case that health-care professionals who undertake telemedicine in a prudent manner will minimize the possibility of medicolegal complications.”

What’s a Doc to Do?

Although our above-described “pretenders” are a minority in the world of healthcare providers, “there certainly can be the threat that we’ll see more of [them,] because of the difficulty in trying to track these types of people,” explained Dr. Alverson. “There is a legitimate concern about unqualified, unauthorized people creating online services that ask patients to fill out a questionnaire on a Web page and then they send them a prescription. That’s a problem that needs to be monitored. These people and the sites they run can have a fairly large impact because the Internet reaches so many people.” He added that improvements in ways to police such activity and track down what he calls the “Viagra doctors” can help in weeding out the “bad actors.” Dr. Alverson also thinks “we have an obligation to educate the general public about the potential harm that can be done by obtaining your healthcare virtually from someone you don’t know who may not be qualified to provide that service. That gets into the area of authentication who is really on the other end? Are they really qualified to provide this service? That goes for video conferencing as well a person can get on a camera in a live monitor and say he’s a psychiatrist, and patients just have to trust that he is. Now there are some very interesting ways of authentication with biometrics, using fingerprints, retinal scans, and so on. I think we’ll see more of that because of these concerns.” Why haven’t ideas and proposals like Dr. Alverson’s come to fruition? Some states are implementing laws to crack down on care provided across borders via the Internet to patients who are never met by the doctor (see The Laws of Telemedicine below). Dr. Sprang noted that “Congress has proposed multiple laws, but I don’t know of any that have passed yet.” He added that in the current Kentucky legislative session, Senate bill 88—meant to address these issues—was introduced and passed in the Senate, sent to the House, amended, and then sent back to the Senate. “I don’t know whether anything is going to happen with this either.”

So, talk to your congressperson, tell him or her about the importance of passing bills like Kentucky’s bill 88. But, when you do, make sure to explain the importance of the bill’s language, warns Sprang. “I’ve been talking to the attorney general of the state, because the attorney general in Kentucky—a very aggressive guy—decided he had enough and that he was going to push the state legislature to clamp down on this.” In that legislation, “the language said to prescribe medication, you had to have a face-to-face encounter. I’m OK with that, unless you interpret it as we have to be in the same room together, which is possible with a strict interpretation. So, I called him and said ‘look, nobody is more supportive of what you’re trying to do than I am, but you need to make sure you qualify that term as including an interactive videoconference encounter.’ His office said, ‘Oh, we would never want to do anything that would damage telehealth. We value that technology.’ So, they came back and wrote in the legislation also including an encounter as defined in my telehealth legislation. It protected us. That’s my only concern with being too zealous about going after this legislatively. If you don’t carefully craft the language, you could put the telehealth industry out of business. Nobody is more supportive of fighting the Internet pharmacies than the telehealth industry, just be careful when you write the legislation that you don’t throw the baby out with the bathwater.”

When it comes to legitimate telemedicine, unless you plan on retiring anytime soon, it’s certainly worth your while to at least check out the technology. Telemedicine is here to stay and growing in numbers and popularity. After all, if you can’t beat ’em, join ’em.

Sites Offering Cancer-Specific Consultation Services

AccurateMD

DoctorInternet Consultants

Dr. Ashley MinasOffshore MD

YourNetDoctor

Your Family Doctor

The Laws of TelemedicineCenter for Telehealth

Telemedicine Overview by StateTelemedicine Legislation