Could teledermatology help with clinical efficiency?

[HDelVe]

Going through the threads, I found a topic that resonated with me. @doctalaughs discussed how practicing dermatologists are finding it difficult to serve more patients (+45/day) while maintaining high quality care.

Since I’m in residency this may not be relevant, but I’m curious to hear all of your thoughts on what I’m about to ask: Could teledermatology increase efficiency?

If we’re looking to serve more patients with equal quality in care, and that “low-maintenance” patients are a breeze, why not use other systems that can take advantage of remote teledermatology?

That way, less-complicated cases can be served without in-clinic interaction, saving that time for the “high-maintenance” patients throughout the day. The simple cases could be addressed whenever you have some extra time, because they would be online rather than face-to-face interaction.

What are your thoughts? Do any of you have experience with teledermatology?

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[TMP-SMX]

Yeah it would be awesome for most routine acne patients. The key is who is taking the responsibility and who gets reimbursement for the service. The issue at the VA is the prescribing physician is taking the responsibility and doing the prescriptions. There's not a uniform regulatory structure available nor reimbursement available yet outside the VA.

 

[asmallchild]

Going through the threads, I found a topic that resonated with me. @doctalaughs discussed how practicing dermatologists are finding it difficult to serve more patients (+45/day) while maintaining high quality care.

Since I’m in residency this may not be relevant, but I’m curious to hear all of your thoughts on what I’m about to ask: Could teledermatology increase efficiency?

If we’re looking to serve more patients with equal quality in care, and that “low-maintenance” patients are a breeze, why not use other systems that can take advantage of remote teledermatology?

That way, less-complicated cases can be served without in-clinic interaction, saving that time for the “high-maintenance” patients throughout the day. The simple cases could be addressed whenever you have some extra time, because they would be online rather than face-to-face interaction.

What are your thoughts? Do any of you have experience with teledermatology?

There are multiple tele dermatology platforms available now, our group uses one

They aren't as useful as you would think, really depends on your patient population. For an older patient population like the one that our group primarily treats, the technology is definitely a barrier. TMP-SMX mentioned reimbursement can be problematic although I was under the impression that has improved for this year as part of the new fee schedule?

The technology isn't great either for lesion spot checks. Image quality and lighting leaves a lot to be desired and I often have to bring patients in anyway for an in-person exam. Same with rashes, anything more complex (and obviously if it requires biopsy) means I'll have to drag the patient in anyway.

I do agree it is nice for acne followups or medication refills but those comprise <10% of the telederm cases sent my way

 

[Dral]

Our practice utilizes several tele-derm platforms. The two most used are both store and forward forms.

We tried to utilize real time for in-patient consults at outside hospitals, but there were too many technical barriers to overcome (I only did one and it took maybe three hours to do it after all the communication/tech issues).

At the end of the day someone still has to meet with the patient to discuss their acne.

While access is an issue, when you're the one in the trenches doing the work, after seeing 40 or so patients in a day, it's not too much of an attractive proposition to have to log in to do telederm visits over lunch or at the end of the day.

 

[HDelVe]

Thanks for the thoughts everyone.

I would have to agree that an older patient population and more complex cases would be very difficult to treat with tech or image quality issues. But I’m surprised to hear that lesion spot checks have been giving you trouble. It seems like patients would probably need a good training session to effectively use their mobile dermoscopes and upload the image to a telederm platform - and that may resonate with some patients more than others (age differences).

Three hours dealing with tech issues for a patient sounds horrible when the whole point of telerderm is convenience. In some of my research I saw that telederm software is starting to use cloud storage, and I came across a few called FotoFinder, FirstDerm, and DermEngine. Ever heard of them?

From the vague research I’ve done on each one, the last one seems to be the most complete in terms of telederm services. Have you ever experimented with it or know anyone who has? I’m interested in using a telederm platform when I start practicing.

 

[doctalaughs]

Thanks for the thoughts everyone.

I would have to agree that an older patient population and more complex cases would be very difficult to treat with tech or image quality issues. But I’m surprised to hear that lesion spot checks have been giving you trouble. It seems like patients would probably need a good training session to effectively use their mobile dermoscopes and upload the image to a telederm platform - and that may resonate with some patients more than others (age differences).

Three hours dealing with tech issues for a patient sounds horrible when the whole point of telerderm is convenience. In some of my research I saw that telederm software is starting to use cloud storage, and I came across a few called FotoFinder, FirstDerm, and DermEngine. Ever heard of them?

From the vague research I’ve done on each one, the last one seems to be the most complete in terms of telederm services. Have you ever experimented with it or know anyone who has? I’m interested in using a telederm platform when I start practicing.

I'm not familiar with those platforms but do have a ton of experience doing telederm.

The problem is not the technology. We know from decades of experience that telederm can be effective (prevent about 60-70% of in-person visits) and be done quicky and high volume. This is of course assuming the PCP is sending the photos with some sort of quality assurance program. Patients sending photos is trash and doesn't work due to lack of QA. Lesion checks can also be done from the PCP office well, as long as dermoscopy and quality control systems are in place.

The main problem is still 1) reimbursement and 2) setting up the large QA process. #1 and #2 can be easily solved at a large integrated place like VA or kaiser. Bigger problem in a fractured system like private practice (where you cannot control #2, and although #1 is getting better it's still completely inadequate to make it worth my time to look at photos).

 

[asmallchild]

Thanks for the thoughts everyone.

I would have to agree that an older patient population and more complex cases would be very difficult to treat with tech or image quality issues. But I’m surprised to hear that lesion spot checks have been giving you trouble. It seems like patients would probably need a good training session to effectively use their mobile dermoscopes and upload the image to a telederm platform - and that may resonate with some patients more than others (age differences).

Three hours dealing with tech issues for a patient sounds horrible when the whole point of telerderm is convenience. In some of my research I saw that telederm software is starting to use cloud storage, and I came across a few called FotoFinder, FirstDerm, and DermEngine. Ever heard of them?

From the vague research I’ve done on each one, the last one seems to be the most complete in terms of telederm services. Have you ever experimented with it or know anyone who has? I’m interested in using a telederm platform when I start practicing.

Not sure what platform you are using, the platform we use utilizes a mobile app which in turn uses the smartphone camera. Lots of variation in terms of image quality, focus quality, and background lighting quality. And even then, if there's suspicion on the lesion, we have to bring the patient in anyway. Do you waive the charge for the telederm consult? Or do you charge the patient twice, once for the consult, and then once for the in-office visit + biopsy?

The other question is how busy do you want to be with this? Some of my colleagues who are very busy and successful with telederm have done a phenomenal job offloading "lower reimbursing" visits to telederm thereby maximizing their in-office time for "higher reimbursing" visits (read: procedures). They hit up the telederm platform before work, during lunch, after work, at the kids' baseball game, etc to clear those visits. I get enough emails from work without being a high volume telederm provider. I don't even want to imagine what their inbox must look like.

Finally, the last question I would add is how good will you be with this, especially right out of residency? I know it's anecdotal but I had a colleague get burned badly because he was supervising a midlevel provider who badly misdiagnosed a lesion via the telederm platform. It took me a couple of years after training to hit my stride and come up with the optimal algorithm as to what lesions to observe, what lesions to biopsy, etc that would satisfy patients, my employer, my own ethics, etc. I don't think I would have been comfortable using telederm myself in such high volumes right out of residency. And I still don't allow my midlevels to pursue this.

 

[KeikoTanaka]

I had this debate with an orthopedic surgeon (My mother-in-law). Obviously orthopedics is very hard to do "telemedicine" wise - probably more difficult than derm because Derm issues can be seen with a camera - internal ripping of a tendon cannot be seen on a camera. However, we both ended up agreeing it would be helpful if her PA could do some low acuity follow-up appointments over the skype/w/e service is available, instead of taking up an exam room, having them wait in the waiting room, waiting to do the patient intake via the MA, have the patient walk slowly back from the waiting room... But, at the end of the day it's just so hard to actually fully utilize because (At least in Orthopedics) you still don't know when a simple Skype call could actually end up being a surgical consult - so, it's hard to say! As i'm only a first year med student, I can't wait to see how Tele-medicine will be in 7 years when I'm actually out practicing - I'm sure there will be reimbursement equality at that point compared to true in-person visits.

Definitely a good question you brought up about charging the patient once. If, lets say the Tele-consult was reimbursed just as much as a real patient visit and you had them come in anyways - I'd probably just take the initial Tele-medicine reimbursement and Edit that same note when they come in and have a "Telemedicine" component part of the HPI and a "In-house" portion of the HPI - all billed under one - but luckily some of your work was hopefully done by collecting all necessary history before they came in.

 

[HDelVe]

It’s fascinating to know that the technology is there, but a lack of QA seems to be the main barrier. As for reimbursement issues, it sounds like large practices may have to be the pioneers so that small practices can adopt their model. But for now, I can see smaller private practices implementing their own structure, in order to best attract and retain repeat patients from a competitive standpoint.

@asmallchild: With the platforms I mentioned above, FirstDerm uses the basic smartphone camera, which by the way, I can see how it would generate image quality variations, simply because of the different types of users. But DermEngine looks to be using their own attachable smartphone dermascope, that claims if it is used correctly, it will take pics showing the same high quality as seen through a traditional dermascope. Here are the YouTube videos I watched:

• FirstDerm: skip to 0:20 for their image-taking process.
• DermEngine: skip to 2:51 for their attachment.

And great points on willingness to be extremely busy with patients via telederm, and being capable of handling high volumes right out of residency. It would really take passion and an exceptional work ethic for any derm to allocate that amount of time to their tele-patients.

I think I’m on the same page as @KeikoTanaka, where I hope in the next ten years or so, we’re able to iron-out the reimbursement and QA kinks so that telederm can compliment our practices instead of overloading them.

 

[PharmaBr0]

Wait what?