New York, New York — Ever expanding and evolving, telemedicine is most commonly a means of physician access for those living in remote areas with limited access to medical care or facilities. It provides patient-to-doctor consults to a population who otherwise might not have that opportunity.
A different application of telemedicine — the physician-to-physician teledermatology consult system — has been employed with great success by Robert R. Stavert, MD, MBA, and his colleagues, Dianne De Leon, MD, and Ahou Meydani-Korb, MD. Dr Stavert reviewed their program at a meeting of the American Academy of Dermatology.
The teledermatology program at Cambridge Health Alliance, an academic community hospital system north of Boston serving nearly 140,000 patients, was piloted in 2013 and launched in 2015 after collaborative efforts from the facility’s information technology department and the primary care and dermatology divisions. It is considered a safety net healthcare system. Dr Stavert explained that more than 50% of patients are nonwhite, more than 25% are non-English speaking, and more than 50% are Medicaid recipients.
Cambridge Health Alliance also functions as a Medicaid-accountable care organization and is therefore incentivized to provide care while keeping costs reduced and maintaining high levels of clinical quality. The facility also strives for high patient satisfaction and patient experience reports.
Specialty Care and Cost
Patients of lower socioeconomic status in the United States often face barriers to accessing specialty care.1 When their teledermatology service began in 2013, “The biggest motivator was to try and improve access to specialty care for our patients,” Dr Stavert said. Secondarily, his team sought to educate and support their primary care colleagues in the management of patients at lower risk for dermatologic diseases through the telehealth modality, allowing those at higher risk for dermatologic disease to be seen in the office by the consulting dermatologist.
In addition to ensuring a high level of clinical quality, the clinicians wanted patients who were clients of their accountable care organization to continue receiving care within the organization.
“When patients leave our system to seek care elsewhere — when they don’t have access to the care that they need or the wait times are very long — it tends to be far more expensive than when they receive it within our institution,” Dr Stavert told Dermatology Advisor. Negotiated contracts between the hospital systems and the payers mean to that Cambridge Health Alliance then pays a high cost for patients receiving care outside of their system, according to the Medicare-Medicaid Accountable Care Organization (ACO) model, he explained.2
Cost savings is a motivator not only for Cambridge Health Alliance but also for patients. For any patient, but especially for patients of lower financial status, taking time off from work, transportation costs, and childcare coverage can affect their finances and create additional barriers to accessing care, Dr Stavert pointed out. Teledermatology can greatly reduce or eliminate these considerations for many patients.
A Different Model
Dr Stavert’s team employs a store-and-forward or e-consult model of teledermatology, although the workflow differs from the traditional patient-to-physician model. The majority of Cambridge teledermatology referrals come from primary care colleagues who send photographs of their patients to the clinic’s electronic medical record system. Photos are uploaded into the patient’s chart in the electronic medical record, and the primary care provider submits an electronic referral with the consult question and relevant information. Referral and photos are routed to an in-basket managed by Dr Stavert, Dr De Leon, and Dr Meydani-Korb.
Consults are reviewed as they arrive, and a consult note with diagnosis and management recommendations is generated within 24 to 48 hours; once returned, the referring primary care provider is responsible for communicating recommendations to the patient. Typically, the teledermatologist does not have direct interaction with the patient and does not prescribe medications or give advice. These tasks are managed by the referring primary care doctor.