Who, and What, Are They Seeing?

Dr Stavert and his team have also been able to perform a review of their initial 3500 teledermatology cases; they have now conducted more than 7,000 teledermatology consults. Their review found the following:

*Approximately 60% of the consults have been for women


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*Approximately 50% of the consults are for rashes or inflammatory conditions

*Approximately 30% of the consults are for discrete or specific skin lesions

*Approximately 20% of consults represent a mix of acne, rosacea, nail changes, and pigmentary disorders 

Colleague Conduit

“Teledermatology has served as a conduit for us to interact in a new way with our primary care colleagues, and has helped improve care for our patients,” Dr Stavert said. Indeed, in the Cambridge Health Alliance system more than 270 unique providers have submitted teledermatology referrals. 

The review also revealed very high levels of diagnostic and management discordance between referring providers and teledermatologists. That is, in the majority of cases, the teledermatologist disagreed with either the presumed diagnosis or with the management plan of the referring provider. “What that’s telling us,” Dr Stavert said, “is that these [teledermatology] consults were really adding a lot of value to many of these cases and were changing the course” of the patient’s treatment.

The same review also revealed diagnostic and management concordance for patients with a teledermatology consult who were then seen in the clinic, providing an internal quality control. The review noted a greater than 90% agreement for diagnosis and management. In a study published in the Journal of the American Academy of Dermatology, Dr Stavert and colleagues demonstrated a measurable difference in dermatologic knowledge, based on their performance on a dermatology quiz, for providers who are using the Cambridge Health Alliance teledermatology platform.3 This difference correlated with how frequently primary care physicians used the teledermatology service; that is, clinicians who used it more frequently showed the greatest improvement in dermatologic knowledge.3 This value to colleagues is reinforced by the steadily rising number of consults Dr Stavert’s team sees, currently at 250 to 300 a month and increasing.

The Greatest Challenge: Melanoma

The melanoma consult can present a challenge, Dr. Stavert said, as the demand for dermatology appointments outstrips the available appointment slots, despite increases in staffing, leading to access challenges for patients.

The priority that a “rule out melanoma” referral receives has fostered a “boy who cried wolf” phenomenon in that the vast majority of cases that are seen in the clinic are not melanomas or even suspicious for melanoma. 

However, the teledermatology platform allows the dermatologist to lay eyes on these referrals before the patient is booked into the clinic. This allows for much more efficient triage, as lesions that appear to be higher risk can be expedited and the patient seen in clinic quickly. Patients whose lesions are reviewed and felt to be lower risk can be seen in the clinic on a less urgent basis to confirm the suspected diagnosis. For approximately two-thirds of the referrals, photos and patient history provide enough information for the teledermatologist and the patient does not need be seen in the clinic, improving access for more patients who need to be seen. The clinicians also found that when patients first have a teledermatology consult, they complete their appointments at twice the rate of patients who did not have a teledermatology consult but who “came through the traditional referral mechanisms.”

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Why? Dr Stavert posited his theory: patients with higher risk lesions place greater value on the appointment because a physician has already “laid eyes on” their dermatologic issue and suggested they be seen in the clinic. This allows his team to use onsite appointments efficiently. Through the initial teledermatology consultation and follow-up with biopsy, his team has diagnosed more than 75 skin cancers. 

Acknowledging that patients in safety net healthcare systems often face many barriers to accessing prompt dermatologic care, Dr Stavert reiterated that teledermatology can improve the dermatologic knowledge of referring providers and improve access challenges. Teledermatology is demonstrating a significant “change and clinically meaningful impact in the patients that we’re serving” because it has helped his team provide prompt access to dermatologic expertise.

References

1. Mulcahy A, Mehrotra A, Edison K,  Uscher-Pines L. Variation in dermatologist visits by sociodemographic characteristics. J Am Acad Dermatol. 2017;76(5):918-924.

2. Centers for Medicare & Medicaid Services. Medicare-Medicaid Accountable Care Organization (ACO) Model. http://innovation.cms.gov/initiatives/medicare-medicaid-aco-model. Updated June 26, 2017. Accessed October 29, 2019.

3. Mohan GC, Molina GE, Stavert R. Store and forward teledermatology improves dermatology knowledge among referring primary care providers: a survey-based cohort study. J Am Acad Dermatol. 2018;79(5):960-961

This article originally appeared on Dermatology Advisor