Online Prescribing: Convenience or Catastrophe?

For over a century, patients received medicines after seeing a doctor. First, you had to call to make an appointment. That usually took several days, but eventually you would end up in an exam room. Then the doctor would listen to your story. Eventually there would be a physical examination. The physician would verify your blood pressure, listen to your lungs and heart, look in your ears and check your reflexes. At the end of this sometimes lengthy process, there might be a prescription on a piece of paper. You would take that piece of paper to a pharmacy and wait while the pharmacist filled the prescription. Such days are long gone. Online prescribing is becoming routine. What does it mean for patients?

The Internet Has Changed Everything:

A lot of people now make their medical appointments online through a patient “portal.” You may have to wait weeks or even months to get an appointment with a specialist. If you are able to get a physical meeting with a doctor, a nurse practitioner or a physician’s associate, the length of the meeting may be shorter than ever. Time is money, after all.

If you get a prescription, chances are that it will be sent electronically to the pharmacy of your choice or to a mail-order pharmacy. Relatively few doctors still hand out paper prescriptions. Most pharmacies now get their orders online.

The web has changed everything. People can buy almost anything online, from books and shoes to music and airplane tickets. They can bypass a doctor’s office to get prescription drugs if they wish. People can get drugs on demand and have them delivered directly to their doorstep.

Commercials on television encourage viewers to visit “telehealth” companies. There, they can fill out electronic forms to access trendy prescription pharmaceuticals to lose weight, grow hair, improve sexual function and even balance their mood.

Medical Self Care: A Radical Idea About Online Prescribing

Nearly three 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?

Two of Doc Tom’s most unorthodox ideas were online consultations and online prescribing. He was convinced that this would allow patients to participate more actively in the prescribing process.

Joe thought this was a terrible idea. Most people don’t have adequate information about the potential risks and benefits of drugs. Joe feared this web-based interaction would lead to overprescribing and drug disasters.

Can Prescriptions on Demand be Safe?

Dr. Ferguson 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 decades ago was that online prescribing 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 wasn’t working as expected.

Dr. Ferguson believed that physicians would be in touch with patients within days of starting a new prescription. They would verify that it was working as anticipated, and they would closely monitor for any side effects. Doc Tom loved technology and assumed that home monitors would supply health professionals in depth and regular reports that would facilitate great communication and up-to-date information about things like heart arrhythmias, blood pressure, weight, blood glucose and a number of other metrics.

Tom believed that this new online prescribing system should also allow for early detection of drug side effects. He was hopeful that prescribers and their assistants would follow up every prescription with email questionnaires, text messages, phone calls or video conferences to verify that all was proceeding as anticipated. While that could, in theory, happen, that does not appear to be the dominant model today.

An Unexpected Development: Online Prescribing AND Selling:

An article in the Wall Street Journal (March 13, 2025) described sexual side effects experienced by some men who had purchased prescription finasteride for hair loss from telehealth companies. Their libidos plunged and in some cases their genitals became smaller and changed shape.

According to the Journal:

“Most said they didn’t realize there were risks of serious side effects from the hair-loss drug; others said they didn’t feel the warnings were adequate.”

A Wall Street Journal reporter tested an online prescribing service:

“…he submitted his intake at 11:18 a.m. A follow-up text said his finasteride prescription was written at 11:19 a.m.”

ED Drugs Shipped Without Visiting a Doctor’s Office:

Some online companies advertise that they can sell prescription drugs for erectile dysfunction that can be obtained without visiting a doctor’s office. Men are told that they can get the generic drug sildenafil (Viagra) by visiting an online website. Just answer some health questions, pick your treatment, verify you are who you say you are and pay.

Many urologists would insist upon a thorough physical exam before prescribing a drug like Viagra. They would also check the man’s medical record to be sure there were no incompatible medications. It’s not obvious that an online prescription system could make sure a man does not have a health problem that might make such medicine dangerous. And it is not obvious that an online physician would check back within a few days to verify that the ED drug is performing as expected and is not causing any interactions or adverse effects.

Is Online Prescribing the Wave of the Future?

Whether it’s medicine for erectile dysfunction, anxiety, depression or insomnia, there are now telehealth companies ready to prescribe and sell medications for anxiety, depression or weight loss. We are all for modern technology. Electronic tools allow healthcare providers to monitor blood pressure, irregular heart rhythms, weight or blood sugar. Video conferences allow dermatologists to examine patients remotely.

For such interactions to produce meaningful outcomes, though, requires time and trust. The follow-up telehealth visits that Dr. Tom Ferguson envisioned would be wonderful if they were based on adequate time and exchange of information.

Unfortunately, in today’s profit-driven healthcare environment, time is money. Telehealth providers may prefer to speed customers through an online experience that minimizes medical doctor interactions or the opportunity for complex questions. In such situations, people may need to make an effort to get the in-depth drug information that they need.

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 20 million people received prescriptions for this ACE inhibitor, making it one of the most prescribed drugs 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. An 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.

More Benefits from Direct-to-Consumer Products and Services:

A study of the “Ethical Issues in Direct-to-Consumer Healthcare” drilled down into the pros and cons of this evolving sector (PLOS Digital Health, Feb. 13, 2024). The authors reinforce one of Doc Tom’s key goals:

“Improves Autonomy:

“Several publications (29%; n = 25) noted that DTC [direct-to-consumer] healthcare has created opportunities for individuals to take charge of their own healthcare. For example, in the realm of DTC testing, it was argued that individuals have greater control over their personal health information, including what tests they order and who they share data with.”

The authors note that patients can choose from a wide array of online mental health platforms. And there are lots of digital tools that help patients be “more actively involved in their care and treatment decision.”

“Improves Convenience:

The study of direct-to-consumer healthcare can reduce appointments, provide access to publications and offer “flexibility to easily select the meeting time and duration of their services.”

Add to that efficiency, self screening and early diagnosis through a variety of tools and digital apps.

The Downside of Prescriptions on Demand:

Despite the benefits, there are also concerns. The current DTC telemedicine outfits seem focused first and foremost on the specific drugs they are offering, rather than on finding the best solution for the patient.

The authors of the PLOS Digital Health (Feb. 13, 2024) article point out that there is a “lack of sufficient evidence of safety and/or rigorous testing for DTC heatlhcare products and services.” Another worry is patient privacy. Is data protected or shared with third parties? Then there is cost. Many of the online mental health services are not reimbursed by insurance companies. Ditto for blood or stool tests.

We imagine that some, if not most, of the online pill purveyors want cash on the barrel head rather than reimbursement from an insurance company. How do we know about the quality of online generic drugs? Anyone who has read our newsletter knows that we worry about inadequate FDA testing of foreign-made pharmaceuticals. If you are buying cheap ED drugs or medicines to restore hair on your head, how do you know you are getting quality products?

Finally, and most important from our perspective, it isn’t clear that DTC drug sites have instituted the type of careful follow-up that Doc Tom envisioned. If and when they address all these concerns, we could imagine a time when online prescribing 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. Nevertheless, we recognize that people are buying prescription drugs directly from online purveyors of weight loss medications, ED drugs and medicines to help restore lost hair.

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. There are also high-tech tools people can use at home.

Could you imagine interacting with an online health professional? Share your thoughts in the comment section. If you think this article has valuable information, please share it with a friend or family member. As always, we are grateful when you encourage people to sign up for our free newsletter at this link.