In this increasingly digitized society, telemedicine represents a rapidly expanding field with recent advancements in the quality, accessibility, and transmissibility of photographs and videos.1–4 Previous studies have demonstrated the reliability and validity of dermatologic care via telemedicine, which has been shown to produce comparable, if not improved, clinical outcomes as conventional consultations.5–7 In particular, telemedicine is emerging as an innovative tool for surgical specialties. Previous studies have demonstrated the utility of telemedicine in plastic surgery for facilitating postoperative care,8 managing burn wounds,9,10 and evaluating trauma patients.11 Similar studies within otolaryngology have shown the value of telemedicine in triaging otology patients,12 providing tele-endoscopy13 and video-otoscopy,14 and performing postsurgical follow-up.15 Several review articles have been published demonstrating the applications of telemedicine within these other surgical specialties.16–19 However, to the authors' knowledge, a review on the use of telemedicine has yet to be published within the dermatologic surgery literature. The authors aim to fill this gap by providing a summary of the diverse applications of telemedicine in the field of surgical and cosmetic dermatology.
Materials and Methods
A comprehensive search with no set date range was conducted in July 2018 in the PubMed database for articles published on telemedicine in dermatologic surgery. The search was conducted with the following parameters: “telemedicine” OR “teledermatology” AND “dermatologic surgery” OR “cosmetic dermatology” OR “procedural dermatology” OR “Mohs surgery” OR “telepathology.” Exclusion criteria included non-English language, reviews given lack of novel data synthesis, and nonrelevance to dermatologic surgery or cosmetic dermatology. If the article was deemed relevant after title and abstract review, the text of the entire article was further examined to ensure eligibility. The bibliographies of relevant articles were searched for additional references.
The initial literature search identified a total of 156 articles (Figure 1). Of these, 131 were excluded based on their titles and abstracts. The full texts of 25 articles were reviewed, and 14 articles were excluded after assessment of the entire article. Ultimately, 11 articles met inclusion criteria: 2 in referral and consultation,6,20 5 in telepathology,21–25 2 in intraoperative uses,26,27 and 2 in postprocedural care.28,29Supplemental Digital Content 1, Table S1, http://links.lww.com/DSS/A257 provides a detailed summary of the reviewed articles, including the objectives, methods, interventions, results, and conclusions of each study.
Referral and Consultation
Given the highly visual nature of dermatology, telemedicine lends itself particularly well to dermatology. This feature combined with the continuous expansion and ease of use of mobile technology provides context for the articles included in this review. The authors seek to highlight the applications of this technology within dermatologic surgery to ultimately improve patient care and management.
Store-and-forward (SAF) teledermatology systems have been previously shown to be effective for patient referrals in general dermatology clinics.30,31 This review includes 2 articles6,20 that depicted similar benefits of SAF teledermatology in surgical dermatology clinics. In a study by Ferrandiz and colleagues,20 new patients presenting to their general practitioner (GP) with a clear-cut diagnosis of nonmelanoma skin cancer or rapidly growing vascular tumor were referred for dermatologic surgery via teleconsultation, which consisted of 2 digital images and clinical information. Notably, lesions expected to require a major reconstruction (e.g., large grafts or flaps) were excluded. After the images and clinical information were evaluated, a report was returned to the GP with the likely diagnosis, preoperative instructions, and scheduled surgery date. On the day of surgery, the patient was examined by the dermatologic surgeon, and if no contraindications were found, the patient was immediately operated on. Ferrandiz and colleagues demonstrated that teleconsultation as a presurgical management tool allowed the surgeon to prepare and plan treatment (surgical technique, type of anesthesia, outpatient vs inpatient surgery, etc.) with a relatively high degree of accuracy of telediagnoses (κ = 0.86; 95% confidence interval [CI], 0.83–0.89) and agreement rate between the planned and performed surgical technique (κ = 0.75; 95% CI, 0.71–0.79). Especially with the increasing quality of digital images, SAF teleconsultation enables the surgeon to not only distinguish between benign and suspicious cutaneous growths in most cases to reach a clear diagnosis of skin cancer but also anticipate the type and extent of surgery needed and thereby prepare accordingly before the procedure.
Furthermore, Ferrandiz and colleagues20 found that SAF teleconsultation decreased the number of unnecessary visits to the hospital for patients while significantly shortening wait times to surgical intervention. This is especially useful for patients with physical limitations, disabilities, or geographically distant locations. Within general dermatology32,33 and plastic surgery,9,34 telemedicine has been previously shown to increase access to care, especially in remote and rural communities. Given that most specialist care is limited to large urban centers, telemedicine, which connects individuals without regard to distance, may help reduce access barriers to surgical dermatologic care by minimizing the number of distant clinic visits, ideally to a single visit for the actual procedure.
In addition, SAF teleconsultation was found to decrease waiting intervals to surgery (mean 26 vs 61 days, p < .001) with lower cancellation rates of scheduled operations (mean 3% vs 9%, p < .005), perhaps as a result of the continuous and direct contact among the patient, primary care physician, and dermatologic surgeon enabled via teledermatology.20 Hsiao and Oh,6 who retrospectively analyzed and compared patients referred via SAF teledermatology to conventional consultation at a Veterans Affairs dermatologic surgery clinic, corroborated that skin cancer patients received faster initial evaluation (4 vs 48 days, p < .0001) as well as earlier definitive biopsy diagnosis (38 vs 57 days, p = .034) and surgical treatment (104 vs 125 days, p = .02) when referred via the SAF teledermatology system. Previous studies have shown similar reductions in wait times and cancellation rates with SAF telemedicine referral systems in general dermatology35 and otolaryngology clinics.36
In the cosmetic dermatology setting, SAF or video teledermatology may be useful for initial preprocedural screening.37,38 However, although teledermatology is helpful as a screening tool, in-person evaluation before actual cosmetic treatment remains crucial. Cosmetic patients are a challenging population, and in-person interactions are critical for shared decision making and setting realistic goals and expectations for treatment results.
Given the numerous studies validating the accuracy and efficiency of remote pathology diagnosis and consultation,39–42 it remains no surprise that telepathology was one of the earlier forms of telemedicine described in Mohs surgery, whose success depends on achieving tumor-free margins via accurate and rapid assessment of intraoperative frozen sections. Using a telepathology system consisting of a motorized microscope stage and remotely controlled microscope functions, Nehal and colleagues21 demonstrated the diagnostic accuracy of telepathology when compared with conventional light microscopy in the setting of Mohs surgery. This finding was further confirmed by McKenna and Florell,24 who used a consumer-grade video camera attached to a microscope and iChat AV videoconferencing software to evince the accuracy, feasibility, and cost-effectiveness of dynamic telepathology with readily available consumer products and software. Remote consultation intraoperatively with a dermatopathologist allowed the surgeon to confirm tumor type when it differed from the original biopsy diagnosis,23,25 obtain additional prognostic information,22,23 distinguish between benign and malignant epithelial proliferations (such as trichoepithelioma from basal cell carcinoma),22,23 and rule out residual inflamed tumor in the setting of inflammatory infiltrates (such as in a patient with underlying hematologic malignancy).23 Overall, the use of telepathology in Mohs surgery proves valuable when surgeons are faced with more challenging or unusual histopathologic evaluations, helping them avoid unnecessary excisions in benign cases to maximize tissue conservation and perform further excisions confidently and without delay in malignant cases to achieve accurate tumor clearance. Moreover, dynamic telepathology offers a unique educational and collaborative opportunity between the dermatopathologist and Mohs surgeon.
Despite the myriad of benefits offered by telepathology, its use among Mohs surgeons remains very limited. Several possible real or perceived barriers to more widespread adoption of telepathology include availability of dermatopathologists, the cost associated with installing telepathology equipment, and lack of a billing system for the dermatopathologist given that reimbursement for Mohs surgery is based on the Mohs surgeon performing both the surgery and the pathology assessment. In a busy practice, coordination between the Mohs surgeon and dermatopathologist to review frozen sections may be challenging, and establishing a workflow that works for both sides may be difficult. In terms of cost, as quality and accessibility of consumer technology continue to improve, expense has become less of an issue, as reinforced by McKenna and Florell24 whose telepathology installation cost only $1,250. Kantor43 further demonstrated a wireless setup that cost less than $150 using a commercially available plastic binocular adapter attached to a smartphone to capture and share digital images or videos. Although reimbursement for telepathology varies based on state and insurance coverage, evidence from newly proposed legislature for changes to private payer and Medicaid handling of telemedicine suggests that the growing demand for these services are being recognized.44
Outside of telepathology, there remains a paucity of studies showing the effective intraoperative uses of telemedicine within dermatologic surgery. This review includes 2 descriptive articles26,27 that explore the potential applications of telemedicine and telecommunication technologies, specifically smartglasses, to facilitate intraoperative care. Hands-free, voice-activated devices capable of photo and video recording and streaming, and smartglasses lend themselves well to Mohs surgery. Hamann and colleagues26 reported their use of smartglasses to record and transmit photos and videos intraoperatively to their otolaryngology colleagues for patients undergoing Mohs surgery who were prescheduled to undergo reconstructions with otolaryngology the next day. Additionally, using the videoconference functionality of the smartglasses, the Mohs surgeon was able to discuss possible closure methods with the otolaryngologist, who could remotely view the operative field live and thereby participate in decision making.
Another valuable asset of the live videoconference functionality of smartglasses includes education and teaching opportunities for residents and fellows. The remote video streaming capability enables any audience regardless of distance to view the surgeon's field. Other potential applications of smartglasses include documentation of consults and preoperative visits with patients' permission, real-time monitoring of vital signs, a version of smartglasses with loupes, access to Google search functions, and built-in speakers and earbuds for music.27 Dermatologic surgeons stand to benefit by taking advantage of emerging telemedicine technologies to provide better coordinated multidisciplinary and surgical care for their patients.
Despite these potential benefits, smartglasses do raise important privacy concerns for recorded patients. Given that subjects may not be aware that they are being recorded via smartglasses, full disclosure and consent by patients prior to recording are crucial.
Traditionally, postprocedural communication with patients involves one or more clinic visits, which represent time and monetary cost to patients and providers. With the widespread adoption of smartphones, even in the older dermatology patient population, web applications are increasingly popular means of communicating and educating patients.28 Most electronic medical records (EMRs) offer web portals, through which surgeons can easily communicate with their patients postoperatively and some of which have the capability for patients to send photos. As an additional benefit, all communications via EMR web portals are incorporated into the patient's medical record.
Text messages offer another means of communicating with and educating patients. In their study, Hawkins and colleagues28 randomized 90 patients undergoing Mohs surgery 1:1:1:1 to educational wound care videos with postoperative text messages about wound care, videos-only, text messages-only, or control with standard nurse-directed wound care instructions and supplemental paper pamphlet. They found that patients experienced a 19% reduction in anxiety after the video (p = .00062) and that they preferred to receive wound care instructions by text messages for future visits (p = .0001), with 91% of patients reporting that the service was “very helpful” or “helpful.”
In the cosmetic setting, Chee and colleagues29 surveyed laser resurfacing patients regarding their experience with smartphone monitoring after laser treatment. Of the 24 teledermatology respondents, most patients found the postlaser smartphone service useful as it replaced clinic visits during recovery, provided monitoring reassurance, and offered prompt contact should concerns arise. Those who used the smartphone service required fewer face-to-face consultations, which translated into reduced costs, travel, and social embarrassment for patients in the immediate postprocedural period.
Additional evidence for the value of telemedicine in the postprocedural period can be seen within the plastic surgery literature. Text messages between the plastic surgeon and patient with postoperative photographs of the operated area have been shown to improve the quality of the postoperative experience for patients and allow for early detection of postoperative complications.45 In addition, plastic surgeons used smartphone applications for postoperative monitoring of free flap perfusion, resulting in improved communication and early diagnosis of flap compromise to ultimately increase flap survival.8,46,47 Similar smartphone applications or postoperative text messaging may prove helpful in dermatologic surgery for avoiding complications after Mohs surgery or laser procedures and maximizing flap or graft survival. Postprocedural care is critical to Mohs surgery outcomes48 and patient experience in the post-treatment period, and telemedicine holds great promise in the realm of postoperative monitoring for ensuring optimal results.
Barriers to Teledermatology
Despite the many potential benefits of teledermatology, there are several important barriers to its widespread implementation within dermatologic surgery in the United States. Reimbursement poses one of the greatest challenges and varies significantly from state to state and among payers. Currently, all states have telemedicine laws and Medicaid policies.49 In the past, reimbursement was restricted to live-video teledermatology for geographically limited patients only,50 but more recently, the Centers for Medicare & Medicaid Services have expanded telehealth access and coverage, eliminating geographical restrictions on telemedicine services. Centers for Medicare & Medicaid Services has also created codes and finalized reimbursement for virtual check-ins, remote evaluation of prerecorded patient information, and interprofessional internet consultation. In addition, private payers are increasingly willing to reimburse these services at equal rates as in-person care as more and more studies demonstrate the cost effectiveness and reliability of telemedicine.51
Another potential concern regarding teledermatology is medicolegal liability. To date, there have been no laws differentiating between telemedicine and in-person practice, meaning that clinicians assume full liability when practicing teledermatology.50 However, most malpractice cases regarding telemedicine stems from physicians prescribing medications across states, and none of these have involved teledermatology.50
Telemedicine is emerging as a valuable aspect of dermatology that offers improved access to care and cost efficiency without compromising quality of patient care. Modern telehealth and telecommunication advancements provide a worthy adjuvant to the dermatologic surgeon's toolkit and are expected to become increasingly integrated into daily clinical practice with expansion of reimbursement policies as well as further refinements in digital imaging resolution, smartphone applications, wireless connectivity, and data encryption.
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