Teledermatology enables efficient patient triage

Timothy Abrahamson, a dermatologist based in Des Moines, Iowa, has used standard telemedicine for patients, patients who would otherwise not be seen by a dermatologist in the inpatient setting.

"Teledermatology is not going to replace seeing the patient, but it can help us (inpatient dermatologists) triage," says Timothy Abrahamson, M.D., a dermatologist with Greater Des Moines Dermatology PC.

"As a solo dermatologist, it is impossible for me to go five separate hospital locations on a randomly requested basis," Dr. Abrahamson says.

In particular, Dr. Abrahamson wishes he could use the store-and-forward format in the comfort of his home to view images when he has availability and make a recommendation for care to the referring physician, a non-dermatologist who may be an emergency physician or internist.

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"Store and forward (teledermatology) is a way to serve patients and a way for dermatologists to decide if a patient needs to be in hospital," explains Dr. Abrahamson. "Standard telemedicine requires too many logistics to provide efficient care for the consultant or the consulted dermatologist. Store and forward will be necessary to make this truly useful as this allows the consulting physician to immediately create the consult and the dermatologist to review the information at a different time.

"Also, the stored information can be saved for a period of time for future reference," he says. "The American Academy of  Dermatology (AAD) is testing a prototype of this system currently. Unfortunately, funding is lacking for coverage even in a rural state like Iowa. Only Hawaii and Alaska are granted this privilege  by Medicare at this time. These two states have been funded for a decade."

And the use of teledermatology for inhospital patient dermatologic service does not compromise the quality of diagnoses, according to research published last spring.

Store and forward enables better triage

Store and forward enables better triage

A study found store-and-forward teledermatology can be employed to assist in the triaging of inpatient dermatology consultations: The investigators were able to triage 60 per cent of consultations to be seen the next day or later. In addition, teledermatologists were able to triage, on average, 10% of patients to be seen as outpatients. There was also good concordance in the decision to biopsy between in-person and teledermatology. Investigators concluded teledermatology to be reliable in the triage of inpatient dermatology consultations and that its use could improve efficiency.1

"There is a dearth of dermatologists able or willing to see patients who are hospitalized," says Misha Rosenbach, M.D., assistant professor of dermatology and internal medicine, director of the Dermatology Inpatient Consult Service at the University of Pennsylvania, Philadelphia, and senior author of the study.

Dermatologists are expected to drive to a hospital for a consult that may take less than 15 minutes, and which sometimes could have been safely seen in the outpatient setting after discharge, which is an inefficient use of their time, Dr. Rosenbach says.

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"Using teledermatology to triage consults by acuity may make it more efficient for dermatologists to decide if a case is urgent, as teledermatologists were able to accurately diagnose and triage inpatient consults in our pilot study," Dr. Rosenbach says. "If dermatologists could evaluate teledermatology images and assess consults for acuity, they could 'lump' consults together on a single, convenient, efficient trip to the hospital and see all the non-acute consults in one bundle."

The AAD has taken the lead with this concept, through the development of the secure teledermatology platform "AccessDerm", which provides timely diagnosis using the store-and-forward approach. Staffed by volunteer board-certified  dermatologists, AccessDerm can be accessed via mobile devices, Dr. Rosenbach notes.

"There is an urgency that comes up with hospitalized patients," explains Lindy Fox M.D., associate professor and director of Hospital Consultations at the University of California at San Francisco. "A patient could have a bump on the leg that is benign and without significance or it could be something that requires further evaluation in a hospital setting."

Enabling access to care

Enabling access to care

Other dermatologists such as Anne E. Burdick M.D., M.P.H., associate dean for TeleHealth and Clinical Outreach, professor of  dermatology at the University of Miami Miller School of Medicine in Miami, Fla., and a leading advocate for the expansion of teledermatology, supplies her clinical judgment to physicians working out of a mobile van and a corporate grant reimburses for this teledermatology service.

"Forty per cent of my practice is done with teledermatology, and I have been doing it for about 20 years," Dr. Burdick says. "In many places, there is a shortage of dermatologists, and this is the way to reduce the disparity in access to dermatological care. It shortens the time (to see a dermatologist) because there can be a wait of many months."

Dr. Burdick also uses the asynchronous store and forward method to provide consultations to personnel aboard cruise ships, but points out the merit of the live interaction with direct communication with the patient or referring provider that allows her to ask questions during the consultation. Dr. Burdick offers that teledermatology can provide accurate diagnosis, provide a recommendation for a targeted work-up, and if need be, offer appropriate therapy.

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There is no doubt that a clinical field like dermatology lends itself to telemedicine, says Jonathan Linkous, Chief Executive Officer of the American Telemedicine Association, noting Veterans Affairs hospitals have been using teledermatology for some time.

Reimbursement limitations

"It is largely a visual specialty," Mr. Linkous says. "We are working with the AAD to overcome barriers to implement teledermatology, issues like reimbursement and liability using store and forward. The issue of payment should not be in doubt for physicians who participate in telemedicine."

The AAD released a position statement on telemedicine which outlined reimbursement for live, interactive dermatology. The statement noted that in some states, Medicaid reimburses for telemedicine services, but many states have restrictions. The statement noted as well that private insurers vary in their reimbursement policies, but most will reimburse services provided to patients in rural areas.

The statement noted that there are more limitations to reimbursement with the store-and-forward format with the exception of demonstration projects or in states like Hawaii and Alaska. There is reimbursement of store-and-forward teledermatology for Medicaid patients in a handful of states including California and Illinois.

Teledermatology services

Teledermatology services

Some have seen the void in dermatological care in the United States and have taken the opportunity to develop private services to match up patients with board-certified dermatologists licensed in a patient's geographic area to provide dermatological care. Dermatologist-On-Call was launched in response to consumer preparedness for teledermatology and technology advances that ensure privacy and supply high-resolution images.

"With severely limited access (to dermatologists) it makes sense to use a tool like store-and-forward to provide the same type of service," says Mark Seraly, M.D., F.A.A.D., Chief Medical Officer and Founder of Dermatologist-On-Call. "Our goal is to give patients access to the highest quality care, and that means consulting with a dermatologist who specializes in hair and skin conditions."

Access to a dermatologist appears increasingly critical given non-dermatologists express a lack of confidence dealing with dermatological presentations. One investigation found 40 per cent of primary care residents in California who were surveyed reported that they did not feel prepared through their medical school education to respond to dermatologic issues.2

Using telemedicine in dermatology

And a retrospective chart review in a mid-western U.S. university hospitals revealed that the primary care team had a correct diagnosis in less than one out of every four cases (23.9 per cent) involving dermatological problems. Consultation with a dermatologist led to a change in or addition to treatment in the balance of cases.3

Patients send images to Dermatologist-On-Call, which then finds a dermatologist in the local area of that patient to review the images and render a clinical diagnosis. If dermatologists receiving the images judge that the image quality is not appropriate, they can request other images, Dr. Seraly explains.

Cameron Rokhsar, M.D., F.A.A.D., a board-certified dermatologist and assistant clinical professor of dermatology at Mount Sinai Hospital in New, New York, said the conventional thinking is that live interaction trumps a video conferencing consultation, but store-and-forward technology is a much more convenient teledermatology format for busy teledermatologists.

"Most dermatologists probably feel that there is nothing that can truly substitute a face-to-face consultation," says Dr. Rokhsar. "You can show someone a picture, but that picture is truly not the same thing as seeing the patient live."

Expanding teledermatology

Expanding teledermatology

The future of teledermatology and how to make it work for you

To expand teledermatology, Dr. Rokhsar comments that it would be preferable for "nice haves" such as multi-state licensing and an interstate compact to enable dermatologists who are participating in teledermatology to easily prescribe treatment and be involved in follow-up care.

The Federation of State Medical Boards is contemplating a new framework for expediting licenses to allow physicians to practice in multiple states, a move that would open the doors more widely to telemedicine and teledermatology. Licensed physicians could apply for rapid multistate licensure to treat patients who reside outside the principal licensing state.

Teledermatology is responding to a "real issue of access", and the expansion of cosmetic dermatology has not been a significant factor in reducing that access, says Darrell Rigel M.D., a clinical professor of dermatology at New York University Medical Center and an AAD past-president.

"There is a greater burden of dermatologic illness," Dr. Rigel says. "There is more and more dermatologic disease such as skin cancer, eczema, and acne. It is still in an embryonic phase, and a lot of insurers don't have official reimbursement policies."

References

References:

1 Barbieri JS, Nelson CA, James WD, et al. The reliability of teledermatology to triage inpatient dermatology consultations. JAMA Dermatol. 2014;150(4):419-24.

2 Hansra NK, O'sullivan P, Chen CL, Berger TG. Medical school dermatology curriculum: are we adequately preparing primary care physicians?. J Am Acad Dermatol. 2009;61(1):23-29.e1.

3 Davila M, Christenson LJ, Sontheimer RD. Epidemiology and outcomes of dermatology in-patient consultations in a Midwestern U.S. university hospital. Dermatol Online J. 2010;16(2):12.