Abstract
Dermatology is a practice that heavily relies on visual observation, and it is a rare field of medicine where what you see may be more important than what you hear from the patient. For these reasons, dermatology lends itself to the innovations that telemedicine has to offer, and it is why teledermatology is one of the most requested consults within telemedicine today.
In some arenas, teledermatology has been in use since the 1990s.
“In the Army, we have provided teledermatology services starting in earnest in 1994 at Walter Reed,” says Ronald K. Poropatich, M.D., deputy director of the U.S. Army Medical Research and Materiel Command Telemedicine and Advanced Technology Research Center, Fort Detrick, Maryland, who has been active in telemedicine for nearly 20 years.
“Today, we have a very well-established program, and Brooke Army Medical Center manages about 40 different teledermatology sites nationally—all military predominant including Navy and Air Force. Brooke Army has conducted as many as 400 store-and- forward teledermatology consults a month since 1998.”
In addition, since 2004, the Army has conducted >9,000 consults for deployed providers overseas in austere environments using a store-and-forward teleconsultation program, according to Poropatich.
“About 47% of the telehealth consults in the military from deployed settings are dermatologic in nature, and a distant second is infectious disease,” he adds. “Dermatology lends itself nicely to this technology.”
“We always have seven dermatologists around the world ‘on call’ who volunteer their time and answer consults out of the approximately 40 dermatologists available. They check e-mails and respond back to people in a deployed setting, and we have maintained, over the last seven years, about a five-hour turn-around time to respond.”
These virtual consultations are from provider to provider and go out over a central mail server to the doctors. “We take advantage of the ‘awake’ clock and are set up to distribute the providers across many time zones,” Poropatich said.
While the benefits of a telemedicine platform for dermatology are evident in a military setting, it has also been successful on the civilian side of things.
Anne E. Burdick, M.D., M.P.H., associate dean for TeleHealth and Clinical Outreach, professor of dermatology at the University of Miami (UM) Miller School of Medicine, and coauthor of ATA's Practice Guidelines for Teledermatology, says that a scarcity of dermatologists—in the United States and worldwide—has increased the need for innovative services such as teledermatology.
“Teledermatology is the top requested specialty for teleconsultations in UM's TeleHealth program, and in part, this is because it is difficult to find a specialist in dermatology particularly in rural areas,” Burdick said. “There also tends to be a very long wait time for new patient appointments and even for follow-up visits.”
The benefits of teledermatology, according to Burdick, who headed the American Academy of Dermatology (AAD) Telemedicine Task Force and spearheaded the AAD's first Position Statement on Telemedicine, include providing specialty access to patients who otherwise would not have access to those services, earlier triage and earlier time to diagnosis, and less costly and more focused medical workup and treatment.
“Teledermatology is amenable to live interactive and store-and-forward technologies, and it enhances the medical home model for primary care being managed by the PCP in the patient's local community,” Burdick said. “In addition, teledermatology also provides an educational tool for the referring provider with information that can be applied for future patients with similar presenting signs and symptoms.”
Burdick comments that the use of teledermatology also has the potential to increase a dermatologists' patient volume without significant costs. “With the use of teledermatology I don't need a receptionist to enter the patient's information and a nurse to put them in a gown,” Burdick said. “On the remote side there are costs for infrastructure and training of personnel on equipment, software, and photographic techniques as well as infrastructure.”
Two of the many innovative clinical applications of teledermatology that UM TeleHealth has been involved in are a Miami Dade County public school initiative, which provides dermatology consults through hybrid teledermatology technology (live interactive videoconferencing with prior images and history) provided through a grant from the Verizon Foundation, and providing teledermatology services to >20,000 crew at sea on the Royal Caribbean Cruise Lines.
Burdick is also the founding chair of the ATA Special Interest Group (SIG) on Teledermatology, and she comments that the Teledermatology SIG-created practice guidelines are endorsed by the AAD. “Teledermatology is a mature well-studied application of telehealth, and the published guidelines have allowed people to become more familiar with the details,” Burdick said.
Teledermatology is also a viable path to reach underserved populations, according to April W. Armstrong, M.D., M.P.H., assistant professor of dermatology, director of Clinical Research Unit, and director of teledermatology at the University of California, Davis Health System, Department of Dermatology.
“There are basically two populations that are served most by teledermatology—medically underserved populations and people in rural areas regardless of socioeconomic status,” Armstrong said. “Medically underserved populations are underserved in terms of their primary care needs, but certainly for their specialty needs.”
In terms of practicing teledermatology, there are two main methods—store-and-forward and live interactive—and advantages and disadvantages to each.
“Store-and-forward is easier to set up and the equipment is less expensive,” Armstrong says. “You need a camera and secure software for transmission of information and can use this modality with both populations (described). The disadvantage is that there is no live interaction between the patient and the doctor, and the dermatologist gives recommendations through the primary care doctor. Because the pictures are taken in primary care doctors' offices and sent to dermatologists for evaluation and then back to the PCP, there can be variability in ways that the information is delivered to the patient.”
Armstrong says that dermatologists often prefer store-and-forward, as images are typically clearer than photographs transmitted over video where the quality of the image is still not as good as store-and-forward.
“The advantages of live interactive teledermatology are that the patient and dermatologist have a direct interaction and are seeing each other on the screen and can ask follow-up questions live and in-person,” Armstrong said. “Patients and clinicians can walk away feeling satisfied because they can ask and address questions, and there are no surprises when the PCP explains the dermatologists' recommendations because the patient has already heard directly from the specialist.”
The comfort level with teledermatology diagnostics increases with the more practice a dermatologist has but of course it is not as comfortable as face-to-face interaction, and Armstrong says that, naturally, most dermatologists are uncomfortable with suboptimal information or a blurry image.
“If a photographer is well trained with store and forward then good images are captured,” Armstrong said. “With live interactive, depending on bandwidth, the images may not be so great. If I can't see a lesion clearly because it is pixilated through live interactive images then I might feel uncomfortable making recommendations without first seeing the person.”
Cutting-Edge Research
Armstrong and her colleagues have been conducting research to compare the clinical equivalence of a novel patient-centered online healthcare delivery model versus in-office care for follow-up management of psoriasis patients. In a recently completed, randomized, controlled trial, 64 patients with an established diagnosis of psoriasis were randomly assigned to being followed online with store-and-forward images or followed in live consultation with a dermatologist over a 24-week period. 1 All of the patients had initial visits in person and had established rapport with the dermatologist prior to the intervention.
Results showed a comparable outcome between those coming to the office versus those who had their visits online.
“Patients who cannot take time off from work especially liked the online visits,” Armstrong said. In an economic analysis of this study, Armstrong and her colleagues also determined that the teledermatology online route was less costly to the entire system compared with the live visits. Specifically, the cost of follow-up psoriasis care with online visits was 1.7 times less than the cost of in-person visits ($315 vs. $576). 2
Another area of research that Armstrong has been working on entails volunteer efforts through teledermatology. 3
“We held a skin cancer screening where we had a dermatologist onsite who evaluated 86 people with 187 lesions, and then volunteers captured images and clinical history with software-enabled mobile phones and sent those images to an offsite teledermatologist for review,” Armstrong said. “We then reviewed how much they agreed in diagnostics and management.”
Results showed that management concordance between in-person assessment and evaluation by the teledermatologist was attained for 81% of the presenting lesions, the categorical diagnostic agreement was 82%, and the aggregated diagnostic agreement was 62%.
“The greatest diagnostic disagreement occurred with pigmented lesions, which are harder to diagnose through mobile technology, and this further supports the argument to evaluate pigmented lesions carefully and to possibly use dermoscopy,” Armstrong said. In addition to assessing pigmented lesions, Armstrong describes other conditions that may be difficult for teledermatology consultation, including patients who want a total body skin check and people with hair lesions.
The Teledermatology SIG, in the paper “Summary of the Status of Teledermatology Research,” comments that the diagnostic reliability of teledermatology is backed by the largest and strongest body of research within teledermatology. The paper states: “The evidence shows that teledermatology consultations, whether using store and forward or real-time interactive techniques, result in highly reliable diagnoses that compare favorably with reliability found in conventional clinic-based care.” 4
In a third study, Armstrong is interviewing teledermatologists in California about the advantages and disadvantages of teledermatology and about reimbursement issues, which continue to be challenging for the field as coverage varies among states and providers.
“Education is key because a lot of insurers are still not aware of the real benefits of teledermatology,” Armstrong said. “Lack of reimbursement is often from a lack of knowledge, so it is important to educate insurance companies. It is also important that teledermatology not be carved out as something different, but as part of dermatology services and not separating out good medicine and provision of care. If people interpret it like that it will be more accepted.”
Considering a Teledermatology Program?
Hon S. Pak, M.D., chief information officer at Army Medical Department, Falls Church, Virginia, has extensively written about issues to consider when implementing a teledermatology program. 5 –7
“Facilities considering teledermatology programs have to ask what their main purpose is for considering such a program. What problems are you trying to solve? What are you trying to achieve?” says Pak. “Some are trying to distribute their services and others are trying to grow their market. Most importantly, you need to understand the setting of the referrals. You will lose trust if you don't have an understanding of the context of the environment that you are practicing in.”
For More Information
American Telemedicine Association. Teledermatology SIG. Available at
Armstrong AW, Sanders C, Farbstein AD, Wu GZ, Lin SW, Liu F-T, Nesbitt TS. Evaluation and Comparison of Store-and-Forward Teledermatology Applications. Telemed e-Health
Whited JD. Economic analysis of telemedicine and the teledermatology paradigm. Telemed e-Health
Edison KE, Chance L, Martin K, Braudis K, Whited JD. Users and nonusers of university-based dermatology services following a teledermatology encounter: A retrospective descriptive analysis. Telemed e-Health
Armstrong AW, Dorer DJ, Lugn NE, Kvedar JC. Economic evaluation of interactive teledermatology compared with conventional care. Telemed e-Health
Pak HS, Datta SK, Triplett CA, Lindquist JH, Grambow SC, Whited JD. Cost minimization analysis of a store-and-forward teledermatology consult system. Telemed e-Health
Pak states that once the context is determined then we have to ask what modalities will be used and says, “If you have a core access problem then you might use a virtual staff for areas in the regions that need that access. You also have to determine if you are going to use live-interactive or store-and-forward, and then you have to ask, ‘what are the resources needed to make sure this works?’ For instance, someone—such as a consult manager or a primary care person—has to package the patient on the remote side and then submit that information. In teledermatology you are shifting the packaging from the specialty to the referral side.”
In terms of specific training for teledermatology, Pak says that dermatologists probably need only a few hours of system training and training on the art of teledermatology. “It's really more of a comfort level that improves with time,” Pak said. “Initially you may ask for more biopsies and referrals. It's really just a different way of doing what you already do.”
But on a deeper level, and on the art of teledermatology, Pak adds, “Every day when we see patients we have to be detectives, and even if you have all the history and information that you need, you focus on certain information more heavily. This is more acute in teledermatology, so how do you take the information without the patient and make the best out of it?”
Pak states that because of this constrained environment there are other things a teleconsultant can do for the best outcomes, such as making sure all of the right questions have been asked on the PCP side and to be aware of treatments or procedures that have already been provided so that there is no duplication of recommendations.
“It is really about understanding the nuances of the PCP setting and how you build relationships,” Pak said. “Most programs are successful when they have a very solid relationship with the PCPs who are sending the consults. If you have no idea where an answer is coming from then you don't have the needed level of trust. This is true in medicine in general but also in telemedicine.”
Fortunately, there are plenty of resources for people getting started in teledermatology through the ATA and the AAD.
“You can contact professional organizations and ask for help and resources, and you can find out what teledermatology is and what it isn't,” Pak advises. “Some of the people interested in teledermatology, for instance, are stay-at-home moms who want to practice and need flexibility. Teledermatology is a field that may offer both, and generally you find out about these types of opportunities through networking.”
In the Future
In terms of the future, Armstrong envisions that teledermatology will not only meet the healthcare needs of underserved and rural communities, but also the challenges facing our healthcare system. She believes that the field of teledermatology will continue to grow because of cost savings, and advancement in technology will make it increasingly satisfactory for assessment and management.
“There will always be people who want to see the dermatologist in person, but the younger generation, which is text savvy and used to communicating with technology, will be more accepting of this modality,” Armstrong said.
Poropatich says that the popularity of mobile devices along with the pervasiveness of patient-centered medical homes may lead to the eventual scenario of patients directly consulting with providers.
“This isn't that far off,” Poropatich said. “The challenges will be sending that information to a central site with dedicated providers to answer the consults and documentation of clinical care in the patient electronic health record. If a provider uploads the image, there has to be a note to say that happened. I don't think regulatory issues will pose a problem.”
Teledermatology is also making its way into medical education, and Burdick envisions that current dermatology residents will be using teledermatology as part of their standard practice and that part-time and retired dermatologists will help fill the specialty gap using teledermatology.
Pak agrees and adds that involving residents in teledermatology is a smart way to both add to and evaluate their knowledge.
“In store-and-forward teledermatology the residents have to show the logic of their thought process and their differential and have to document this fully,” Pak said. “With teledermatology, residency evaluations can be done very objectively as the residents have to be more self-sufficient and are not relying on the cues of those around them. Interestingly, it is a consistent way of evaluating their skills and knowledge, so in that way the use of teledermatology can be an asset to residency programs.”