Abstract
Direct-to-consumer (DTC) telemedicine is increasingly popular and enables patients to obtain medical advice and treatment via electronic media (e.g., computer, telephone, or smartphone) without a prior doctor-patient relationship. Convenience, accessibility, and home delivery make DTC telemedicine attractive to patients. Concerns about DTC telemedicine include: a lack of regulation, transparency, and an established patient-provider relationship (physician and pharmacist). In future, researchers, providers, and insurers need to better understand the concerns and challenges that this new form of healthcare poses.
Background
Direct-to-consumer (DTC) advertising of pharmaceutical products has been a “normal” practice for many years. In 1962, Congress passed the Kefauver-Harris Amendments which granted the FDA jurisdiction over the advertising of prescription drugs to patients.1 Drug manufacturers have used an array of promotional activities and professional marketing techniques in an effort to increase their market share ever since. Consumers in the United States easily see on television, hear on the radio, read about in print media (newspapers, magazines, internet ads), and view on social media, advertisements for prescription medications. Direct-to-consumer pharmaceutical advertising is now the leading type of health communication that the lay public encounters.2 Disease states often targeted for DTC advertisements with brand-name treatments include high cholesterol, diabetes, depression, erectile dysfunction, and others. Spending for DTC advertising continues to rise, increasing from $2.1 billion (11.9% of total spending) in 1997 to $9.6 billion (32% of total overall prescription drug marketing spending) in 2016.3 Also, marketing departments are spending more and more on digital promotion including: product websites, online display advertising, search engine marketing, social media campaigns, and even mobile advertising.2 More recently, a rise in prescription-on-demand services, or direct-to-consumer telemedicine companies, have been seen.
The Institute of Medicine defines telemedicine as “the use of electronic information and communication technologies to provide and support healthcare when distance separates the participants.”4 The term telemedicine has been around since the 1960s and describes using technology to deliver healthcare services and information at a distance in order to improve access, quality, and cost.5 Similarly, the term telehealth is using electronic information and telecommunications technologies to support long-distance clinical healthcare, health related education, public health, and health administration.6 Direct-to-consumer telemedicine services, however, are different, with care being provided to patients from an organization outside the patient’s medical home. There is little or no patient-provider relationship or coordination with the patient’s primary medical doctor.7 When patients utilize multiple pharmacies and/or multiple providers, a complete medication history is often lacking. Drug-drug interactions are often missed if patients do not make their dispensing pharmacist and primary provider aware of medications obtained from outside sources. These direct-to-consumer telemedicine services are providing consumers with around-the-clock access to care for common, nonemergency conditions through phone and live video via Webcam or smartphone applications.8 These direct-to-consumer telemedicine companies often will have a contract with patients’ insurance companies or healthcare organization, or they simply charge patients directly for their services. In response to the growing number of these companies, the American College of Physicians (ACP) released a position statement related to the use of telemedicine in 2015. The ACP supports DTC telemedicine companies within the context of an established patient-provider relationship in a medical home if it meets the same standards of practice as in-person care. DTC telemedicine companies, however, are pushing for telemedicine outside the traditional medical home. Additionally, some state medical boards require an in-person exam before a telemedicine consult can take place.7
It appears patients are utilizing telemedicine at an increasing pace despite a lack of research about whether these sites provide comparable care to an in-patient visit. From 2017–2018, telehealth use grew twelve percent.9 Similarly, the global direct-to-consumer telemedicine market is expected to be a $35 billion-dollar industry by 2020 and an $86.7 billion-dollar industry by 2023.10 The number of DTC telemedicine website visits in 2015 reached 1.25 million.11 The novel coronavirus disease 2019 (COVID-19) required the necessary expansion of telehealth for routine care by providers. It is anticipated this type of care will continue to grow in the future as many insurance companies have pivoted to incorporate payments for these services. Little is known if patients prefer this type of care. Several reports have indicated that a majority of patients would be comfortable with telemedicine. These reports do not distinguish between telehealth provided by patients’ own provider or by an unknown provider.7 A nationwide survey (with more than 4,000 respondents) found that patients are less willing to use telehealth as they become further detached from their own provider; these results were statistically significant. Over 50% of respondents were either very willing or willing to use telemedicine with their regular provider, only about one-third were if utilizing a different provider at their same institution, and under 20% were when asked about using a different provider at a different institution.7
Procedure
A thorough internet search revealed 21 sites advertising direct-to-consumer medications available for patients with no prior physician-patient relationship (Table 1). The majority of these sites focus on promoting prescription items for a limited set of conditions or diseases including: sexual health, hair loss, contraception, dermatologic conditions, performance anxiety, and even primary care. What patients have to complete online to get a prescription varies by site (Table 2). Typical steps include completing an online questionnaire (to rule out any contraindications) followed by a live virtual visit with a provider (physician, nurse practitioner, or physician assistant). In some models, the clinician contacts the patient via messaging, telephone call, or video chat.12 The company then either e-prescribes a prescription to a local pharmacy (rare) or mails the medication directly to the patient’s home (more common).12
Table 1.
Direct-to-Consumer Telemedicine Sites
Site Name and URL | Prescription item(s) to treat: | Cost to be seen? | Insurance accepted? | Medication mailed to home? | Prescription e-prescribed to local pharmacy? |
---|---|---|---|---|---|
Hims www.forhims.com |
Hair loss, ED, premature ejaculation, performance anxiety | OTC product pricing available on website, once monthly or quarterly subscription cost for Rx | No | Yes | Yes |
Roman www.getroman.com/ron |
ED, premature ejaculation, cold sores, genital herpes, hair loss, testosterone support | $15 for online visit, refunded if determined unsuitable for telemedicine | No | Yes | Yes through SureScripts |
Curology Curology.com |
Acne treatment | Starting at $19.95/mo | No -Accepts FSA/HSA | Yes | Yes |
Keeps www.keeps.com |
Hair loss | $20 annual fee Subscription based: Minoxidil $10/mo, Finasteride $25/mo |
No | Yes | Yes |
Lemonaid Health www.lemonaidhealth.com |
ED, birth control, hair loss, herpes, hypothyroidism, depression, cholesterol, sinus infection, acid reflux, acne, smoking cessation, anxiety | $25 online consultation, $95/mo for anxiety/med, $2/pill Viagra, variable Rx costs | Not for consultation; may for Rx at pharmacy | Yes | Yes |
Nurx www.nurx.com |
Birth control, STI testing, emergency contraception, HIV preparation, HPV screening | $12 med consultation - includes unlimited messaging for one year, plus cost of drug (if not covered by insurance) | Yes; Medicaid included | Yes | Yes $12 delivery fee |
The Pill Club thepillclub.com |
Birth control, emergency contraception | $15 med consultation, cost of drug (if not covered by insurance) | Yes; Medicaid in certain states | Yes | Yes |
Hers www.forhers.com |
Birth control, hypoactive sexual desire disorder, skin/acne treatment, hair loss, performance anxiety | $5 follow up consultation, $30 birth control | No | Yes | Yes |
Cove www.withcove.com |
Acute and preventative migraine treatment | $15 online consultation - includes messaging access for one year, $3 shipping, cost of drug | No | Yes | Yes |
Rory www.hellorory.com |
Latisse, cold sores, herpes, sleep, sexual health, hot flashes | $15 online consultation, monthly subscription prices depend on drug | No | Yes | Yes |
Zero www.quitwithzero.com |
Smoking cessation | $15 online consultation, buproprion: $45/mo, nicotine gum: $42/box | No | Yes | Yes |
Sprout Addyi.com |
Hypoactive sexual desire disorder | $18 for telemedicine appointment, first 60 days free, $25/mo for subsequent fills | Yes FSA/HSA accepted | Yes | No – filled through home delivery; KippeRx |
TwentyEight Health Twentyeighthealth.com |
Birth control, emergency contraception | $20 for initial value plus price of drug | Yes; Medicaid | Yes | Yes |
Kick Health www.gokick.com |
Social anxiety | $49 online consultation, may receive 48 doses if approved | No | Yes | Yes |
K Health www.khealth.ai/ |
Headaches, depression, anxiety | $9/mo, $19/one-time consultation, $99/yr | No; FSA/HAS accepted | Yes for mental health Rx | Yes |
Maven https://www.mavenclinic.com/ |
Birth control, postpartum depression | Contracted with employer, may have additional costs for video chats with specialists | No | No | Yes |
Simple Health https://www.simplehealth.com/ |
Birth control | First consultation $20, free Rx with insurance or $15/mo without | Yes | Yes | Yes |
Pandia Health https://www.pandiahealth.com/ |
Birth control | First consultation $20, free Rx with insurance or $15/mo without | Yes | Yes | Yes |
Alpha Medical https://www.helloalpha.com/ |
Birth control, acne, mental health, UTI, sinus infection | $10 for treatment, $99 annual fee for full access | Yes | Yes | Yes |
Blink Health https://www.blinkhealth.com/ |
Birth control, erectile dysfunction, high cholesterol | Starts at $5 for first month, $9.95/mo thereafter | Yes, with Blink Pharmacy Plus membership | Yes | Yes |
Dear Brightly https://www.dearbrightly.com/ |
Photoaging | Tailored retinoid and consult $29.50/mo | No | Yes | Yes |
Table 2.
Processes for Obtaining a Prescription from DTC Telemedicine Sites
Site Name | Methods to Obtain Rx |
---|---|
Hims | Online questionnaire, reviewed by a physician, contacted through messaging platform |
Roman | Online questionnaire, reviewed by a physician, contacted through messaging platform/phone call/video chat |
Curology | Online questionnaire and pictures of affected area, physician determines proper treatment plan |
Keeps | Online questionnaire and pictures of affected area, physician determines proper treatment plan |
Lemonaid Health | Online questionnaire, reviewed by a physician, contacted through messaging platform/phone call/video chat |
Nurx | Online questionnaire, reviewed by a physician, contacted through messaging platform |
The Pill Club | Online questionnaire, reviewed by a physician, contacted through messaging platform |
Hers | Online questionnaire, reviewed by a physician, contacted through messaging platform |
Cove | Online questionnaire, reviewed by a physician, contacted through messaging platform |
Rory | Online questionnaire, reviewed by a physician, contacted through messaging platform/phone call/video chat |
Zero | Online questionnaire, reviewed by a physician, contacted through messaging platform/phone call/video chat |
Sprout | Online questionnaire, reviewed by a physician, contacted by phone call |
TwentyEight Health | Online questionnaire, reviewed by a physician, contacted through messaging platform/phone call |
Kick Health | Online questionnaire, reviewed by a physician, no virtual interaction with doctor |
K Health | Online questionnaire using AI, reviewed by a physician, contacted through messaging platform |
Maven | Video chat or messaging platform |
Simple Health | Online questionnaire, reviewed by a physician, contacted through messaging platform |
Pandia Health | Online questionnaire, reviewed by a physician |
Alpha Medical | Online questionnaire, reviewed by a physician, messaging platform available to Alpha Members |
Blink Health | Online questionnaire, reviewed by a physician |
Dear Brightly | Online questionnaire and pictures of affected area, physician determines proper treatment plan, messaging platform available |
The cost to the patient varies by telemedicine site and treatment (i.e., medication) alternative. In most cases, there is a patient out-of-pocket cost for the online visit/consultation; this cost is not covered by insurance. For example, Lemonaid Health charges $25 (via credit card) for a typical patient-doctor evaluation and prescription—not including the cost of the medication.13 In the event that a prescription is not recommended by the physician (e.g., safety), the patient is not charged the consultation fee. Separately, the cost of the medication may be paid in part or total by insurance (depending on the patient’s insurance copayment) when picked up at a local pharmacy; alternatively, the medication may be paid for on a monthly basis (cash or insurance) and shipped to the patient’s home. The actual medication costs to the patient may vary by telemedicine site, medication, local pharmacy versus mail-order, and prescription insurance (Table 1).
The vast majority of these sites use unaffiliated pharmacies to complete the prescription fulfillment step (mail order pharmacies) or send electronic prescriptions to the patients’ local pharmacies. In contrast, the direct-to-consumer telehealth company HIMS and HERS have plans to launch a closed-door pharmacy in Columbus, Ohio, in 2020.14 The estimated 300,000–400,000 square foot facility will house a mail-order pharmacy, customer support center, and fulfillment center for their online customers. The $1.5 million investment’s goal is to speed order fulfillment for its customers instead of relying on alternate pharmacies.15
Discussion
DTC telemedicine visits offer significant advantages to patients seeking care, including: improved access, efficiency, and convenience. Obtaining a prescription without leaving the home can be a valuable time-saver. Also, these companies endorse prescriptions for treating conditions some patients would prefer not to discuss during a live face-to-face visit; examples include: erectile dysfunction, hair loss, acne, and genital herpes. The option of visiting with a provider you may never have to see again could be regarded as an advantage for some. Additionally, in this model, overhead costs of a traditional clinic are minimized. Overhead costs like front-end staff, clinic space (rent), and utility bills are minimized, allowing for a reduction in the cost of the primary care visit.12
DTC telemedicine likewise has several important disadvantages. These companies offer “solution-oriented” services; therefore, they target their questionnaire to screen for patients who cannot take the medication(s) they offer, rather than investigating the best possible treatment for that patient’s medical need.12 The lack of a patient-provider relationship is also a concern. Patients are now interacting directly with online companies that have a financial interest in the patient (who may or may not have medical knowledge) utilizing the drug(s) they are promoting.16 Similarly, these interactions may lack transparency, have limited choices for patient treatment, and lack diagnostic testing.11 The lack of care coordination with patient’s primary care provider (PCP) can be problematic, putting the onus on the patient to update his/her current medication list with the PCP. Additionally, telemedicine may intensify legal concerns including HIPAA data disclosure and physician malpractice exposure—as medical malpractice law dictates that a physician’s duty exists if there is a patient-physician relationship. Eliminating or modifying the face-to-face visit may make it more difficult to determine if a patient-physician relationship is present. A relationship is typically established if a physician gives personalized medical advice to a patient.17
One of the biggest disadvantages to never having a fully developed patient-provider relationship is the lack of follow-up and monitoring required with these therapies. Patients can now choose to completely bypass their PCP in order to seek a swift solution to obtaining a medication due to cost, ease of acquisition, or avoiding embarrassment. These sites are geared toward diagnosis, risk assessment, and ultimately treatment, but offer limited follow up services, including efficacy and safety evaluation of the therapies given. While some of the first drugs available via online providers were lifestyle drugs that required minimal monitoring, as the scope of their services grow, so does the requirement for closer monitoring.
Antibiotics like ciprofloxacin, trimethoprim/sulfamethoxazole, and nitrofurantoin commonly prescribed for urinary tract infections all have clinically relevant adverse effects that can result in significant morbidity and mortality. This is especially true if consumers are not up front with their providers regarding the amount of exposure to drugs such as nitrofurantoin.18 Similarly, monitoring the routine use of hormone therapies for relief of symptoms associated with menopause is necessary including a range of products from topical to systemic hormone replacement therapy (HRT). While all these sites have extensive screening for appropriate initiation of therapy, none provide any evidence-based recommended monitoring or counseling.19 Patients who choose to get their medications from these online services may keep this information from their physician, increasing the risk for medical errors and/or drug-drug interactions.
In the state of Missouri, health care providers can provide telehealth or telemedicine services, but this does not include prescribing based solely on an internet questionnaire or prescribing based on a telephone examination without a valid prescriber-patient relationship. Missouri pharmacies may fill prescriptions issued based on telemedicine exams; these pharmacies are, however, prohibited from filling prescriptions issued without a valid prescriber-patient relationship or based solely on an internet questionnaire.20
As discussed, the first closed-door telehealth pharmacy will be opening this year (HIMS and HERS). It is unknown at present how this may affect the traditional healthcare model and if more DTC telemedicine companies will be making this transition. It is anticipated that direct-to-consumer telehealth companies will continue to push for healthcare changes that allow more prescriptions to be prescribed outside of the conventional patient-PCP relationship. As Pat Carroll (a past Walgreens top executive), new chief medical officer of HIMS, wrote in a blog post, “looking forward, we’ll add more categories of care so we can keep expanding access.”15 This expansion of DTC telemedicine might include the following therapeutic areas: statins for cholesterol, mental health, menopause, migraines, infections, gastrointestinal disorders, and asthma.21
Future Issues
Optimal medication management requires an effective relationship between the patient and health care professional.22 Exponential growth has been seen in direct-to-consumer telehealth companies in the past decade. The internet will continue to see a rise in these companies offering patients “lifestyle drugs.” Looking to the future, direct-to-consumer telehealth will continue to incorporate prescriptions for chronic disease state management and long-term/maintenance medications.
One of the newest ways direct-to-consumer telehealth companies are positioning for increased market share is to offer subscription services. For example, the Alpha Mental Health Service offers patients treatment for anxiety and depression. The cost to belong to the subscription service for a full year is $120. The yearly fee covers all medical consultations, a personalized treatment plan, unlimited messaging with the care team, and insurance coordination.23
Several complications in the traditional physician-patient-pharmacist relationship/model can be projected from this shift to “internet doctoring.” Patients seeking care from internet providers, with whom they do not have a relationship, may not inform their established provider of these telehealth visits. This lack of a complete and up-to-date medication history hinders medication reconciliation as well as the drug utilization review process that screens for duplicate therapies and drug-drug/drug-disease interactions. Säfholm et al. showed in a study of Swedish primary care patients that medication lists were only accurate 16% of the time.24 The World Health Organization has stated that these medication errors are the leading cause of avoidable harm in the healthcare system.25 An incomplete medication list could lead to a disruption in coordination of care amongst specialists the patient may be referred to as well. Patients not informing their providers of medications purchased elsewhere can be problematic at the pharmacy level as well. When patients use more than one pharmacy (that are not linked to one another) for their routine care, screening for drug-drug and drug-disease interactions are limited. Additionally, pharmacists that are not made aware of all of a patient’s medications, including items purchased online, non-prescription items, herbal, and dietary supplements, will not be able to catch and correct many preventable medication errors. Also, utilizing mail-order or closed-door pharmacies for medication delivery to a patient’s home removes the pharmacist from the patient-pharmacist relationship. Medication counseling by a pharmacist, whereby the patient and pharmacist discuss the medication’s directions, side effects, etc. as well as any patient questions, is less likely when the medication is delivered to the patient’s home. Patients are forced to simply read a pamphlet regarding the new medication, possible adverse effects, mechanism of action, and how to use or apply the medication/device (e.g., inhaler).
An established, effective provider–patient relationship should encourage and enable patients to ask questions and be a part of the decision-making related to their care and follow-up plans,22 which happens when patients utilize routine providers for their care.
Conclusions
As the internet and its role in healthcare continue to evolve, patients will expect increased access, convenience, and speed in their interactions with healthcare providers as well as obtaining prescriptions. In 2009, 80 million households in the U.S. had high speed broadband access. By 2018, that number rose to close to 110.57 million.26 It is well known that the millennial and Gen Z generations have grown up with digital access and “instant” information which has helped shape not only their personalities but also their perception of healthcare. These are the patients of the future; they want providers that email and text, provide online scheduling, have extended hours, and explain costs of care. Online access to health information is particularly important to the patients of these generations; they often research health and conditions before reaching out to a provider.27
The direct-to-consumer telehealth model was initiated with the intent of treating diseases like hair loss and minor dermatologic conditions. The medications used to treat these conditions historically have lacked routine monitoring. However, as these companies expand access and services in the future for digital patients to chronic conditions like oral contraceptives, erectile dysfunction, and even diabetes and hypertension, the ethical, practical, legal, and patient-centered outcomes have not been well defined. It has been shown that patient satisfaction is an indicator of the quality of the health care services received by patients.22 How satisfied patients are with their care is also a predictor of maintaining a relationship with the health care provider and adhering to a medication regimen.22 As more and more digital telehealth companies emerge, providers and pharmacists must continue to strive to create meaningful relationships with patients so that patients will see the value in these interactions and obtain optimal health outcomes, both now and in the future.
Footnotes
Suzanne G. Bollmeier, PharmD, FCCP, BCPS, AE-C, is Professor, Pharmacy Practice; Emily Stevenson, is a pharmacy student; Patrick Finnegan, PharmD, BCPS, Associate Professor, Pharmacy Practice; and Scott K. Griggs, PharmD, Ph.D, Associate Professor, Pharmaceutical and Administrative Sciences; all at the St. Louis College of Pharmacy.
References
- 1.Donohue J. A history of drug advertising: The evolving roles of consumers and consumer protection. The Milbank Quarterly. 2006;84(4):659–99. doi: 10.1111/j.1468-0009.2006.00464.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Ventola CL. Direct-to-consumer pharmaceutical advertising. Therapeutic or toxic? P&T. 2011;36(10):669–84. [PMC free article] [PubMed] [Google Scholar]
- 3.Schwartz LM, Woloshin S. Medical marketing in the United States, 1997–2016. JAMA. 2019;321(1):80–96. doi: 10.1001/jama.2018.19320. [DOI] [PubMed] [Google Scholar]
- 4.Angaran DM. Telemedicine and telepharmacy: Current status and future implications. Am J Health-Syst Pharm. 1999:1405–26. doi: 10.1093/ajhp/56.14.1405. [DOI] [PubMed] [Google Scholar]
- 5.Kvedar J, Coye MJ, Everett W. Connected health: A review of technologies and strategies to improve patient care with telemedicine and telehealth. Health Affairs. 2014;33(2):194–9. doi: 10.1377/hlthaff.2013.0992. [DOI] [PubMed] [Google Scholar]
- 6.The Medical Dictionary. [Accessed June 15, 2020]. https://medical-dictionary.thefreedictionary.com/telehealth.
- 7.Welch B, Harvey J, O’Connel NS, McElligott JT. Patient preferences for direct-to-consumer telemedicine services: a nationwide survey. BMC Health Services Research. 2017;17:784. doi: 10.1186/s12913-017-2744-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Uscher-Pines L, Mulcahy A, Cowling D, Hunter G, Burns R, Mehrotra A. Antibiotic prescribing for acute respiratory infections in direct-to-consumer telemedicine visits. JAMA Internal Medicine. 2015;175(7):1234–5. doi: 10.1001/jamainternmed.2015.2024. [DOI] [PubMed] [Google Scholar]
- 9.Murphy J. FAIR health finds use of telehealth, retail clinics grew 12% from 2017–2018. [Accessed April 7, 2020]. www.pharmacytimes.com.
- 10.Hesse CM. A brave new telehealth world. The Computer & Internet Lawyer. 2019;36(12):17–20. [Google Scholar]
- 11.Resneck JS, Abrou M, Steuer M, Tam A, Yen A, Lee I, Kovarik CL, Edison KE. Choice, transparency, coordination, and quality among direct-to-consumer telemedicine websites and apps treating skin disease. JAMA Dermatol. 2016;152(7):768–75. doi: 10.1001/jamadermatol.2016.1774. [DOI] [PubMed] [Google Scholar]
- 12.Jain T, Lu RJ, Mehrotra A. Prescriptions on demand. The growth of direct-to-consumer telemedicine companies. JAMA. 2019;322(10):925–6. doi: 10.1001/jama.2019.9889. [DOI] [PubMed] [Google Scholar]
- 13.Lemonaidhealth.com. [Accessed June 10, 2020].
- 14.Becker Hospital Review. [Accessed May 17, 2020]. https://www.beckershospitalreview.com/pharmacy/telemedicine-startup-to-open-first-brick-and-mortar-pharmacy.html.
- 15.Fierce Healthcare. [Accessed May 17, 2020]. https://www.fiercehealthcare.com/tech/digital-health-company-hims-and-hers-building-pharmacy-operation-columbus.
- 16.Gagne Y, Helm B. Just what the patient ordered. [Accessed March 30, 2020]. www.fastcompany.com.
- 17.Kaspar BJ. Legislating for a new age in medicine: Defining the telemedicine standard of care to improve healthcare in Iowa. Iowa Law Review. 2014;99:839–66. [Google Scholar]
- 18.Syed H, Bachuwa G, Upadhaya S, Abed F. Nitrofurantoin-induced interstitial pneumonitis: albeit rare, should not be missed. BMJ Case Rep. 2016;2016 doi: 10.1136/bcr-2015-213967. bcr2015213967. Published 2016 Feb 24. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.The NAMS 2017 Hormone Therapy Position Statement Advisory Panel. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause. 2017;24(7):728–753. doi: 10.1097/GME.0000000000000921. [DOI] [PubMed] [Google Scholar]
- 20.Missouri Board of Pharmacy Newsletter. Aug, 2016. [Accessed March 30, 2020]. pr.mo.gov/pharmacists.
- 21.The Digital Apothecary. [Accessed May 17, 2020]. https://www.thedigitalapothecary.com/pharmacy-innovation-news/2019/10/6/direct-to-consumer-prescription-services-a-rundown-of-these-health-startups-and-online-pharmacy-services.
- 22.Alghurain SA, Simpson SH, Guirguis LM. What elements of a patient-pharmacist relationship are associated with patient satisfaction? Patient Prefer Adherence. 2012;6:663–76. doi: 10.2147/PPA.S35688. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Hello Alpha. [Accessed June 10, 2020]. https://www.helloalpha.com/membership/
- 24.Säfholm S, Bondesson Å, Modig S. Medication errors in primary health care records; a cross-sectional study in Southern Sweden. BMC Fam Pract. 2019;20(1):110. doi: 10.1186/s12875-019-1001-0.. Published 2019 Jul 31. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Patient safety - data and statistics. World Health Organization; 2018. [Accessed 4 June 2020]. http://www.euro.who.int/en/health-topics/Health-systems/patient-safety/data-and-statistics. [Google Scholar]
- 26.Number of fixed broadband subscriptions in the United States from 2000 to 2018 (in millions) [Accessed May 17, 2020]. https://www.statista.com/statistics/183614/us-households-with-broadband-internet-access-since-2009/
- 27.What do millennials want? [Accessed May 17, 2020]. https://www.pharmavoice.com/article/2017-10-millennials/