The People's Perspective on Medicine

Prescriptions on Demand from Online Doctors

Do you ever buy anything online? Would you consider visiting online doctors or prescriptions on demand? Online prescribing and dispensing are expanding.

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.

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About the Author
Joe Graedon is a pharmacologist who has dedicated his career to making drug information understandable to consumers. His best-selling book, The People’s Pharmacy, was published in 1976 and led to a syndicated newspaper column, syndicated public radio show and web site. In 2006, Long Island University awarded him an honorary doctorate as “one of the country's leading drug experts for the consumer.” .
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Citations
  • Jain, T., et al. "Prescriptions on Demand: The Growth of Direct-to-Consumer Telemedicine Companies, JAMA, July 26, 2019, doi:10.1001/jama.2019.9889
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My doctor and I have been doing this for several years: when I have an issue I can’t adequately describe, I take a picture with my iPhone and email it to him with accompanying narrative. A while back when I was in the office, he said, “you know, we are practicing telemedicine.”

honestly, from a patient perspective, physical exams are over-rated. I see my PCP about once a year. She walks in and I tell her I need a script for X issue. and she writes it out at the end of the appointment. She may ask a few follow up questions for a new issue. Or she may just say ok, as there isn’t a lot to discuss about it. But usually nothing that could not be done over the internet or phone.

All renewals of all my scripts can and usually done via email. I write her and 12-24 hours later I get a scanned image or she faxes the script direct to the pharmacy.

I currently live in Central America. Despite what US doctors and pharmacies think, the medicines sold in Central America are just as pure and safe as those sold in the US or Canadian mail order services. It is only US hubris that is the difference.
And usually I no longer need a script to acquire most of the medicine I need. The pharmacists are there to answer any questions about it if necessary.

Most doctors spend your time looking at a computer screen anyway. I don’t need to be in front of them for that. I can answer questions and they can input data with me sitting in my comfortable chair at home. I can take my temperature and heart rate and even check my blood pressure at home with minimal monetary investment.

For me, I broke my hip in February 2019 and had open heart surgery in April 2019….imagine all the doctor’s office visits. I have wonderful home health care for rehab and physical assessment.

I lived in Mexico City for 10 years and back then, we could go to the pharmacy and describe our symptoms to the pharmacist. He would suggest a medicine and you could buy it. Naturally, that bypassed the doctors and they got that changed.

I’d like to talk to a doctor on line, I think it would be a very good way to stay on top of your own medical health. I have given up trying to tell the doctor my side effects of a medicine. He acts like he doesn’t believe it. It would also be nice to have an online vitamin and herb specialist for health issues.

I developed a UTI last year, was out of town and not near an emergency Center where I could see a doctor. I tuned in to Dr On Demand on my phone, explained my symptoms (which were the usual urgency, and burning pain when urinating) and was put onto a face time with a board certified geriatric gynecologist.

After a 30 minute conversation discussing everything from my age to medication I was allergic to, she prescribed an antibiotic. She even told me to start taking a probiotic along with the Keflex. Within ONE day I was better and able to enjoy the rest of our trip.

Fast forward to yesterday, one year from that first UTI. I had same symptoms, went to my gynecologist who took a specimen and I turned out to be all negative. Was told to get estrogen cream to help with atrophy, and was told they would not prescribe anything for my symptoms because the TEST was negative. Urine was perfectly clear of infection.

Four days later, blood in my urine appeared. Doc said no way it can be an infection because you were “clear” four days ago. However, I insisted on a quick in/out catheterization, and sure enough, the urine had 3+ blood. I was put on an antibiotic, urine has cleared up and no more symptoms! But I practically had to fight my doctor to convince him something was going on that needed an antibiotic!

Next time I think I might first opt For the Dr. On Demand. So appreciate Dr Phil creating this service.

Thanks Joe and Terry. I have learned so much from you about self advocating!

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