We appreciate the letters from Joshi and from Hersh and colleagues in response to our study. We are in general agreement with the points raised regarding the momentum behind direct to consumer (DTC) telemedicine. Our prior analysis identified rapid increase in DTC telemedicine use over the last 5 years.1  We anticipate that this trend will continue, and for this reason, we believe that this is a crucial time for identifying and promoting best practices in DTC telemedicine, including antibiotic stewardship.

We agree with the letter writers on the importance of bringing antibiotic stewardship best practices into DTC telemedicine. Many antibiotic stewardship methods used in traditional care settings, such as continuing education, providing individual audit and feedback to clinicians, requiring justification of inappropriate antibiotic use, and strengthening clinician shared decision-making skills, are likely to be as effective within telemedicine models as in traditional practices. Indeed, some DTC telemedicine companies have reported improved antibiotic stewardship through such methods,2  and Hersh and colleagues report a comprehensive antimicrobial stewardship program as a key context of their findings.

In addition to these general antibiotic stewardship strategies, another key component of prudent antibiotic stewardship within telemedicine will be identification and referral of clinical scenarios that require in-person diagnostic evaluation, consistent with the concerns noted in the editorial by Gerber.3  Some of these scenarios may be prevalent enough to warrant advice to seek in-person care before even initiating the telemedicine encounter (for example, ear pain in the absence of tele-otoscopy). Other cases requiring in-person evaluation may become apparent during the course of a telemedicine encounter. Acknowledging and planning for these circumstances will also be crucial for high-quality antibiotic stewardship in a telemedicine program. Practically, this may mean developing strategies to facilitate timely follow-up in-person care and avoid additional fees to families, as Hersh and colleagues note. Also important will be avoiding any explicit or implicit incentives that might discourage clinicians from referring to in-person setting when clinically warranted. Setting appropriate expectations with families may be useful as well, including general guidance about clinical scenarios for which telemedicine may be more or less appropriate, and about the possibility that a telemedicine encounter may need to be followed by an in-person visit if clinically warranted.

Finally, the letters underscore the importance of attention to the variation in key features across DTC telemedicine models which may result in variation in the quality of care. Indeed, when standardized patients sought care through virtual visits, guideline concordant treatment of viral pharyngitis and acute rhinosinusitis scenarios varied significantly across 8 companies.4  Factors potentially influencing such company-level variation could include clinician training and experience (including pediatric-specific training); continuity with usual care (including informational, management, and relationship continuity); understanding of local contexts of care and referral options; use of peripheral devices (facilitating tele-otoscopic images or tele-stethoscope sounds); and company commitment to continuous improvement in general and antibiotic stewardship specifically. Through careful antibiotic stewardship efforts and transparent data reporting across a range of models and outcomes, we will continue to refine our understanding of best practices for pediatric telemedicine.

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Competing Interests

CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.