COEUR D’ALENE, IDAHO – Teledermatology is gathering steam – and supportive data – as a potentially invaluable way to address the overlapping problems of a dermatology workforce shortage, gruelingly long wait times for appointments, limited dermatologic skills on the part of busy primary care physicians, and the anticipated sharply increased demand for dermatologic services as the Affordable Care Act brings many millions of new patients into the ranks of the insured.
But, in the main, it won’t be telemedicine in the familiar form that physicians have come to think of: that is, as remote, face-to-face, real-time video conferencing. The future lies in mobile teledermatology, also known as store and forward, Dr. Carrie L. Kovarik asserted at the annual meeting of the Society for Pediatric Dermatology.
Dr. Carrie L. Kovarik
Store-and-forward teledermatology takes advantage of the ubiquity of smart phones and the dazzlingly high quality of their photographic capability. Here’s how it works under AccessDerm, a mobile store-and-forward teledermatology platform developed by the American Academy of Dermatology. Dr. Kovarik, a University of Pennsylvania, Philadelphia, dermatologist and a pioneer of teledermatology in Africa, heads the AAD AccessDerm initiative.
Mobile teledermatology is conducted between a primary care provider and a remote consulting dermatologist. Using the AccessDerm app, the primary care physician submits a case, providing clinical images, and filling out a standardized template to provide mandatory information regarding clinical history.
At present, AccessDerm is connected in 19 states and the District of Columbia. Any AAD member in those locales can serve as a voluntary teledermatology consultant. At the University of Pennsylvania, the dermatology department faculty and residents serve as a pool as the cases come in, picking them up as their workflow permits.
The program operates in 14 Philadelphia health clinics, including all 10 city public health clinics. It has been a hit with patients, many of whom are immigrants who are reluctant to go to the university dermatology clinic and who are far more comfortable in their local clinic, where translators are available. The city council loves the program as well.
In an as-yet unpublished prospective study involving 202 AccessDerm consultations in which the primary care provider was asked in submitting the case to provide their thoughts regarding diagnosis and management, the Penn dermatology consultants overturned the primary care providers’ opinions in the majority of instances. Indeed, the diagnostic concordance rate was just 22%, and the concordance rate regarding management was 23%.
A total of 77% of the cases were managed via teledermatology alone. In the other 23%, an in-person dermatology consultation was recommended; this rate was higher than when primary care providers are taught to do careful skin biopsies and submit them as part of the teledermatology consult.
"Typically, if you teach primary care providers to do biopsies, you need to see patients only 5%-10% of the time as a safety net for those complex cases in a teledermatology program," according to Dr. Kovarik.
The primary care providers stated that, in the absence of teledermatology, 61% of the patients would have not had any access to dermatologic care.
"We’re providing a lot of access where there was no access," Dr. Kovarik observed.
An added benefit of the Philadelphia mobile teledermatology experience is that the primary care clinicians are getting better and better at dermatology.
"They’re asking us harder questions now," she said. "They’re not asking us about eczema anymore."
In another recent study, Dr. Kovarik and her Penn coworkers demonstrated that mobile teledermatology is a reliable and efficient way to triage inpatient dermatology consultations. This is an issue of practical importance to office-based dermatologists. Most of the time, if they get asked to consult on a hospital inpatient, they feel obligated to go to the hospital that day because they can’t tell from the phone conversation how urgent the situation really is.
In this prospective study of 50 adult inpatients for whom a dermatology consultation was requested, all participants were evaluated separately by an in-person dermatologist and two independent teledermatologists. At least 90% of the time, the on-site dermatologist recommended the patient be seen that day, so did the teledermatologists. When the in-person dermatologist recommended a biopsy, 95% of the time the teledermatologists did, too. The teledermatologists were able to triage 60% of the consultations to be seen the next day or later, enabling office-based teledermatologists to bunch some of their inpatient consultations (JAMA Dermatology 2014;150:419-24).
"At Penn, we’re big advocates of teletriage. We’re setting up a system where we have all the consults come to us as teledermatology. We’ll look at the case and say we can help the primary care provider treat that problem, we can triage it to a certain clinic, or the patient could go see the next available dermatologist. But everyone is going to be seen by teledermatology first so we can put [the patients] in the right place to get the care they need. Otherwise, the consults come in with a note saying ‘rash on the right leg’ and who knows how bad it is," Dr. Kovarik said.