Best Practices in Direct-to-Consumer Teledermatology

The recent JAMA Dermatology article by Resneck et al. is a thought-provoking study of the current state of “direct-to-consumer” teledermatology, and it represents a valuable contribution to the discussion around best practices in the field.1 We compliment the authors on their choice of topic, as we agree that the subject is both fascinating and deserving of continued academic inquiry. Our number one priority at Spruce is, and always has been, patient safety, and we welcome the discussion and this opportunity to collaborate with the rest of the dermatologic community on the best way to advance high-quality care.

In the article in question, Resneck and colleagues analyzed 16 teledermatology services, including Spruce, and they reported their findings primarily in aggregate analyses of the group as a whole. Since this was an extremely diverse group of organizations, and since data on each particular service and its performance was not discussed, we wanted to lay out our policies and performance relative to the authors’ recommended guidelines.

Spruce Policies Relative to Recommended Guidelines

We’ve put an immense amount of time and energy into designing the Spruce technology platform so that it puts physicians in the best position possible to provide excellent care, and we’d like to go point by point and discuss how our approach compares to the recommendations provided by Resneck et al.:

  • Disclose the licensure, credentials, and location of their clinicians, making sure that all are licensed in the states where patients are located, and give patients some choice of which clinician will provide their care.

Every doctor practicing on the Spruce platform is a board-certified dermatologist located in the United States, with educational background and credentials easily visible to all patients and with a well-vetted track record of success treating dermatologic patients in person. While Resneck et al. found that they could not pick a specific doctor 68% of the time, patients on Spruce can choose or change their physician, and physicians are always licensed in the patient’s state.

  • Obtain proof of identity of patients seeking care, and establish an initial relationship with live interactive video before beginning a store-and-forward relationship (when a patient’s existing health care team is uninvolved).

We believe in the sanctity of the patient-physician relationship and its fundamental bedrock of trust. Patients on Spruce are expected to represent themselves in a non-fraudulent manner, as they would be expected to do at an in-person clinic, and we ask all patients to agree to this during our signup process. You can always lie to your doctor, in person or on the internet, and there is no technology that can ever stop you from doing this. However, no controlled medications are prescribed on Spruce, and no physician on Spruce bills any insurance plan, so it is unclear what motive for fraud exists outside of the artificial confines of a research study.

We furthermore believe that “live interactive video” for the sole purpose of trying to determine the truthfulness of a patient’s identity information serves only to begin the doctor-patient relationship on a somewhat antagonistic note, while doing nothing to further that patient’s medical care. Live video also necessarily imposes temporal constraints on visits that would disadvantage patients who have schedules that prevent them from seeking care during business hours, sacrificing a major benefit of asynchronous telemedicine.

  • Collect relevant medical history, including at least a history of present illness, review of systems, medication list, and drug allergies. In many instances, appropriate past medical records should be available to the consulting clinician.

Every visit on Spruce includes a complete solicitation of medical history, history of present illness, review of systems, current medications, drug allergies, as well as many other categories of information. There are also open-ended text boxes in which patients can provide additional medical history to their doctors. Patients enter information at their own pace, taking as much time as is needed, and doctors are subsequently equally free to take their time in reviewing it, as opposed to the often hectic pace of in-person appointments. We feel that our platform provides patients with a highly effective and clinically rigorous way to tell their doctor what’s really going on, on their own time and terms.

  • Recognize that the accurate diagnosis of disease often requires an interactive history, and train participating clinicians to ask appropriate follow-up questions to complete a patient’s relevant medical history.

We couldn’t agree more, and that’s why we have built Spruce to aid physicians but not to stand in for their decision-making. Each patient on Spruce is connected to their doctor and the rest of their care team at all times by a secure messaging thread, and both physicians and patients use this routinely to ask follow-up questions. This lets all parties clarify details and make sure that everything is understood. An interactive history is crucial to many patient presentations, and we will always enable and encourage this.

  • Seek the use of laboratory studies in clinical scenarios when an in-person physician would have relied on those studies.

We have business agreements with major lab providers that cover all geographic areas in which physicians on Spruce see patients. If a physician on Spruce requires lab work to properly treat a patient, they can always get it. Doctors on Spruce are encouraged to practice exactly how they would in person in this regard.

  • Provide diagnoses and treatments consistent with existing evidence-based guidelines.

We are proud of the evidence-based clinical protocols developed and used consistently by our dermatology practice group, and we have worked closely with these physicians and with our senior dermatology advisors at all times to ensure that the history and physical exam gathered for each patient is as likely as possible to contribute to proper diagnosis and treatment. All physicians on Spruce are board-certified dermatologists making independent management decisions within the guidance of the practice group, and we feel strongly that this is the ideal situation to promote evidence-based, modern care that respects both guidelines and the individuality of each patient presentation.

  • Engage in meaningful informed consent, including discussion of risks, potential adverse effects, pregnancy concerns, and a clear follow-up plan when prescribing medications.

Our software ensures that patients always have details available for all treatments that they are prescribed, including safety warnings for pregnancy and breastfeeding. The written format has proven to be a reliable way for patients to absorb information over time, as opposed to inevitably forgetting some of the many things that are conveyed during a verbal office encounter. Follow-up is also baked directly into Spruce encounters, and patients receive at least a light check-in shortly after their visit. Longitudinal care is important to the doctors practicing on Spruce, and this is reflected through the platform from top to bottom.

  • Collect information about a patient’s existing health care team and provide medical records to relevant team members—unless a patient opts out.

Since all details of any medical interaction on Spruce are written and preserved indefinitely, they are able to be referenced easily at all times by both patient and care team. Patients can always download their complete Spruce medical record for easy sharing with their primary care physician or other medical provider, and similarly, we include a place in each patient’s Spruce record for them to enter their primary physician’s name and contact information. With patient consent, this lets our care coordinators facilitate ongoing care and avoid medical silos and missed information.

  • Have relationships with local physicians in all areas where they treat patients, so that patients are not sent to emergency departments or left on their own when they need urgent in-person follow-up or experience medication adverse effects.

When a dermatologist on Spruce determines that a patient’s case requires in-person medical attention or otherwise cannot be handled remotely at the standard of care, our care coordinators work with the dermatologist and the patient to get the patient to appropriate local care. We have had many instances of dermatologists on Spruce seeing their patients in person when presentations are complex or when they simply need something that can only be done hands-on. We have also observed many physicians coordinating personal referrals to specific specialists for complicated issues.

Lack of specialized care during after-hours, weekend, and holiday times is a difficult challenge, and it appears to us that no one has fully solved it, regardless of clinical context. No reasonable amount of personal, local physician relationships will get a patient seen by an outpatient clinic at midnight, and emergency departments are routinely full of patients who were in an in-person clinic hours earlier. We can’t completely fix this either, but we have seen many physicians on Spruce communicating with patients at non-standard times and attending to their issues, likely because the barrier to doing so is much lower via asynchronous telemedicine than via traditional modes of care.

  • Create quality assurance programs that regularly monitor clinical performance, patient outcomes, follow-up, and care coordination.

In addition to a strong technological framework for success, we have also worked hard to ensure that the right human systems are in place to promote good outcomes. Perhaps most importantly, there is a quality assurance and case review committee that meets regularly and is composed of members of the care coordination staff and the head of the physician group that practices on Spruce. This committee takes its findings back to individual physicians for review and development and also to the Spruce product team, creating a feedback loop that has improved our software to better address the ways in which patients present and seek care.

On Diagnostic Accuracy

After the publication of the Resneck et al. paper, the aforementioned quality assurance committee has investigated and believes that it has identified the fictitious cases submitted by the researchers. These have been discussed with the involved physicians, and because of this responsive QA system, we already know how care on Spruce compared to care as generally reported by the investigators. We are happy (but not surprised) to report that care on our platform was found to be appropriate in each of the six cases, and our physician group would gladly stand behind the interactions as they occurred. Thanks to the detailed recording system that is inherent to the Spruce platform, every facet of each case is preserved, letting us identify exactly what decisions were made, when they were made, and what information they were based on. The contribution this clarity provides to performance improvement cannot be overstated.

Above all, Spruce does not make operational choices lightly or without structured thought. We have deeply studied the body of academic dermatology literature that provides support for teledermatology, and physicians on Spruce seek to stay within the scope of high-quality care at all times. We favor studies that have well-defined control groups and that seek to compare outcomes for patients seen in person versus those seen via telemedicine. In a recent general review of studies using such methodology, the authors concluded that “both [asynchronous] and [synchronous] teledermatology had acceptable diagnostic accuracy and concordance compared with clinic dermatology.”2 The current study by Resneck et al. provides much food for thought, makes many valuable guideline recommendations, and raises appropriate concern about issues of choice, transparency, and licensure with telemedicine services. However, in regard to its analysis and discussion of diagnostic accuracy, it lacks any sort of comparison to in-person dermatologic assessment. This absence of a control group fundamentally hinders the authors’ ability to assess the true diagnostic capability of a well-run teledermatology service and how it might compare to an in-person clinic. We strongly hope that future research will take this into account, and we look forward to results from such studies.

Looking Ahead

Beyond believing that teledermatology is safe and effective, we also firmly believe that it represents a way for patients to access specialized dermatologic care that they otherwise might not be able to receive. A 2013 survey of dermatology practices in US metropolitan areas found an average wait time of nearly 29 days for a new patient appointment, and in some locales, this number stretched to two months and beyond.3,4 Further exacerbating this shortage is an unequal geographic distribution of specialists: if it is hard to see a dermatologist in a metropolitan setting, it can be near impossible to see one in a rural area.5 Platforms like Spruce are helping to solve this problem every day: our case response times are typically less than 24 hours, and no area of a state we serve is too rural for prompt attention. The dermatologists practicing on Spruce also charge a flat rate of $40 per visit, a sum which is now less than many people’s specialist insurance copays, and which is certainly less than the typical out-of-pocket expense for an uninsured patient seeking dermatologic care. From all angles, Spruce is inarguably expanding the availability of high-quality care, and we are proud of that.

It has been a joy to build Spruce over the last few years, and we love talking with doctors on our platform and hearing about all of the patient successes that there have been. Our many positive online reviews, posted directly by patients, also speak to the power of our model and to our execution on it, and we go to work every day excited to expand our abilities and to help people get better. Academic contributions from authors such as Resneck et al. play an important role in this, providing recommendations on what is safe and effective, and we look forward to continuing to be a part of this discussion and of this community.

Sincerely,

David Craig, M.D.
Medical Director, Spruce Health, Inc.
President, Spruce Physicians, P.C.

Laurie Kohen, M.D., F.A.A.D.
Dermatology Medical Director, Spruce Physicians, P.C.

Ray Bradford
CEO, Spruce Health, Inc.


  1. Resneck, J. S. et al. Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease. JAMA Dermatol. (2016). doi:10.1001/jamadermatol.2016.1774
  2. Warshaw, E. M. et al. Teledermatology for diagnosis and management of skin conditions: a systematic review. J. Am. Acad. Dermatol. 64, 759–772 (2011).
  3. Coates, S. J., Kvedar, J. & Granstein, R. D. Teledermatology: from historical perspective to emerging techniques of the modern era: part I: History, rationale, and current practice. J. Am. Acad. Dermatol. 72, 563–74; quiz 575–6 (2015).
  4. Miller, P. 2014 Survey: Physician Appointment Wait Times and Medicaid and Medicare Acceptance Rates. (Merritt Hawkins, an AMN Healthcare Company, 2014).
  5. Yoo, J. Y. & Rigel, D. S. Trends in dermatology: geographic density of US dermatologists. Arch. Dermatol. 146, 779 (2010).

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