Teledermatology – Access to Specialized Care Via a Different Model
Teledermatology offers near-immediate access to specialty medicine for underserved populations. Robert Stavert, MD, MBA, describes the successful physician-to-physician model his team employs at a safety net healthcare system.
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.
Who, and What, Are They Seeing?
Dr Stavert and his team have also been able to perform a review of their initial 3500 teledermatology cases; they have now conducted more than 7,000 teledermatology consults. Their review found the following:
*Approximately 60% of the consults have been for women
*Approximately 50% of the consults are for rashes or inflammatory conditions
*Approximately 30% of the consults are for discrete or specific skin lesions
*Approximately 20% of consults represent a mix of acne, rosacea, nail changes, and pigmentary disorders
Colleague Conduit
“Teledermatology has served as a conduit for us to interact in a new way with our primary care colleagues, and has helped improve care for our patients,” Dr Stavert said. Indeed, in the Cambridge Health Alliance system more than 270 unique providers have submitted teledermatology referrals.
The review also revealed very high levels of diagnostic and management discordance between referring providers and teledermatologists. That is, in the majority of cases, the teledermatologist disagreed with either the presumed diagnosis or with the management plan of the referring provider. “What that’s telling us,” Dr Stavert said, “is that these [teledermatology] consults were really adding a lot of value to many of these cases and were changing the course” of the patient’s treatment.
The same review also revealed diagnostic and management concordance for patients with a teledermatology consult who were then seen in the clinic, providing an internal quality control. The review noted a greater than 90% agreement for diagnosis and management. In a study published in the Journal of the American Academy of Dermatology, Dr Stavert and colleagues demonstrated a measurable difference in dermatologic knowledge, based on their performance on a dermatology quiz, for providers who are using the Cambridge Health Alliance teledermatology platform.3 This difference correlated with how frequently primary care physicians used the teledermatology service; that is, clinicians who used it more frequently showed the greatest improvement in dermatologic knowledge.3 This value to colleagues is reinforced by the steadily rising number of consults Dr Stavert’s team sees, currently at 250 to 300 a month and increasing.
The Greatest Challenge: Melanoma
The melanoma consult can present a challenge, Dr. Stavert said, as the demand for dermatology appointments outstrips the available appointment slots, despite increases in staffing, leading to access challenges for patients.
The priority that a “rule out melanoma” referral receives has fostered a “boy who cried wolf” phenomenon in that the vast majority of cases that are seen in the clinic are not melanomas or even suspicious for melanoma.
However, the teledermatology platform allows the dermatologist to lay eyes on these referrals before the patient is booked into the clinic. This allows for much more efficient triage, as lesions that appear to be higher risk can be expedited and the patient seen in clinic quickly. Patients whose lesions are reviewed and felt to be lower risk can be seen in the clinic on a less urgent basis to confirm the suspected diagnosis. For approximately two-thirds of the referrals, photos and patient history provide enough information for the teledermatologist and the patient does not need be seen in the clinic, improving access for more patients who need to be seen. The clinicians also found that when patients first have a teledermatology consult, they complete their appointments at twice the rate of patients who did not have a teledermatology consult but who “came through the traditional referral mechanisms.”
Why? Dr Stavert posited his theory: patients with higher risk lesions place greater value on the appointment because a physician has already “laid eyes on” their dermatologic issue and suggested they be seen in the clinic. This allows his team to use onsite appointments efficiently. Through the initial teledermatology consultation and follow-up with biopsy, his team has diagnosed more than 75 skin cancers.
Acknowledging that patients in safety net healthcare systems often face many barriers to accessing prompt dermatologic care, Dr Stavert reiterated that teledermatology can improve the dermatologic knowledge of referring providers and improve access challenges. Teledermatology is demonstrating a significant “change and clinically meaningful impact in the patients that we’re serving” because it has helped his team provide prompt access to dermatologic expertise.
References
1. Mulcahy A, Mehrotra A, Edison K, Uscher-Pines L. Variation in dermatologist visits by sociodemographic characteristics. J Am Acad Dermatol. 2017;76(5):918-924.
2. Centers for Medicare & Medicaid Services. Medicare-Medicaid Accountable Care Organization (ACO) Model. http://innovation.cms.gov/initiatives/medicare-medicaid-aco-model. Updated June 26, 2017. Accessed October 29, 2019.
3. Mohan GC, Molina GE, Stavert R. Store and forward teledermatology improves dermatology knowledge among referring primary care providers: a survey-based cohort study. J Am Acad Dermatol. 2018;79(5):960-961.
