Teledermatology: Benefits, Types and Implementation
This whitepaper outlines the key things to consider when implementing telemedicine between patients and dermatologists.
What is Teledermatology?
Teledermatology is the term commonly used for telehealth (telemedicine) carried out in dermatology and covers the delivery of dermatology care through modern electronic or digital forms of communication1.
It is one of the areas of telehealth that is most developed because most skin diseases are visible and can be photographed or filmed for a healthcare provider, such as a dermatologist, for remote diagnosis, assessment, and management recommendations.
Benefits of Teledermatology
In the era of smartphones and the ease with which you can photograph the skin, online dermatology is one of the areas in medicine that can potentially benefit from innovative telehealth implementations2.
In the right setting and context, diagnosis and disease management can be facilitated through teledermatology. It can be a cost-effective approach to pre-screen patients and determine which patients need to be seen in person and which patients can be prescribed new treatment without a physical visit.
Therefore, teledermatology can facilitate increased patient convenience, access to care if a physical visit is not possible, reduce wait times, make scheduling of dermatologists more flexible, and lower healthcare costs3 4.
Teledermatology can be a way for new patients to be able to see a dermatologist, especially in rural areas with a lack of providers and large distances between patients and clinics. Management of existing patients with a previous relationship with the dermatologist and a prior diagnosis and treatment plan may be an even more fruitful approach for teledermatology consultations. Patients with chronic diseases such as eczema, acne, and psoriasis often require many follow-up visits for complex treatments and some of these follow-up visits could occur remotely5.
Teledermatology may also benefit patients at risk of developing skin cancer or patients with a previous skin cancer diagnosis. Some patients require annual mole exams. Teledermatology could complement these consultations, leading to increased patient participation, satisfaction, and reduced cost6. It can be particularly helpful to the dermatologist if the patient has a well-documented photographic history of their skin, such as close-up photos of atypical moles and large body areas, to help evaluate for changes in skin lesions.
Types of Teledermatology
Teledermatology can be characterized based on who participates in the online dermatology consultation, the mode of communication that is employed, and the clinical objective of the consultation.
Types of Teledermatology
- Participants in Teledermatology (Primary, secondary, tertiary)
- Teledermatology modes of communication
2.1 Real-Time Synchronous Modes (Voice calls, Live Video Interaction)
2.2 Asynchronous Modes (Store-and-Forward teledermatology)
2.3 Real-time Video vs. Store-and-Forward
- Clinical Objectives in Teledermatology
3.2 Follow-up consultations
1. Participants in Teledermatology
With regards to the participants in a consultation, primary teledermatology covers direct communication between a patient and a healthcare provider such as a dermatologist. Secondary teledermatology describes communication between healthcare providers. For instance, a general practitioner may request a specialist consultation from a dermatologist in secondary teledermatology. Lastly, tertiary teledermatology refers to a telehealth collaboration between dermatologists, often to seek a second opinion or to obtain consensus7.
2. Teledermatology modes of communication
In the different modes of teledermatology, transfer of audio and visual information along with patient data (such as patient-reported information or data from the patient’s electronic health record) can be utilized.
It can be delivered synchronously between the participants (i.e. a real-time conversation between patient and dermatologist (live-interactive teledermatology or videoconferencing) or asynchronously at different points in time.
2.1 Real-Time Synchronous Modes
The simplest and most widespread form of teledermatology in practice today is a simple voice call via the telephone. This allows the practitioner and patient to quickly exchange information. Given the lack of visual information (images/video), its use for diagnosis, assessment, and management is limited and very rarely meets the criteria for reimbursed teledermatology due to the lack of physical examination and verifiable disease. Therefore, most teledermatology employs visual data implemented into practice for accuracy and quality assurance.
Live Video Interaction
Live video interaction is a popular mode of communication in telemedicine and has been thoroughly researched for implementation in dermatology. It offers the same voice interaction between the participants as on the telephone and the live camera can be directed towards a rash or skin lesion for visual inspection in real-time. In most cases, it lacks the quality of high definition still images in particular because patients’ internet speed may not be able to support a full high-definition video consultation.
2.2 Asynchronous Modes
In ‘store-and-forward’ teledermatology images or video are transmitted to allow for a consultation to happen asynchronously. It allows the participants to not only communicate at a distance but also at different points in time. A consultation typically happens with a series of high-quality images and relevant patient information being sent for remote evaluation.
Given the flexibility of the asynchronous nature of store-and-forward teledermatology, it is the most promising and convenient variant of teledermatology. It does not require scheduling for the provider and patient to be available at same time. It allows for more efficient use of a providers’ scarce time since they are not waiting for patients to present and avoids “no shows,” which can be a big issue in healthcare systems with long wait times for access.
Within store-and-forward teledermatology, teledermoscopy utilizes a dermatoscope attachment to the camera to acquire optically magnified images. These images often have a zoom level of 20x and yield more information for the remote evaluation of images performed by a specialized professional trained in dermoscopy, such as a dermatologist.
2.3 Teledermatology: Real-time Video vs. Store-and-Forward
Live video interaction between a medical practitioner and a patient is currently the most commonly reimbursed form of teledermatology since video is an already commonly reimbursed telehealth solution in other medical fields.
Store-and-forward telehealth services may be a better solution in dermatology and are also reimbursed. Some of the advantages of store-and-forward over real-time are that it works on any internet connection speed and does not require appointment scheduling between the patient and provider for more flexibility and convenience for both. It can, therefore, help reduce wait times8 9.
There is evidence that store-and-forward teledermatology in the right setting can be more cost-effective, especially when used as a triage mechanism to reduce face-to-face appointments and in rural settings10.
A cost-effectiveness study demonstrated that store-and-forward teledermatology achieved high patient satisfaction and afterwards no evident increased utilization or further post-consultation costs11.
3. Clinical Objectives in Teledermatology
The patient’s first consultation with a dermatologist and the establishment of the patient-doctor relationship often takes place face-to-face. For some patients, if a face-to-face appointment for the first consultation is possible, this may be the preferred choice. However, if there are long waitlists or travel distances more, patients may be able to be seen remotely as a first consultation, depending on the objective of the consultation and treatment need.
Teledermatology consultations can help make dermatologists’ schedules more efficient for the patient and the dermatology clinic through efficient triage and care follow-up.
Triage is a common telehealth strategy whereby qualified healthcare providers assign urgency and potentially preliminary care to patients and sort them based on their reported signs or symptoms. It is often carried out via telephone and the healthcare professional evaluates the presented concerns and recommends a management course for the patient12.
In many medical specialties, a patient can reasonably communicate their symptoms via the telephone, and telephone triage can be used to screen for patients in critical need of care. Dermatology is different because patients cannot adequately describe visual signs on their skin and patient concerns seldom require urgent intervention or an emergency room visit13.
For increased efficiency in dermatology triage, patient-recorded images can play a very important role to determine a preliminary diagnosis of common dermatological skin problems. This can result in remote initiation of treatment or confirm the need for physical face-to-face consultation for further evaluation and management.
3.2 Follow-up consultations
Telehealth may allow for easier follow-up consultations for patients far away from their dermatologists in addition to prioritizing the need for in-person follow-up. A telehealth solution can maximize efficiency of the dermatologists’ time and resources while still providing necessary care through remote access.
Follow-up dermatology consultations can be done asynchronously through a ‘store-and-forward’ solution and then in real-time via video or on the phone after the patient has pre-recorded high resolution images that the healthcare professional can view during the live consultation.
Telehealth and Dermatology Guidelines
When implementing a teledermatology service, there are a number of elements that need to be considered.
Organizations, such as the American Medical Association, American Academy of Dermatology, and the British Association of Dermatologists, have published guidelines for telehealth and teledermatology. There are likely similar guidelines in most other countries.
United States COVID-19 Note: The US public health emergency following the COVID-19 pandemic has led to a temporary relaxation of the American Academy of Dermatology’s Position Statement on Teledermatology (SOURCE). Similarly, HIPAA has also been relaxed during the pandemic. Temporary lifts of regulations in telehealth may have been carried out in other countries as well (SOURCE).
Besides acknowledging the teledermatology and telehealth services guidelines recommended in your own country, below are some key elements to consider when implementing your teledermatology program.
Commencing a teledermatology program
1. Usability is key
When creators of digital experience talk about usability, they mean that the process for the end-user (patient/provider) should be clear, understandable, and well structured. This is often an area that is overlooked because creators of telehealth systems are often medical, legal, and technical experts who tend to focus more on their areas of expertise and less on the user experience.
It is vitally important to get user experience right. Even a strategic teledermatology program will fail if patients and providers do not find it convenient to operate in practice. Whether it is a teledermatology app-based solution for phone or desktop or a web-based solution, user experience is key.
2. Make a commitment to quality
It is also important to make sure that the quality of the technical implementation is sufficient. There are three areas that are very important to consider:
- The system should be well-tested. Nothing is more annoying than experiencing a glitchy and error-prone platform. Users will quickly lose motivation if there are too many interruptions and annoyances in the experience.
- It is important that data is securely captured and not lost in the process since vital information is handled through telehealth and findings may not be reproducible.
- If the platform captures photos or videos, the clarity and quality of the digital images or video stream are important. In mobile-based dermatology (mobile teledermatology), video streams can be problematic due to poor data connections that cause the video to be unclear and useless. An image-based store-and-forward solution may enable the dermatologist to get a better view of a rash or lesion on the skin than a video-based solution.
The good news is that the camera quality of newer smartphones more than meets the requirements set out in recommended guidelines. It is important that images are taken in proper lighting conditions and at the right distance from the skin. A well-thought-out teledermatology application can enable users to take useful photos with the help of state-of-the-art computer vision and artificial intelligence.
3. Ensure patient data privacy
In any health solution, including telehealth, patient data privacy is very important. Data or information privacy is the right for the individual to know what type of information is being collected, for what purpose the information is collected, and freedom from undesired intrusion of your data. Data privacy is dealing with proper and transparent handling, processing, access, storage and usage of your private data.
Data shielding and security is how the data privacy is enforced to secure your privacy and the prevention of unwilling intrusion. This includes:
- Storage encryption
- Transport encryption
- Network security
- Identity management and secure authentication
- Access control and audit logs
- Breach response
In the USA, health information is protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA is a federal law enforced by the US Department of Health and Human Services (HHS) that protects sensitive patient health information from being disclosed without the patient’s consent or knowledge.
In the European Union, patients’ data privacy is protected by the General Data Protection Regulation (GDPR) but it’s important to pay attention to the additional requirements that may apply around sensitive health information, such as strict adherence to patient consent and extra high focus on data shielding and security.
4. Gather the correct patient consent
Patient data consent is essential when securing data privacy and can be a transparent, informative, and elegant solution to explain how and what your data is used for before processing the information in a teledermatology context. Before any patient-recorded images or other information are used for a teledermatology consultation, it is important that the patient gives explicit consent for the intended use of personal images for his or her care.
5. Coordination with existing care team
Whether a patient has a consultation directly with their own healthcare provider or a third party teledermatology provider, it is important that all relevant information about the teledermatology consultation can be relayed back to the patient’s record and the existing care team. Similarly, teledermatology requires adequate patient history for the consultation. Given these demands, teledermatology may best be delivered by the patient’s own healthcare provider instead of a stand-alone independent teledermatology service operating in parallel to the patient’s existing care team.
6. Now is a good time to start
Since the onset of the COVID-19 crisis, many clinics have implemented teledermatology video consultations through well-known platforms like FaceTime and Zoom. This enabled the clinics to resume some consultations and patients to be able to remotely see their doctor again to receive care. Solutions like FaceTime and Zoom may be reimbursed by some health insurers during this crisis, but critically high-quality patient-recorded still images may be a much-needed add-on for such consultations. The ability to offer a user-friendly and affordable ‘store-and-forward’ teledermatology solution to patients could therefore be beneficial for many providers, both during the pandemic and beyond.
The anticipation is that teledermatology will remain highly relevant and a necessary element of any future dermatology service.
For healthcare providers looking to launch a store-and-forward teledermatological service for their patients please contact Miiskin to learn more about how the HIPAA-compliant Miiskin PRO service can be implemented in your practice.
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