Digital dermatology: Telemedicine gains popularity

As medical groups grow in size and doctors tend to migrate toward larger population areas, it’s often harder to find specialists in smaller towns. Particularly in lesser-populated states, such as Oklahoma, South Dakota and Wyoming, a patient needing dermatologic care often has to drive hundreds of miles before finding a dermatologist.

That’s been one impetus for the growth of telemedicine operations around the country. Additionally, with improvements in telecommunications, networked computer systems, and advances in communications software, doctors and patients are finding ways to provide specialty care without the inconvenience and expense of traveling. The visual nature of dermatology makes it a logical specialty to take advantage of telemedicine.

Jonathan A. Dyer, M.D., has been using teledermatology at the University of Missouri for nearly six years. As assistant professor of dermatology and child health, Dr. Dyer says while different methods of performing teledermatology can be useful, combining two techniques can yield the best and most natural results.

Trying telederm

Dr. Dyer uses both the “store-and-forward” and live interactive teledermatology practices. Each offers advantages and drawbacks in diagnosing skin conditions.

“The store-and-forward system allows for high-quality digital photography of the affected skin,” Dr. Dyer says. “The live interactive system is videoconferencing over a secure high-speed telephone line from the remote sites to here.

“Basically, I have a couple of rooms in my clinic where it’s designed to mimic a regular clinic exam room. We just walk in the room, and instead of a live patient, we’re talking to a camera and looking at the TV screen.”

The University of Missouri uses a hybrid system that, according to Dr. Dyer, takes advantage of the strengths of both types of teledermatology.

“The video cameras at most of our sites are capable of taking high-pixel, high-quality digital stills,” he says. “Before we even link up with the patient, the nurse or technician at the site will take digital stills of the affected skin. We can take a look at the high-quality stills, and then go back to the patients.

“We get the best of both worlds. It really mimics what we do in the clinic, where we take the history and talk to the patient before examining the skin. Visits are conducted in real-time, using live video conferencing, then looking at detailed stills, and then discussing what we’re going to do.”

Replicating real life

Dr. Dyer explains that the advantage of the live interactive visit is that a real doctor-patient relationship exists.

The downside of the live camera, he says, is that it doesn’t have the resolution for close-up imaging of the skin, so sometimes the skin condition is not very clear.

“You get a distribution pretty easily, but not a close, clear shot. Especially with kids who move a lot - the camera can’t keep up with them, can’t focus,” Dr. Dyer says.

With the hybrid system, he explains, it’s possible to get excellent digital stills and do the assessment, yet maintain a doctor-patient relationship.

“You don’t have to struggle to hold kids really still while you try to focus the camera. Plus, a lot of kids like the idea of ‘being on TV.’ Some are kind of stunned into silence, but a lot of them really enjoy seeing themselves and talking to the TV and having the TV talk back to them,” he says.

Legal matters

Dr. Dyer says in order to make pediatric teledermatology most effective, it’s important to be aware of the rules and regulations where you are operating.

“The biggest issue with store-and-forward is HIPAA compliance and patient confidentiality. I’ve had doctors take pictures of puzzling skin conditions (and) e-mail them to me,” he says. “Technically, that’s not incredibly secure or HIPAA compliant. Doctors need to make sure they’re protecting patient confidentiality.”

Another issue is that insurance companies don’t always reimburse for the store-and-forward type of teledermatology.

“The interactive often is reimbursed because it so closely mimics a true patient visit. But the way care is delivered is changing, and as carriers get used to that and adapt to it, I think there should be more acceptance of billing for it,” Dr. Dyer says.

Dr. Dyer says that as good at teledermatology technology is, physicians should not be afraid to tell a patient to come in for an in-office visit if necessary.

“I recently examined a patient with a rash on his scalp and who lives four hours away. We instituted a treatment, but it wasn’t effective,” he says. “Scalp rashes can be difficult, and even with high-quality digital stills, we couldn’t be sure what he had. So I told them we could keep trying options, but it would really be better for them to drive up to see us in the clinic.”

Dr. Dyer says most of the available data shows that dermatologists’ telemedicine accuracy is similar to live patient visits, although the doctors’ confidence levels in their telemedicine diagnostics is not as high.