The coronavirus disease (COVID-19) pandemic has caused a surge in demand for teledermatology, reducing regulatory barriers and improving insurance reimbursement. Dermatology practices are under pressure to offer telemedicine options for their patients in order to maintain business operations and provide care during the time of physical distancing requirements. In response to the pandemic and patient care needs, previous guidelines and barriers to use have been relaxed and offices are scrambling to determine what is best for their practice.
The specialty of dermatology, being largely visual, is especially suited to digital image or video transfer leading to remote diagnosis. That said, dermatology is also a procedural specialty, which requires patients to be seen in person for excisions, injections, and laser treatments. One of the strengths of teledermatology is to aid in triaging patients that need to be seen urgently vs deciding who can be managed remotely. This is extremely important during this time when public health restrictions are imposed on patients to prevent the spread of COVID-19. But as a long-term solution, teledermatology can streamline a practice and maximize population health by taking care of patients who need to visit the clinic with shorter wait times and greater efficiency.
In the Past
Historically, digital technologies (online shopping, streaming video, dating apps, etc) have had a significant effect on our society. Consumers are proficient and comfortable obtaining a wide variety of products, services, and information online. Due to reduced consumer cost, time savings, and technology advances, the digital marketplace continues to expand.
Teledermatology has been used by some practices, in informal ways, even before telemedicine platforms were available. Patients may have been asked to take a photo of a particular problem and send it through email or text or upload it to a patient portal. There were also informal or “unofficial” uses of video conferencing, including FaceTime, Skype, and other video chats.
Considering the spectrum of conditions treated in dermatology practices on a daily basis, many can be managed through teledermatology with a high level of care. In fact, with the right software collecting the appropriate information and pictures, these cases can easily be performed by store-and-forward (SF) teledermatology with the use of video or phone consultation as needed. The easiest way to start with teledermatology is to manage follow-up patients who do not normally require procedures: follow-ups on biologic therapy for patients with psoriasis, monitoring patients on isotretinoin for acne, and uncomplicated rashes or lesions. Furthermore, teledermatology can be used as a tool for cosmetic consultation as well. By the time the cosmetic patient arrives at the office, he or she is already scheduled for a procedure, is aware of pricing, and has been counseled on any down time or potential side effects.
During the Present
The COVID-19 pandemic has already made a significant impact on the delivery of medical care. It will likely change the way we practice medicine, both in general dermatology as well as aesthetics. Many dermatology offices in the United States are currently closed or working under limited hours, yet patients still need to be treated. Patients still need access to care for routine concerns, follow-up visits, and prescription refills, even when they are mandated to stay at home in most states. However, they are worried about coming to their doctor’s office, urgent care, or emergency room where there is the risk of exposure to the viral infection. Therefore, patients may not be scheduling, delaying, or cancelling their dermatology visits. This has a profound impact both on patient care and practice revenues during this time.
As a result, millions of patients and thousands of dermatologists are now learning about and using telehealth services for the first time. Providers may even be skeptical about the potential to provide good clinical care in a virtual manner. Many practices are experimenting with homegrown telemedicine solutions, such as commonplace video conferencing solutions as well as communicating by text or email, as these are cost-effective, short-term solutions. While these solutions provide immediate help during this critical time, they pose some potential downsides:
- The inherent digital and in-person privacy concerns that would be noncompliant with HIPAA standards;
- Issues with management of scheduled video calls, as both patient and provider must be available and adhere to a given time;
- Difficulty keeping virtual visits within the scheduled length of appointment, given the added factor of technological issues;
- Suboptimal documentation for patient records and billing;
- Inadequate video quality for close-up assessment of a skin condition; and
- Security concerns of sharing of a provider’s cell phone (ie, future unscheduled or unwanted calls or texts).
Luckily, technology continues to improve at one of the most rapid paces in history. Cameras on smartphones offer the ability to take high-quality photos that could be enlarged to note finer details. In addition, newer software and mobile phone application technologies allow older telehealth platforms and methods to be customized and improved for dermatologic needs.
Telehealth guidelines have been temporarily relaxed to help fill the gap in patient care during the pandemic. These relaxed standards include many changes in the areas of practice management. Possibly the most important changes center around HIPAA regulations. The Office for Civil Rights at the US Department of Health and Human Services notes the rules regarding privacy, security, and breach notification all fall under the latest notification enforcement discretion. This temporary slack protects covered health care providers from penalties for violations of those rules that occur in the good faith provision of telehealth. In addition, physicians or other health care professionals may serve across state lines, no longer limiting their patient base to the state in which a physician is licensed. Reimbursement is also a point of emphasis, as physicians may bill for the telemedicine visit at a parity for an office visit.
However, dermatologists should be aware of a number of factors when it comes to incorporating telehealth into their practice during the COVID-19 pandemic. Despite current conditions regarding HIPAA rules, providers should always be concerned with protecting patient security and privacy. The type of teledermatology format, SF vs live interactive (LI), should also be weighed heavily. I believe LI telehealth is not as suited for dermatology compared with SF. Unlike high-resolution still photos, the quality of video is often not high enough for providers to see finer details, and zoom capabilities are frequently not possible. The lighting and visibility can also be suspect to changes, affecting the imaging of a skin lesion. Documentation during a LI appointment can also be tricky, necessitating a scribe and limiting reimbursement without proper records of the visit. Lastly, LI visits require the same efforts to coordinate a schedule as with traditional in-person care, with the added factor of patient internet access before and during the video visit. All of these elements, even those that are technically outside the control of the provider, can affect patient satisfaction, which may play into future business opportunities following the return to in-person visits.
Toward the Future
Dermatology will be significantly impacted by the COVID-19 pandemic. Just as the use of video conferencing is impacting the way we receive news and conduct business, teledermatology will influence care delivery and patient expectations of receiving care.
The necessity of providing care during the crisis will impact the way providers need to protect their patients, their staff, and themselves. As providers gain experience with teledermatology, they may realize the associated benefits to their practice: convenience for their patients, ability to provide care from any device and at times convenient to them, and ability to fulfill basic services that can be time-consuming (prescription refills, quick follow-up visits, determining the need of an actual office visit, recommending and selling ancillary skin care products). In particular, aesthetics practices will have the ability to offer online consultations; these virtual visits can allow patient education and follow-up care of basic aesthetics procedures while reducing discomfort to the patient during the healing process.
New technologies are now available that are designed specifically to meet the needs of the dermatologist. There are solutions that combine the quality of SF photos with LI options if desired. Some platforms are even customizable for addressing multiple aspects of a practice, including general and aesthetic dermatology. Practices have the choice to offer a fee-for-service cash payment or submit the teledermatology visit for reimbursement with insurance.
The good news is that the incorporation of teledermatology is not nearly as disruptive as what our profession has recently been through with the adoption of electronic medical records, which was a systematic change that involved our entire practice. Incorporating teledermatology, whether SF/asynchronous or LI/synchronous, is much easier and has clear short- and long-term benefits to patients and the practice. n
Mr Leon is a dermatology physician assistant in Simi Valley, CA, and founder of fixwarts.com. Dr Rubinstein is the medical director of Dermatology and Laser Centre in Studio City, CA.
Disclosure: Dr Rubinstein is a medical advisor to SkinCheckOnline.com.