Transitioning to teledermatology over night
Answers in Practice
By Victoria Houghton, managing editor, July 1, 2020
Dermatology World: Tell us about your practice setup.
Dr. Perkins: In terms of what our practice looked like in the pre-crisis era, we had three main clinical sites (in New Haven, Branford, Middlebury) and one site within the Yale Health Plan, a closed system mainly for students, faculty, and staff at the university. We have 24 full-time faculty members. Yale is a huge research enterprise, so a good portion of those faculty members aren’t seeing patients every day. Across those sites, we were accommodating about 1,100-1,200 patients a week.
Dermatology World: Prior to the COVID-19 pandemic what were the teledermatology capabilities at your department?
Dr. Perkins: The issue was that we had absolutely no telemedicine services prior to the pandemic. However, our electronic medical record system did have the capability to do these telemedicine visits. We were incredibly fortunate in that the infrastructure to allow us to conduct these visits was already in place. We officially closed our offices on March 16, 2020. That weekend prior we had an emergency faculty meeting where everyone discussed the escalating pandemic and our potential response. Our New Haven office on Monday morning was scheduled to see 150 patients so it became clear to everyone that this was just not going to be safe. We made the decision to close and very quickly started looking into alternative options.
Dermatology World: How did you get started?
Dr. Perkins: Yale Medicine had a telehealth program already in place and they were very instrumental in helping us figure out what we could do. Our EHR system has a patient portal that allows patients to send messages to their doctors, request refills, and schedule appointments. They can also download an app where they can do many of those same functions, but they can also enter into a video visit with their doctor. The nice thing about this is that it is a HIPAA-compliant platform. While the federal government has relaxed regulations in terms of the software that we’re permitted to use for telemedicine for the sake of patient care, I do think that in dermatology in particular, we’re often dealing with sensitive issues or private areas of the skin and things that can be more personal. It’s nice to have that secure line of communication between just the patient and doctor.
Dermatology World: When you closed your offices and launched your EHR system’s telemedicine platform, what steps did you take to get staff up to speed on how to use the platform?
Dr. Perkins: We trained everybody. It’s somewhat intuitive if you are a person who uses FaceTime and is generally comfortable with technology. For a lot of our doctors, nurses, and staff, however, it wasn’t the most intuitive technology. We fortunately had institutional training videos that were instrumental in getting everyone up to speed. Many staff members downloaded the app themselves to experience the process and be better able to guide patients.
Dermatology World: How did you transition patients from their scheduled in-person visits to telemedicine visits?
Dr. Perkins: As a department, we developed a telemedicine taskforce which I lead with two of my colleagues and we developed detailed protocols for this. In our minds, while a video visit with your dermatologist is absolutely not an equivalent substitute to being in the office with your dermatologist, there are a lot of issues that can be dealt with, at least in the short term, over a video visit. Rather than going through our schedules and triaging which patients need to be seen, we took a patient-centered approach and gave every single patient who was scheduled the option to have a video visit.
Even if it says on my schedule that you’re just coming in for a total body exam — which I wholeheartedly believe cannot be accommodated through a video visit — you may have a specific lesion that you want me to look at, or you may also have some itching or psoriasis in your scalp that you want to speak with me about. If I just went through my schedule and decided to re-schedule the total body exams for six months from now, you may not get the opportunity to do that.
Dermatology World: How has the use of telemedicine affected your patient load?
Dr. Perkins: We went through established schedules using our call script and protocols to walk patients through their options and get them scheduled, if desired. Of course, not everyone wanted a telemedicine visit. That created another unique opportunity where we now had openings in schedules that we typically don’t have. That allowed us to go through some referrals or new patients who were scheduled over the next several months. We were able to reach out and move some of those appointments up. This has helped us to somewhat address some preexisting access issues.
During the height of the pandemic, we were probably only seeing 30-40% of existing patients and 10% new patients, so our overall volume was about 40-50%. That may be because patients didn’t have a concern and felt fine waiting, but it could have been that that they didn’t feel comfortable on the video.
Dermatology World: What types of cases were you able to successfully manage via telemedicine?
Dr. Perkins: In terms of the actual numbers, over about four weeks, maybe four or five patients were seen in person. Things like acne, psoriasis, eczema, and rashes can be handled reasonably well over the video visits. Telemedicine has also been a useful tool to triage patients. However, we’ve had to make some difficult decisions. In terms of skin cancers, even for melanomas they’re recommending deferring these treatments for one to three months. Our surgical colleagues put together an excellent schematic to guide us in making these decisions that breaks down: how high-risk is the patient based on their preexisting factors? How high-risk is the lesion — do you think it’s a BCC, SCC, or melanoma? Where is it — is it in a high-risk area of the body? Is it symptomatic? Is it quickly growing or painful? We’re using those criteria to figure out how emergently, urgently, or soon but not too soon the patient needs to be seen for a biopsy or treatment. This has allowed for consistency and offers clear departmental guidance.
Dermatology World: What is your system for triaging emergency patients?
Dr. Perkins: What we did as a department was create an expert panel with senior members in medical dermatology. All acute or potentially acute issues are evaluated in real-time by telemedicine first. If you’re on a telemedicine visit and you feel that the patient may need to be seen, you can discuss the case with the panel. They weigh in and help you determine if the patient needs to be seen in person. The panel also has liaisons in pediatric and surgical dermatology who can weigh-in as needed. If there’s a high-risk skin cancer lesion that needs immediate attention, our Mohs colleagues are seeing those patients for excisional biopsies depending on the clinical scenario.
Dermatology World: What have you learned about utilizing teledermatology so far?
Dr. Perkins: In doing the visits, we have continually refined our scripts and our processes. Telemedicine is not new in medicine or dermatology, and people have noted that there have been issues with both live interactive and store-and-forward modalities. One thing that has been discussed is this hybrid model where you have patients upload photos before their visit, as in the store-and-forward modality, and then you pair it with a live interactive video. We have found that’s the ideal way to do this. Real-time video quality is not that good. It’s hard for them to see what you’re seeing. Having patients have someone take a photo and send that to us to review prior to our live interactive session has become our gold standard. We have incorporated the instructions into our scheduling scripts and now send patients a message with instructions on uploading a photo, how to download the app, how to access the video visit, etc., prior to their visit.
The other thing we recently started to do, in an effort to make these telemedicine visits as much like an in-person visit as possible, is we have our MAs call the patients before the visit to “virtually room” them. They call them about 15 minutes before the visit, review their medications, allergies, and medical history, and they get them logged into the app so that they’re in the virtual waiting room and they’re ready to go for the doctor.
Dermatology World: Did you have any hiccups of note?
Dr. Perkins: I think there have been technology glitches. While we’ve always had this capability in our EHR system, I don’t know if it was prepared to handle 2,000-3,000 video visits across Yale Medicine every single day. There have been issues with the app crashing, the video working but the audio not working, and we’ve had to troubleshoot things like that. One challenge has been that patients want to access the patient portal and the visit on their computers. However, the technology is most reliable when you use a smartphone or iPad, which has a small screen and that’s a significant limitation.
Dermatology World: Outside your practice, what are you seeing in terms of the specialty’s willingness to adapt and respond during this pandemic to ensure high-quality access to care?
Dr. Perkins: The response from the dermatology community has been incredibly impressive. Everyone has really worked together. People have been sharing tips, call scripts, and their approaches. Everyone has this mantra that medicine succeeds when we all succeed. It’s been refreshing to be a part of. For us at Yale, we have benefited so much from what our colleagues have put forth. Even in casual forums, people are sharing their approaches; what works and what doesn’t. A colleague shared a website that walks patients through how to take high-quality photos whether for a rash or lesion and it’s been incredibly helpful. We’ve been sharing that with our patients and some of the primary care physicians who have been uploading photos.
There absolutely are limitations with telemedicine, and one thing that I suppose we all knew before but is now clear is that there is no substitute for the in-office visit in many cases. However, what this does allow us to do is continue to provide high-quality care while keeping our patients, staff, and communities safe.
Sara Perkins, MD, is assistant professor of dermatology at Yale School of Medicine’s Department of Dermatology. Dr. Perkins and her colleagues have submitted a letter to JAAD regarding their experiences integrating telemedicine for in-person clinics.
