First there were walk-in visits to strip mall clinics, then medical care during errands at CVS. Now, a Massachusetts medical technology company has launched a service that allows patients to visit a doctor over their computer, smartphone, or wireless tablet.
Boston-based American Well has worked with US insurance companies for several years to provide "telehealth" services to some of their members. But since October, it has begun offering its virtual visits directly to consumers, typically charging $49 for the convenience of an online primary care visit available 24 hours a day without an appointment. As part of its Massachusetts launch Thursday, a patient's first visit here will cost $20.
Doctors can write prescriptions for common medications such as antibiotics, but not for drugs such as painkillers. The direct-to-consumer service is available in 43 states and Washington, D.C.; about 10,000 consumers enrolled in the first month.
Doctors, hospitals and regulators are scrambling to keep up with the evolving field of telemedicine, trying to balance patient convenience with quality-of-care considerations. American Well's direct-to-
consumer model is part of a new frontier in medical technology, but one that leaves some physicians squeamish. Among their concerns is that doctors won't be able to properly diagnose patients without seeing them in person.
In the past decade, telemedicine has mostly been used by doctors to supplement care for their own patients, as a way to monitor them between visits to the office, and by teaching hospitals to provide specialized consultations to community hospitals for stroke and intensive care patients. In the American Well model, the doctors will provide the service to many patients they don't know.
"Telemedicine holds out a lot of promise," said William Ryder, regulatory and legislative counsel for the Massachusetts Medical Society. But "what are the limits here?''
Dr. Roy Schoenberg, chief executive of American Well Systems, said the company has put in place safeguards that will ensure care is appropriate. Telemedicine, he said, has been shown to reduce the cost of urgent care, often replacing emergency room visits. He said consumers are demanding convenience. "People are running around, and they don't have access to or don't have time to find a physician.''
American Well works with the Online Care Group, a national network of hundreds of physicians owned by Massachusetts physician Dr. Peter Antall. The group conducts background checks on doctors and makes sure they are available for consultations.
Patients log into the system and see which doctors are available and their backgrounds. Doctors must collect a medical history from patients. They can prescribe antibiotics and other common drugs for strep throat, headaches, bronchitis, and urinary tract infections, but not controlled-substances, such as addictive painkillers, Schoenberg said. In the direct-to-consumer model, patients pay for the visits themselves.
Responding to criticism that the virtual visits will lead to poorly coordinated care, he said physicians will log into a national prescription registry that will show them medications prescribed to the patient by other doctors. At the end of the visit, patients will be asked if they want to forward a summary to their regular doctors.
"We didn't want to make this an episodic visit that would fragment care," Schoenberg said.
Others are skeptical.
"This is very expensive, uncoordinated care for the 'medically homeless.' It is sadly symptomatic of the shortage of access to robust primary care, which provides personalized, comprehensive care," said Dr. Allan Goroll, a primary care doctor at Massachusetts General Hospital.
Dr. Lynda Young, a Worcester pediatrician who is part of a group developing a telemedicine policy for the American Medical Association, said "we certainly understand the need in rural areas and especially when it involves access to a specialist. My concern is for illnesses that may or may not be able to be treated in this manner,'' she said. "We are trained observers. For us not to have the ability to see the patient other than on the phone, is a big disadvantage.''
Take strep throat. The gold standard for diagnosis is a throat culture, but Schoenberg said a doctor can look for the trademark swollen tonsils and pale dots using a smartphone. The doctor can interview the patient about other symptoms like fever and swollen glands.
That is true, Young said, but certain viruses look like strep, with spots that are a bit whiter. "Can you see the color difference on the phone?'' she asked.
Young said a doctor would not be endangering patients by prescribing an antibiotic if they did not have strep, but may be providing unneeded treatment. Overuse of antibiotics also contributes to the emergence of strains of bacteria resistant to antibiotics.
Massachusetts rules allow for the practice of telemedicine.
Schoenberg said his firm spoke with the state Board of Registration in Medicine to make sure it is complying with the rules. Katherine Bowles Dudich, the board's interim general counsel, said that "the Board expects all physicians to follow standards of care in the treatment of patients.''
Blue Cross Blue Shield of Massachusetts is finalizing contracts with two or three physician groups to test American Well's platform for online visits.