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Is your practice ready for telemedicine?

When COVID-19 became a fast-moving reality, dermatology was quick to respond to the limitations being put on doctors’ offices and patients across the nation, and telemedicine rapidly became part of the solution. In the AAD VMX session “Making Teledermatology Work,” Cory Simpson, MD, PhD, added his expertise to the mix by giving a detailed presentation about how to choose a platform that works best for dermatologists.

Consult submission and review

Dr. Simpson said cases can be submitted either straight from patients (direct-to-patient/consumer model) or from a medical provider, like a primary care physician or other non-dermatologist who needs advice regarding a particular patient (provider-to-provider or consultative model).

Simpson headshot
Cory Simpson, MD, PhD
“For store-and-forward (static photo review), whether images are submitted by patients or medical providers, you must be sure they understand what type of photographs will give you the best ability to make a diagnosis and provide a plan of action,” Dr. Simpson said. “It’s a good idea to offer them some basic instructions, such as taking a zoomed-out photo along with a close-up of a rash, marking which specific lesion they are inquiring about (it is not always obvious), or including a size reference like a ruler or a coin.” For video encounters, Dr. Simpson said it’s important that patients understand how to maneuver their webcam to show the affected areas of skin. “Knowing how to ‘flip the camera’ between the front- and rear-facing lenses is essential,” he said.

With the direct-to-patient model, dermatologists are providing advice and communicating directly with the patient, whereas in the consultative model, dermatologists give advice to another clinician, who will communicate with the patient and implement a plan. “The latter involves a partnership with another medical provider, so it tends to be less demanding of time per encounter from the specialist, as the inquiring colleague will be the one contacting patients and writing needed orders or prescriptions,” Dr. Simpson said. “However, this less direct model may leave room for error in executing a treatment plan that may be unfamiliar to a non-dermatologist. For example, for recommending potent topical steroids, it is wise to provide specific instructions, like which vehicle to choose and how much to dispense, and to set guardrails on their use, stating how often and how long to apply it and to which body areas.”

Dr. Simpson said cases can usually be viewed via any device capable of displaying clinical photographs. Some teledermatology platforms offer an app that is easily viewable on a smartphone (many allow pinch-and-zoom of pictures), which is convenient and portable; others may recommend using a tablet, which offers a larger screen size for viewing images and typing a text reply. Certain platforms work better through an internet browser on a PC, which can offer a bigger screen as an advantage for viewing detailed skin morphology, often critical for diagnosis in dermatology. “Some teledermatologists even use dual PC monitors so they can use one whole screen for image review while they type clinical notes or a consult reply on the other screen,” Dr. Simpson noted, “and this can be a real time-saver.”

Logistical considerations

Dr. Simpson said the challenge will be for dermatologists to effectively integrate virtual care through teledermatology into their existing practice. He suggested asking these questions: For live videochat, patient appointments are needed, but how will they be scheduled? Does it make sense to have a half-day or full-day clinic dedicated entirely to live virtual appointments? Or would it work better in your practice to intersperse virtual and in-person appointments? “It’s also important to know how much time will be needed per appointment on average so you can stay on time,” Dr. Simpson said. “You may want to have your staff gather the bulk of the information like history, medications, and allergies, before you engage the patient so that your time can be more focused on making a diagnosis and discussing treatment options.”

For store-and-forward dermatology (which works via asynchronous review of photos), Dr. Simpson said the timing of responding to consultations is more flexible. However, the dermatologist should establish a reasonable turnaround time to review photographs and reply to the patient or an inquiring provider with a diagnosis and plan of action. “Setting these ground rules up front will make sure patients do not have unreasonable expectations for you to reply within minutes or on your days off,” he said. “While some might prefer to keep their queue clear by replying to each consultation as it comes in, others may find it more efficient to set aside dedicated time to batch their consult replies all at once.” He added that store-and-forward consultations can be a great way to fill in unexpected gaps between patients or to utilize down-time from a no-show if dermatologists want to maximize their clinical productivity while in the clinic.

Put patients first in your plan

“It is important to tailor your teledermatology approach to your specific practice and patient population,” Dr. Simpson said. “In general, offering multiple virtual pathways will allow you to engage the most patients, but this may require more investment and flexibility on your part. For example, while some patients have access to smartphones and webcams and can engage with you via live interactive videochat, others may prefer to use their desktop to send still photos captured on a digital camera via an email-based platform.” In order to make your teledermatology efforts worthwhile, Dr. Simpson believes it is important to survey patients to find out how they would feel most able and comfortable engaging in virtual care.

Image of Simpson with patient for VMX News
“Choosing a simple, logical platform will minimize technical troubleshooting,” Dr. Simpson said.

“You certainly don’t want to make a huge investment in a fancy virtual platform only to find out your patients don’t find it convenient and decline to use it,” Dr. Simpson said. “And, importantly, don’t assume based on age that a patient won’t be able engage via teledermatology — many geriatric patients have become very adept at videochat through apps like FaceTime and actually prefer the convenience of an in-home visit.” Indeed, Dr. Simpson and Carrie Kovarik, MD, recently published a paper in JAAD offering tips for geriatric teledermatology.

Dr. Simpson said that keeping a teledermatology workflow simple is also important — fewer steps to connect will bring down the barrier for all your patients to participate in virtual care. “For example, if a patient can enter a virtual encounter through a secure link sent via text message at the time of the appointment, this leaves little room for error or no-shows,” Dr. Simpson said. “However, if a patient must download a new app, create a new username and password, complete an exhaustive pre-visit questionnaire, then follow complicated instructions to upload photos, they may be unlikely to complete the process.” No matter what platform and workflow you choose, Dr. Simpson said it’s essential to provide clear and simple instructions so that patients are prepared to effectively engage in a virtual encounter at the appointment time.

Avoiding technical issues

In order to provide photographs or live video feed amenable to making a diagnosis, patients or consulting providers will need to have a camera or a webcam that can capture images of the skin with sufficient resolution. This will depend on each user’s own equipment. “While most smartphones currently in use are equipped with a digital camera that can obtain images amenable to making a dermatologic diagnosis, some older phone models may capture images at too low a resolution to display details of a lesion or rash essential to the diagnosis,” Dr. Simpson said.

The patient’s internet connection speed may be of less importance for store-and-forward consultations; however, for live videochat encounters, the patient will need to have an internet connection (WiFi, wired ethernet, or cellular signal) that is fast enough to provide a clear live video feed. “To avoid patient dissatisfaction with the outcome of an encounter, you may want to consider including in your pre-visit instructions or consent form what the minimum image resolution and internet speed should be to prevent receiving images or video that are not clear enough to make a diagnosis,” Dr. Simpson said. “Even so, patients may still provide sub-optimal images or videos and you should have a clear policy on charges for such encounters in which you are unable to make a diagnosis or recommend a specific treatment.” In the consultative model, Dr. Simpson suggested you could teach referring providers to employ a dermatoscope attachment for a smartphone or camera. “With some simple training, they will be able to provide magnified, properly lit images of skin lesions of concern — this is especially important if you will be evaluating pigmented lesions or other neoplasms in a high-risk population,” Dr. Simpson said.

“Choosing a simple, logical platform will minimize technical troubleshooting needed during the appointment, which will allow you to see patients more quickly and avoid de-railing encounters altogether if the connection simply does not work,” he said. “If you spend the first few minutes of each appointment explaining to the patient how to change security settings to let the platform engage their webcam, this will surely put you behind schedule.” Providing clear pre-visit instructions to patients will minimize these issues, he said. “To provide the best chance for a successful virtual encounter, consider having trained staff members do a trial run with the patient’s webcam or preview the patient’s submitted photos the day before the appointment to be sure everything is optimized for you to provide a diagnosis and plan of care.”

What works best for you and your patients?

Most importantly, Dr. Simpson said, dermatologists should find a platform that they are comfortable with and that works for their specific practice and patients. He said that many telemedicine vendors offer a trial period to test out their platform and see whether it meets your needs. “If you are not interested in carrying another device and want to field consults on the go, look for a platform that you can engage using the smartphone you already keep in your pocket,” Dr. Simpson said. “If you want larger images, you may want to use a web-based platform that works via an internet browser from your desktop PC.” He further suggested dermatologists may want to inquire if there is a platform that will integrate with their existing EMR, or at least be simultaneously viewable with their EMR, so they can easily document the encounter and write orders while still engaging with the patient or while viewing their photographs. “Alternatively, it might be more efficient to use a multi-party platform in which you can have an assistant or scribe engage in the encounter at the same time to help take notes, write orders, or complete billing details,” he added.

Dr. Simpson emphasized that making platform “convenient for you and your patients” will ensure that encounters are completed in an efficient manner and that patients are satisfied with the virtual care they receive.

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