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Despite lingering issues with access and reimbursement, the use of telemedicine in numerous specialties continues to expand. According to a recent report, there were nearly 20 million telemedicine consultations in 2014, and the number is expected to increase to approximately 158 million by 2020.1 Telemedicine often fills a critical gap in rural US areas and developing countries, where there is typically a lack of specialty physicians. However, as consumers increasingly embrace all types of communication via messaging and video chat technology, many nonrural patients are beginning to expect the ease of simply connecting online with a doctor for nonurgent medical care.
With its primarily visual focus, dermatology has proven to be especially appropriate for delivery via telemedicine, and studies have linked teledermatology to improved diagnosis and cost, as well as outcomes similar to those observed for in-person visits.2 Although the use of live interactive video is common among some specialties, the most commonly used format in dermatology is store-and-forward, in which the physician receives patient information and photos via email, usually from the referring physician.3
To learn about the variety of ways in which teledermatology is currently being used, Dermatology Advisor spoke with Joseph C. English, III, MD, professor of dermatology and director of teledermatology at the University of Pittsburgh in Pennsylvania; and Jules Lipoff, MD, assistant professor of dermatology at the University of Pennsylvania Medical Center in Philadelphia and deputy chair of the Teledermatology Task Force at the American Academy of Dermatology.
Dermatology Advisor: When did your center start offering teledermatology services, and in what format?
Dr English: In 2008, we were requested by the University of Pittsburgh Medical Center to offer inpatient consults between the main teaching facility in Pittsburgh and multiple sister hospitals throughout Pennsylvania. We now do inpatient consults with 10 of these hospitals, and we also have a telemedicine rotation for dermatology residents.
We then expanded to outpatient consults with physicians: they can go online and send photos and almost have a virtual e-visit with the dermatologist while the patient is in their office. In addition, consumers can now come straight to us through our e-dermatology service, and we can take care of them while they’re at home or wherever. This is a website that is secure in the University of Pittsburgh Medical Center firewall once the patient is logged in, and each visit costs $49. We have recently started doing follow-up visits for those patients.
Dr Lipoff: Although we are not regularly providing teledermatology services at the University of Pennsylvania, we are nearing completion of a prospective interventional study on teledermatology. In addition, we continue to support municipal health clinics and underserved populations on a charity basis: several dermatologists support a provider-to-provider store-and-forward teledermatology service called AccessDerm, a program supported by the American Academy of Dermatology to deliver dermatology care remotely and triage in-person care when needed. AccessDerm has connected providers using both a smartphone app and an internet interface. We have supported these programs for years.
We have also supported triage of dermatology patients for other clinics including the Penn Medicine student-run Puentes de Salud clinic, which primarily supports the Latino community. We are able to care for most patients without needing an in-person visit, thus speeding up the delivery of care and opening up in-person appointment spots to those who especially need them.
In addition, personally, I am a volunteer telemedicine consultant and answer consults (more than 100 since 2014) for Doctors Without Borders internationally, and I have previously supported teledermatology in programs for both Uganda and Guatemala.
Dermatology Advisor: What types of patients do you typically see via telemedicine?
Dr Lipoff: We see all kinds of patients with all kinds of skin conditions and lesions; for example, new rashes, changing moles. One patient with a changing mole had their appointment expedited given telemedicine, and thus had a melanoma diagnosed and treated faster. In circumstances such as with Doctors Without Borders, we may see severe infections and complicated cases that are uncommon in the United States.
Dermatology Advisor: What have been some of the top benefits thus far, and what are barriers or other issues related to teledermatology?
Dr English: The hardest thing is reimbursement. It would be nice if the Centers for Medicare & Medicaid Services would cover it. Store-and-forward is not covered as often as live video, but people don’t like it as much because it is still so inconsistent and less efficient. With the hospitals, we have service contracts in place that allow for a certain number of consults, with additional fees for additional consults. The service definitely saves money for the referring hospitals by preventing unnecessary admissions and helping to make the admission process more efficient when it is necessary.
Consumers should be selective about dermatology services offered through direct-to-consumer websites and mobile apps. One study found that in many cases, there was insufficient follow-up with these, and patients don’t really know who they’re getting with some of these services.2 Consumers using these apps and sites should make sure there are ways of following up and that the doctor can write them a prescription if needed.
Dr Lipoff: Telemedicine truly has the potential to expand access to healthcare, both here in the United States and globally to promote health equity. It can allow access to a subspecialist provider’s expertise generally within days, as opposed to months for in-person appointments. Many patients have difficulty making in-person appointments, given barriers from lack of insurance, insurance with limited coverage, living in a rural area or far from specialists, day care or work responsibilities, and so on. Further, patient satisfaction with teledermatology is high, and primary care providers gain knowledge and expertise in treating these conditions, and thus, over time, they may not need to consult dermatology experts as often, improving efficiency in care.
The biggest barriers to implementing teledermatology are 3-fold: concerns over liability, licensing restrictions, and reimbursement. Because telemedicine inherently introduces new kinds of relationships with patients, many are concerned about liability. Laws require that doctors have a license for the state a patient is physically located in; thus, since I have a license for Pennsylvania and not New Jersey, I cannot start a doctor-patient relationship with a patient a few miles away in New Jersey.
Still, the biggest barrier is nonreimbursement. Although in some places Medicaid and Medicare may pay for telemedicine, at least for live interactive video, and parity laws exist, insurance is generally not required to cover this. Many business models have been tried, but for now, practically, it’s difficult to expand a service, no matter how effective, if the doctors who perform it will not be paid. At Penn, we have been involved with a prospective study implementing provider-to-provider store-and-forward teledermatology service in collaboration with Independence Blue Cross, with the hope that we can find a way to make this work within the fee-for-service model.
Dermatology Advisor: What should be next steps in this area in terms of policy, development, or research?
Dr Lipoff: With time, we expect to see more and more reciprocity in licensing between different states. In addition, I am hopeful that insurance companies will be persuaded that teledermatology should be covered, as it improves access to care, while seemingly improving quality of care at minimal if any additional cost, while increasing patient satisfaction.
We are also seeing more direct-to-patient teledermatology services start up, and I think that patients want this, but it is important that quality remain a priority. When dermatologists are directly taking care of patients without an in-person relationship, patients must check for credentials to ensure they are getting reputable care. Further, it is important to keep primary care providers in the loop about such visits to prevent fragmentation in care.
References
- Business Wire. Telehealth video consultation sessions to reach 158 million annually by 2020, according to Tractica. Accessed on October 11, 2017.
- Resneck JS Jr, Abrouk M, Steuer M, et al. Choice, transparency, coordination, and quality among direct-to-consumer telemedicine websites and apps treating skin disease. JAMA Dermatol. 2016;152(7):768-775.
- Trettel A, Eissing L, Augustin M. Telemedicine in dermatology: findings and experiences worldwide – a systematic literature review [published online July 4, 2017]. J Eur Acad Dermatol Venereol. doi:10.1111/jdv.14341
