INTRODUCTION TO TELEDERMATOLOGY
Teledermatology, that is to say, remotely seeing, diagnosing, and treating patients for dermatologic conditions using technology, dates back to 1995 and was one of the first telemedicine practices in place (Tensen et al., 2016). The visual nature of dermatology makes it uniquely suited for telemedicine-based healthcare delivery. Advantages of teledermatology include avoiding long wait times for office visits, eliminating transportation obstacles, and increasing access to dermatology care in more remote areas. Advances in teledermoscopy, in which patients can send providers dermoscopic images using their smartphones, allows providers to accurately diagnose skin lesions (Zink et al., 2017). A Cochrane review found that teledermatology can correctly identify most malignant lesions and may be particularly useful to triage those lesions requiring face-to-face assessment by a specialist (Chuchu et al., 2018).
Teledermatology exists in many forms. It may be an interface between a referring clinician and a consulting dermatologist (a provider-to-provider model) or between a patient and a dermatologist (a provider-to-patient model; Wang et al., 2020). There are two main methods of teledermatology: store-and-forward and live-interactive techniques. Store-and-forward involves images and information being sent to a dermatology provider and then reviewed by the provider at a later time, generally hours to days later (Wang et al., 2020). Because of the flexibility in timing, store-and-forward is advantageous when time zones and scheduling differences can pose an obstacle to in-person visits. Although store-and-forward teledermatology does not generally involve any direct patient–provider interaction beyond written exchanges, it is more cost-effective (Wang et al., 2020). Store-and-forward is highly utilized for teledermoscopy, where detail is important to examine lesions (Whited, 2001).
Alternatively, live-interactive teledermatology is an interactive visit between the patient and the provider in real time via a virtual videoconference. The interactive nature of live-interactive visits allows providers to establish good rapport with patients (Whited, 2006). A hybrid method of teledermatology can utilize features from both store-and-forward and live-interactive modalities, such as with an interactive videoconference review of high-quality still images of lesions. When compared with face-to-face clinic evaluations, both store-and-forward and live-interactive modalities have been reported to produce reliable diagnostic outcomes, and store-and-forward has been found to have comparable diagnostic accuracy (Whited, 2001).
EFFICIENCY OF TELEDERMATOLOGY
Most studies indicate that teledermatology is likely cost-effective for both the healthcare system and the patient (Wang et al., 2020). This is especially true for patient populations with insufficient access to dermatologic care (Wang et al., 2020). Teledermatology appointments have lower costs compared with in-person encounters (Wang et al., 2020). Cost reductions are directly proportional to the distance to dermatology clinics as well as the number of prevented in-person visits (Eminović et al., 2010; Wootton et al., 2000). A Philadelphia study in 2019 found that store-and-forward teledermatology programs saved $10.00–$52.65 per consult compared with face-to-face visits (Yang et al., 2019). Another study found that half of primary care referrals could be avoided by the use of teledermatology (Barbieri et al., 2019). The ease of teledermatology may also increase patient adherence to risk-based skin cancer screening guidelines, decreasing the long-term costs associated with skin cancers (Young et al., 2020). However, teledermatology may be associated with high startup costs in the form of digital cameras, computers, and Internet access (Loane et al., 2001; Zuo et al., 2013).
Teledermatology may also reduce wait times for patients in the emergency department, as many hospitals do not have inpatient dermatologic consultative services (Barbieri et al., 2014). A study found a 100% agreement in suspected diagnosis between teledermatological evaluation and clinical evaluation of the same physician in an emergency room setting, concluding that emergency teledermatology is safe and effective (Villa et al., 2020). Furthermore, teledermatology may assist dermatologists in determining the urgency of inpatient consultation when requested (Barbieri et al., 2019). One study found that teledermatologists were able to triage 60% of consultations to be seen the next day or later and 10% of patients to be seen as outpatients after discharge (Barbieri et al., 2014). Teledermatology offers potential ways to increase efficiency and reduce costs in multiple care settings.
LIMITATIONS OF TELEDERMATOLOGY
Teledermatology comes with disadvantages as well. A good image is the most basic requirement to make a diagnosis in teledermatology (Pasquali et al., 2020). Low image quality, insufficient view, and incorrect patient positioning are the most important limitations to teledermatologists (Pasquali et al., 2020). Both clinical and dermoscopic images need to be of good quality, which may be unpredictable between patients (Pasquali et al., 2020). Teledermatology also does not allow for physical examination with touch, which may be important for diagnosing conditions such as actinic keratoses, psoriasis, and atopic dermatitis (AD; Coates et al., 2015). Remote medical visits carry the major and obvious drawback of being unable to perform procedures or many diagnostic tests remotely. Patients may still have to be seen in person for such visits, even after an initial teledermatology appointment.
Teledermatology may be significantly limited in the evaluation of pigmented lesions such as atypical nevi and melanoma. Evaluating pigmented lesions can be more challenging because of the substantial mortality and morbidity associated with malignant melanoma, and teledermatology and teledermoscopy should be used judiciously. For the management of suspected malignant pigmented lesions, both diagnostic accuracy and management appropriateness were higher for face-to-face dermatology (Warshaw et al., 2009b). Up to seven of 36 of index melanomas would have been mismanaged with store-and-forward teledermatology, as opposed to one of 36 in clinic (Warshaw et al., 2009b). To increase patient safety and outcomes with teledermatology, nondermatologists should operate with a lower threshold of suspicion for lesions.
International teledermatology programs present additional challenges, including language barriers, lack of availability or affordability of recommended treatments, navigating cooperation of governments and healthcare providers, difficulty of establishing sustainable programs, Internet access, access to dermatopathology, and avoiding patient exploitation (Chang & Kovarik, 2010; Desai et al., 2010; Tsang & Kovarik, 2010). Furthermore, expanding teledermatology programs has the potential to interfere with the establishment of specialist training programs in underserved areas, which could exacerbate the disparities in accessible in-person healthcare.
Technical difficulties are a frequently voiced challenge by both patients and providers (Norum et al., 2007). With changes in the typical physician–patient interaction through teledermatology, there are some ethical concerns that widespread adoption of teledermatology could deteriorate the ideal patient-centric relationship with overemphasis on technology, leading to depersonalization of medical care (Pala et al., 2020). It can be difficult to obtain proper informed consent through teledermatology, as many patients and providers are new to the process. Storing and transferring images and patient data through the Internet raises concerns for privacy and security (Goldberg, 2004). Some teledermatology providers have been using mobile messaging applications, such as WhatsApp, for care communication because of their ease of use and low cost. However, such applications have limited privacy (Black & Ali, 2020; Jakhar et al., 2020). As teledermatology becomes more established, medicolegal protection, quality analysis for safety and privacy, and Health Insurance Portability and Accountability Act-approved security compliance will need to be addressed. However, patients do not commonly voice apprehensions about privacy and confidentiality in teledermatology (Coates et al., 2015).
ADVANCES IN TELEDERMATOLOGY
Teledermatology has advanced along with technology changes since its introduction in 1995. The availability and variety of devices and systems for dermatologic use has greatly expanded, extending from mobile applications, small dermoscopic attachments for smartphones and cameras, to three-dimensional imaging systems. Mobile phones are increasing in prevalence, including in medically underserved countries. Smartphones have higher availability and reliability than alternative electronic communication technologies in such countries (Massone et al., 2008). Handheld tablets are also growing in popularity and have been found to have superior utility for image analysis than smartphones (Brandt & Hensley, 2012).
Smartphone technology has become well adapted for telehealth use and allows patients to be more engaged and active in their own healthcare by sending images and information. Smartphone image quality can be acceptable for use for teledermatology (Lehman & Gibson, 2013; Warshaw et al., 2009a), as images taken on smartphones have been reported to have diagnostic agreement between face-to-face and virtual dermatology consultants in 61%–80% of cases (Boyce et al., 2011; Ebner et al., 2008; Kaliyadan et al., 2013; Lamel et al., 2012; Massone et al., 2006; Shin et al., 2014; Weingast et al., 2013). Although smartphone dermoscopy attachments have been shown to increase diagnostic accuracy (Warshaw et al., 2009a), it is important to consider that most patients will not have access to this equipment as it can be very costly. Mobile applications for patient education have also been created, with the goal of inexpensively informing patients about skin cancer risks and recommendations for sun protection and self-examination (Chao et al., 2017). However, there is great variability among applications, and their safety, efficacy, and quality have not been well established in the literature.
TELEDERMATOLOGY DURING THE COVID-19 PANDEMIC
Since the escalation of the COVID-19 outbreak, social distancing became implemented throughout the United States. In the first few months of the pandemic, the American Academy of Dermatology echoed recommendations from the Centers for Disease Control and Prevention, recommending that all patients being seen for nonessential care be rescheduled or offered telemedicine alternatives, no matter their exposure status (“Everyday Health and Preparedness Steps in Clinic,” 2020).
As the pandemic continued, it became clear that postponing treatment could lead to exacerbation of many chronic skin conditions and potentially delay identification and treatment of malignant dermatologic disorders. Furthermore, dermatologic evaluation of patients is critical for understanding the variable signs and symptoms of COVID-19, as skin manifestations related to the virus may be present in 20% of patients with COVID-19 (Galván Casas et al., 2020). However, dermatology practices could become potential vectors for the spread of COVID-19 if patients with such symptoms are seen in person. To save hospital bed space, equipment, and resources for the pandemic response, triaging and evaluating patients via teledermatology has served as a ready solution for dermatology providers.
In reaction to COVID-19, most academic and private dermatology clinics now offer teledermatology. Video modalities are common among both private practices and academic institutions. As of April 2020, 86.5% of websites from a sample of 153 private dermatology practices, three from each state and Washington, DC, noted that teledermatology was offered as an alternative to face-to-face visits. The websites of 40 academic institutions were reviewed as well, and 60% of the corresponding dermatology departments mentioned the availability of teledermatology (Gorrepati & Smith, 2020). To help patients with imaging, 16.6% provided detailed recommendations for taking quality photos. However, 92.2% of the sample practices and 95.8% of the institutions did not outline which conditions would be best suited to address via teledermatology (Gorrepati & Smith, 2020).
Although reimbursement rates were previously noted as a primary barrier to the growth of teledermatology (Mayer, 2015), reimbursement rates for telemedicine have changed during the COVID-19 pandemic. The Centers for Medicare & Medicaid Services (CMS) released guidelines on March 30, 2020, broadening coverage of Medicare telehealth services so that beneficiaries could avoid travel to healthcare facilities. CMS is the largest healthcare payer and the model for the private payer system in the United States (Wang et al., 2020). The new guidelines indicated that dermatologists can now bill for telehealth visits for any patient in any location, dermatologists and nonphysician clinicians can now provide virtual check-in services to both new and established patients, and virtual evaluation and management visits are now considered the same as in-person visits and are paid at the same rate as regular, in-person visits (“Teledermatology toolkit,” 2020). It is unclear how long the telehealth guidelines will last and whether permanent reimbursement changes are on the horizon.
As reopening phases have progressed throughout the United States, in-person visits have recommenced, often with recommended or required precautions such as face masks and increased cleaning. Current recommendations now include prioritizing teledermatology visits when possible to minimize the risk of COVID-19 exposure and transmission, prioritizing in-person visits for patients with potentially life-threatening presentations, identifying patients at a high risk for exposing providers to COVID-19, limiting in-person resources for low-risk visits, and organizing a system for inpatient dermatology consults when needed (Trinidad et al., 2020). An algorithm for these various settings in the context of COVID-19 has been proposed and adopted by many institutions in the Society of Dermatology Hospitalists (Trinidad et al., 2020).
With in-person care still somewhat discouraged, teledermatology may be the most attractive option for dermatologists in some cases. Patients with confirmed or suspected COVID-19, as well as those at an increased risk for infection, can be safely evaluated. After knowledge about skin manifestations of COVID-19 was disseminated to the public in April 2020, more patients presented after noticing such suspicious lesions on themselves and more referring physicians requested dermatology consults (Galván Casas et al., 2020). Addressing inpatient consults during the COVID-19 pandemic can greatly increase exposure and transmission risk for providers, staff, and patients. One study in Turkey found that 72.8% of dermatology consults during the pandemic could be effectively handled by teledermatology, which would significantly decrease this risk (Temiz et al., 2020). Most established skin lesions related to COVID-19 are mild and do not require face-to-face visits for diagnosis and management (Temiz et al., 2020).
Certain skin conditions are particularly manageable via teledermatology during the COVID-19 pandemic, including acne, psoriasis, rosacea, rashes, and AD (Armstrong et al., 2018; Perkins et al., 2020; Sharma et al., 2020). The disease burden and quality of life for patients with chronic inflammatory dermatologic conditions, such as AD, have been greatly affected by COVID-19 (Shah et al., 2020). Frequent hand washing and sanitizing, increased stress levels, and long-term mask and glove wearing can exacerbate dermatitis. To address this, providers have been recommended to prescribe 90-day supplies of medications and encourage patients to purchase or order moisturizers in bulk (Shah et al., 2020). Teledermatology is integral for continuing care while lessening exposure to emergency department visits, which are increasingly common among patients with AD (Kwa & Silverberg, 2018). Other conditions remain difficult to treat virtually, such as autoimmune conditions. Many of the immunosuppressive drugs used as treatments are given intravenously and require in-person medical visits. Furthermore, providers must weigh risks and benefits of providing a drug that may increase COVID-19-related mortality risk, such as rituximab for the treatment of pemphigus (Shakshouk et al., 2020).
There is also significant overlap of populations at the greatest risk for both COVID-19 infection and delayed melanoma diagnoses, as both rates are highest among older men with comorbid conditions (Chen et al., 2020; Conic et al., 2018). The large-scale postponement of in-person medical and surgical therapies, including for melanoma and other skin cancers, is likely to lead to delayed identification and treatment (Conic et al., 2018). As discussed previously, teledermatology and teledermoscopy can be used to diagnose malignant lesions but still operate with lower accuracy than face-to-face evaluations (Warshaw et al., 2009b). Inability to perform full-body skin examinations, regular skin cancer screenings, and procedures is one of the most important limitations of teledermatology. Teledermatology cannot substitute for these services, which may have tremendous impacts on health outcomes particularly for melanoma (Gomolin et al., 2020). The incidence of melanoma in the United States was rising at a higher rate than other preventable cancers before the pandemic, and this disruption to standard medical care may accelerate this dangerous trend (Okhovat et al., 2018). Provider and hospital availability for surgical procedures, such as melanoma removal, is also exacerbated by the pandemic (Hwang et al., 2020).
Teledermatology will likely become an integral part of dermatology, especially as a result of the COVID-19 pandemic and the related CMS expansion of telemedicine coverage and reimbursement. Dermatology providers should be aware and informed of teledermatology systems, benefits, and barriers to effectively incorporate teledermatology into patient care. Future guidelines and recommendations for teledermatology would likely help standardize quality and practice protocols as unified legislation for telemedicine has been emphasized as a necessity by many researchers (Gioia & Salducci, 2019). For example, guidelines and recommendations for teledermatology in Australia were developed through partnership of the University of Queensland's Centre for Online Health and the Australasian College of Dermatologist's E-Health Committee (Abbott et al., 2020). These guidelines address provider competency, patient consent, technology, imaging, privacy, communication, and documentation (Abbott et al., 2020). Other countries may follow suit by recommending practices for successful and effective teledermatology care.
Barriers to adoption and continuation of teledermatology programs include costs, technological proficiency, staff training on imaging and data collection, medicolegal concerns, and reliable reimbursement. As of 2019, there have been no reported cases of medical malpractice in patient-to-provider telemedicine. However, telemedicine opens up possibilities for new modes of malpractice, termed “telemalpractice,” so it may be necessary to modify or expand insurance coverage for the protection of teledermatology providers and to thoroughly train providers so such malpractice is averted (Nittari et al., 2020).
Residents are now authorized by the Accreditation Counsel for Graduate Medical Education to see patients using teledermatology with supervision (“ACGME Response to the Coronavirus (COVID-19),” 2020). Training in teledermatology may be useful to incorporate into residency programs, as early exposure may lead to improved comfort with this practice modality (Qureshi & Mostaghimi, 2016). In a 2016 study, 67 of 100 residents reported that teledermatology was practiced at their institution, but only 21 of the 100 residents had participated in teledermatology themselves (Qureshi & Mostaghimi, 2016). Teledermatology conferences can be used to increase training and education for physicians in rural and underserved areas (Pala et al., 2020) and to connect dermatologists across distances for continuing education and consulting (van der Heijden et al., 2010).
There is an age discrepancy among patients and providers using teledermatology. Only 9.8% of surveyed dermatologists over the age of 50 years used teledermatology, as opposed to 34.9% of dermatologists aged 30–35 years and 24.5% of doctors aged 25–30 years (Sharma et al., 2020). Younger patients tend to send higher quality images, be more willing to pay for teledermatology, and navigate teledermatology more easily (Berndt et al., 2012). Elderly patients may experience more challenges with teledermatology, so engaging older populations with detailed instructions and assistance will be an important focus to avoid leaving the elderly population without access to care (Simpson & Kovarik, 2020). Telephone-only or web-based platforms can adapt more familiar technologies to increase ease of use. Pictorial, video, or telephone walk-throughs of instructions can further assist with patient comfort and understanding of new systems (Simpson & Kovarik, 2020). In accord with younger patients being more engaged in teledermatology, teledermatology could be primarily utilized for younger patients and those with benign conditions, which could open appointment availability for in-person visits for those with more concerning and severe diseases (Uscher-Pines et al., 2016).
Given its recent expansion and advancement, clinicians in dermatology and primary care will likely continue or begin to use teledermatology in the future. Over 70% of dermatologists surveyed in one study predicted they would continue to use teledermatology after COVID-19 in conjunction with face-to-face visits, whereas 10% predicted they would shift toward more teledermatology while limiting in-person consults (Sharma et al., 2020). Research on teledermatology is growing and will likely become increasingly important in the future. Many questions on cost-effectiveness, reimbursement rates, and technical and legal considerations of teledermatology have not yet been fully answered (Wang et al., 2020). Research on the long-term outcomes of patients managed with teledermatology will also be of increasing importance going forward as teledermatology programs become more established.
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