For over a century, patients got their medicines by seeing a doctor, getting a prescription and going to a pharmacy. Of course, that was before the Internet. The web has changed everything. People buy almost everything online, from books and shoes to music and airplane tickets. Now they can bypass a doctor’s office to get prescription drugs if they wish. People can “see” an online doctor, get prescriptions on demand and have them delivered directly to their doorstep.
Medical Self Care: A Radical Idea
Two decades ago, a dear friend of ours, Dr. Tom Ferguson, proposed a radical idea: Telemedicine. He understood the power of the internet to bring patients and health professionals together online long before anyone else could imagine such a thing.
Dr. Ferguson was a physician who believed passionately in self-care. In fact, he founded a journal called Medical Self Care: Access to Health Tools. It was published from 1975 to 1989.
Prescriptions on Demand?
Over two decades ago, Dr. Ferguson conceived of online consultations. He was convinced that this would allow patients to participate more actively in the prescribing process.
We thought this was a terrible idea. Most people don’t have adequate information about the potential risks and benefits of drugs. We feared this web-based interaction would lead to overprescribing and drug disasters.
Can Prescriptions on Demand be Safe?
Dr. Ferguson (also known as Doc Tom) convinced us that online prescribing could actually be safer than face-to-face prescribing if one crucial element were present: GREAT follow-up!
Physicians frequently write a prescription without telling the patient how they plan to monitor progress or problems. As a result, patients can go weeks or months between doctor visits and not realize that some aspect of the prescription is suboptimal.
A 21st Century Prescribing Pattern:
Doc Tom’s brilliant concept more than 20 years ago was that every online prescription would require periodic feedback from the patient to the provider, starting shortly after the prescription was filled. This would allow for rapid dose adjustments or replacement of the medication if it weren’t working as expected. It should also allow for early detection of drug side effects. To work, though, the online prescriber must be attentive and follow up every prescription with email questionnaires, text messages, phone calls or video conferences.
A Dirty Little Secret: Trial and Error!
Many health professionals like to talk about precision or personalized medicine. In theory, it sounds like an excellent idea: tailoring each prescription to the special needs of the individual patient.
In reality, much of medicine is still based on trial and error. Take the treatment of hypertension as an example. Many doctors prescribe lisinopril as the first-line drug to lower blood pressure. At last count over 21 million people filled 110,611,325 prescriptions for this ACE inhibitor, making it the most prescribed drug in the country.
Many people take this medication without any difficulty. However, others develop an unbearable cough while taking lisinopril or another ACEi such as captopril, enalapril or ramipril.
ACE Inhibitor Cough:
We have received hundreds of reports of uncontrollable coughing brought on by an ACEi. Sometimes doctors need weeks, months or years to figure out that the cough is a side effect of lisinopril.
Here is just one such story from Mark:
“I have been on lisinopril for 30 years and have lived with the cough and other annoying side effects until recently. That’s when my lower lip swelled up like a bratwurst! No kidding!
“This has happened four times now. My new doctor just took me off lisinopril because of the swelling. Now it’s on to the next BP medication.”
It is outrageous that a patient would have to endure a drug-induced cough for so many years. Mark’s swollen lip signaled angioedema, a potentially life-threatening complication.
Prescriptions on Demand from Online Doctors:
Online monitoring could, in theory, detect an ACE inhibitor-induced cough early. Having the patient monitor her blood pressure at home and submit the readings to a secure portal online would permit consistent tracking.
Following Patients’ Progress:
Currently, many devices that patients use at home are capable of sending reports directly to the doctor’s office. Blood pressure monitors, blood glucose meters and even bathroom scales may be connected via wifi.
Reviewing the readings would give the prescriber a good idea of how well the therapy is working. This interactive process should help the prescriber find an effective medicine that doesn’t cause unacceptable side effects.
Doc Tom: Ahead of His Time!
Doc Tom’s ideas were far too radical for the time. Now, however, online access to prescription medications has gone mainstream. A recent article in JAMA (July 26, 2019) describes the advent of DTC (direct to consumer) telemedicine companies that specialize in prescriptions patients might not wish to discuss with their primary care physicians.
Some of the companies mentioned in the article offer people prescriptions for contraceptives, erectile dysfunction (ED) medicines or treatments for premature ejaculation, genital herpes or cold sores.
Online Doctors Offer Prescriptions on Demand:
The JAMA authors point out that:
“DTC telemedicine companies are focused on improving convenience within a health care system that many patients find overly complex.”
Many people find shopping online for consumer items more convenient than driving to the mall. Getting to the doctor’s office and then to the pharmacy is no more appealing than shopping in person. The Harvard Medical School authors who wrote about “Prescriptions on Demand: The Growth of Direct-to-Consumer Telemedicine Companies” added this:
“DTC telemedicine visits have several potential advantages over traditional clinic visits as a more standardized, efficient, convenient, and accessible model of care. Information gathering can often be variable across traditional patient-clinician visits; however, the DTC telemedicine questionnaire can be structured to be both consistent and comprehensive.”
Online telemedicine clinics have less overhead than traditional medical offices. And online prescribing is also more cost effective. As a result, the companies might sell the drugs they prescribe at a significant discount. Access may also be improved for people who live in remote rural areas.
The Downside of Prescriptions on Demand:
Despite the benefits, there are also concerns. The current DTC telemedicine outfits are focused first and foremost on the specific drugs they are offering, rather than on finding the best solution for the patient.
In addition, it isn’t clear that they have instituted the type of careful follow-up that Doc Tom envisioned. If and when they address these concerns, we can imagine a time when they could become an important part of the US health care system.
Telemedicine and Online Prescribing:
What do you think about prescriptions on demand from online doctors? Changing a paradigm is challenging. The idea of ordering books online was radical. We love locally-owned bookstores, so we completely understand the reluctance to change.
Be honest, now. Do you ever shop online? How well does it work for you? There will always be the need for a physical exam. That is harder with online doctors practicing telemedicine, but not impossible. Nurses, PAs and other health professionals can travel to a patient’s home, do the physical exam and communicate with a specialist online. Could you imagine interacting with an online health professional? Share your thoughts in the comment section.