Dermatology World October 2011 : Page-24

CROSSING BY  JOHN CARRUTHERS , STAFF WRITER 24   Dermatology WorlD  // October 2011  // October 2011



Leaps in technology have the ability to bring great change to any field. Teledermatology, which once relied on coordination between patients, their primary care providers, and dermatologists, along with expensive equipment and broadband, is now easily accessible in some of the world’s most remote and underserved areas. As dermatologists continue to strive toward specialty care for vulnerable and remote populations, mobile phones, email servers, and cellular networks may provide a lifeline for patients in need.

As recently as a few years ago, live teledermatology was the accepted standard for treating patients remotely. Specialists would coordinate with a physician or clinician in a remote location to see patients brought in for the occasion, and the dermatologist would direct the remote clinician’s use of the camera or make inquiries to the patient. With so many variables — patient, clinician, and specialist scheduling, equipment use and training, and the reliability of broadband networks in remote locations — it often proved a frustrating endeavor. Even store-and-forward teledermatology, where a referring physician sends photographs of the patient over email or through the Internet, was beset by expensive equipment requirements, a lack of standardized training, and issues of broadband and hardware.

At present, store-and-forward teledermatology has become much more available and reliable, according to William D. James, M.D., immediate past president of the American Academy of Dermatology, who made expanding care to underserved patients through teledermatology a high priority during his time in office.

Teledermatology, he said, could help mitigate the workforce shortage by eliminating muchdiscussed geographical distribution problems.

“I think that this way of seeing patients that separates both time and distance is really expanding. The use of store-and-forward dermatology is becoming more widespread. I think that people are looking at it for the future as a way to help dermatologists to be more efficient in seeing patients,” Dr. James said. “There’s a problem with patients getting in to see dermatologists, and if we’re able to see, for instance, follow-up patients by using teledermatology, if we’re able to extend our reach to vulnerable populations either in inner cities or rural areas, I believe that teledermatology can expand our reach to more patients with the same number of dermatologists. And that’s really key in our present situation.”

Dr. James remains convinced that teledermatology has a large role in the future as a tool for triage. He published a study in Archives of Dermatology (2004; 140:525-528) comparing the opinions of teledermatologists and in-person dermatologists regarding whether growths needed to be biopsied. The goal was to ascertain whether the technology could safely be used to triage growths.

“There was 100 percent agreement in the decision to biopsy or not,” Dr. James said. “I think it’s a good tool for extending access.”

Beyond the rise of store-and-forward teledermatology as the accepted standard, mobile phone-based teledermatology has become a reality, according to University of Pennsylvania dermatologist Carrie Kovarik, M.D., who helps run the Africa Telederm Project. In fact, she said, the proliferation of inexpensive cell phones with advanced image technology has rendered this option realistic and affordable for teledermatology projects and remote practitioners in certain areas. Purchasing a phone and SIM card, she said, is much cheaper than obtaining a computer and camera (and subsequently worrying about finding an adequate broadband connection). This has not only brought additional convenience to referring practitioners, but has eliminated the equipment and broadband barriers that stood in the way of regular referrals.

“Once we scaled up the Africa Telederm Project we realized that most people in our referring countries didn’t have Internet on a computer, but they did have very good cell phone connectivity,” Dr. Kovarik said. “In 2007, the cell phone networks were pretty limited. But two years later, very good networks penetrate through the most rural areas, like Botswana, where I work the most. The carriers have 3G covering the majority of even the small towns.”

Aside from providing patients in great need with vital specialist care, teledermatology in foreign nations also serves as an incubator for ideas that may translate well to the U.S. The limits of time, funds, and geography require physicians to think in non-traditional ways to extend access and care to its greatest possible extent. As such, many of teledermatology’s biggest advances have been pioneered by physicians working in foreign nations with limited resources. This set of circumstances explains, in part, how teledermatology has moved from sometimes-spotty live teledermatology sessions to mobile smartphone applications in a matter of a few years. While the U.S. health care system has grappled with many of the same familiar problems over the last half-decade, dermatologists working abroad have figured out how to take a referral from and provide a diagnosis to, for example, a physician in rural Uganda with a mobile phone.

“What we realized was if we developed a mobile application, we could reach a lot more clinicians for sending consults. We started developing a system on mobile phones, which has over the years progressed to smartphones. The first version was fairly simple, but now it’s getting more user-friendly. We have our mobile telederm application on both Android and iPhone,” Dr. Kovarik said. “We get an email that there’s a consult from one of the phones, and it’s the same thing [as a case sent via computer]. I log on, see the case, and answer it. The answer goes back to the phone, so it’s independent of the Internet. If they couldn’t send it from the computer, they probably can’t retrieve the result on a computer.”

University of Washington dermatologist Roy Colven, M.D., who has worked on a number of teledermatology projects, agreed with Dr. Kovarik’s assertion that mobile teledermatology is the best solution so far to extending access to underserved nations. However, he notes that the U.S. has its own technology infrastructure consider. “Underserved countries have had cell phone use to a more sophisticated and greater degree than the U.S. It’s a perfect test for mobile telemedicine,” he said. “[These countries] are not going to have the money to put down broadband connections anytime soon, whereas here, we have a system in place.”

Aside from patients in underserved countries, U.S. Air Force Lieutenant Colonel and dermatologist Chad Hivnor, M.D., said that the military is able to utilize teledermatology to save vital travel distance and personnel time both in the U.S. and across the globe, including war zones.

“The technology has been beneficial in particular to get patients diagnosed and treated sooner. For our U.S.-based personnel, if someone is out in the middle of Kansas or in North Dakota, they can be hundreds of miles away from the nearest dermatologist. So to get them treatment sooner, and save time and money and travel time, if it’s something like eczema, we can get it treated sooner. It’s similar to how the technology is used in Native American centers and in remote areas of Alaska. The rapidity of a consult is a good thing,” Dr. Hivnor said. “In Iraq and Afghanistan, you may be out in the middle of nowhere with a PA or a medic. The soldiers don’t want to have to go all the way back to a hospital. We can really increase the care and the appropriate treatment. A soldier can be out there fighting the fight without having to come back to look at a rash or a bite, or any number of common conditions.” In addition, teleconsults can minimize the need to move a patient in a combat zone, greatly reducing risk in non-urgent cases.

For many patients in remote or underserved parts of the country, accessing specialist care may present a near-impossible burden. Remote patients, especially those with diminished physical or financial ability to travel, could benefit greatly from teledermatologic care to address minor issues that don’t require in-person treatment or to monitor chronic conditions without a 100-mile trip for each visit.

As part of the Academy’s pilot teledermatology initiative, a host of dermatologist volunteers and institutions are linked to free clinics, which allows referring clinicians in underserved communities to submit store-andforward dermatologic cases for specialty opinion. The program began taking shape in 2009. It has since seen more than 400 patients treated, and continues to improve mobile technology in hopes of lowering barriers even further for referring providers.

“This kind of system had worked well in Africa, and we figured we could bring it here. In 2009, we did a quick pilot in Philadelphia to show that it would be accepted and work in these clinics. We’ve scaled it up to 26 clinics in the U.S. over the last year. We’ve gotten about 400 consults, and the users are able to send cases from a phone, or they can submit part of the consults on the phone and complete the consult on the Internet portal,” Dr. Kovarik said. “Those cases go to designated dermatology groups who are partnering with the clinic. Here at Penn, we partner with two local clinics, so when they send a case, all of the doctors that answer the cases at Penn get an email and whoever logs on first and answers the case gets it. We have also built in a kind of safety net, so if a patient needs a biopsy or a procedure and they don’t have insurance, we will see them here anyway,” she said.

“Teledermatology is a method that can be used to triage patients, to be able to see if a person needs to come in, or if they could be taken care of in their referring doctor’s office,” Dr. James said. “If I can take care of some of those patients at a distance and save them all that travel time, that’s an opportunity to increase access. I can see the people that really need to see me in person, and I can help others care for those patients from their local practice. Another area is monitoring chronic problems such as leg ulcers. You can have an image sent to you every week or every other week, to see how the ulcer is closing. It could be a great help to patients who may not be so mobile.”

At present, Dr. James said, the project runs at capacity. But he hopes that soon, it will be able to take on more dermatologist volunteers and primary clinics to further extend the network of dermatologic care.

A few challenges remain for proponents of teledermatology. By and large, Dr. Colven said, they remain the challenges that teledermatology has faced in the past.

“There’s going to be more widespread adoption of telemedicine in this country, but I believe the barriers to adoption have remained the same. It’s concerns over liability, it’s deciding who’s going to pay for it, and it’s how it’s going to count versus an in-person encounter. There are also interstate licensure considerations. Those things haven’t changed a whole lot,” Dr. Colven said. “The Veterans Administration is one exception where people are treating patients in another state who are still part of the VA system. So they’ve made headway using the health system to overcome the interstate issues. Hopefully that sets an example.”

Pigmented lesions, Dr. Hivnor said, remain a particular problem best addressed in person. In addition, he said, a diagnosis is only as good as the information that goes into it.

“As far as the downside, you’re at the mercy of the person giving you the information. If they don’t include all of the history, you may not connect all the dots. If they show you a whole bunch of pictures but don’t give you the background, it can be hard to make conclusions,”

Dr. Hivnor said. “We had a patient where we were sent six or seven different pictures for a ‘cancer screening,’ which was not appropriate. They were all benign keratoses. But they didn’t take a picture of a 2-centimeter basal cell, so we didn’t know that the patient had it. You’re at the mercy of the information you have. It can be hard to make the appropriate diagnosis.”

Payment for teledermatology remains a sticky scenario. Technology has outpaced the health care system’s ability or willingness to pay for its proliferation. At the moment, only a few payers in certain states, such as Alaska, offer reimbursement for telemedicine, and even then, usually only for specific live telemedicine consults. The AAD Telemedicine Task Force, Dr. Kovarik said, remains committed to finding a solution beneficial to all involved.

“We feel like with the evidence that we get from this work, we may have more information going to Medicare and Medicaid and show them that this demonstrates cost savings, that it’s effective, it’s a way to get specialty consults for patients that they weren’t going to get before or that would cost a whole lot more money before,” she said. In its recent comment letter regarding the proposed 2012 Medicare fee schedule (see p. 7), the AADA urged CMS to include teledermatology on its list of approved telehealth services.

Privacy is also a concern, given the portable nature of mobile devices, according to Dr. James. Vendors have to do extra work to make sure that pictures are transmitted securely, and captured and stored in a way that doesn’t leave patient pictures in the phone’s gallery.

Even considering the challenges, according to Dr. James, teledermatology should prove to be an effort multiplier for committed dermatologists and a lifesaver for thousands of patients in need. “The longer we are in the digital age, and the more people get used to it, and the more tools that are available,” he said, “the more we’ll be able to use it to improve treatment for patients.”

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