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Lessons in Teledermatology

Lessons in Teledermatology

When Carrie Kovarik, MD, thinks of memorable cases, she recalls a scalp ulcer that was so large, it covered nearly all of the patient’s head. She eventually diagnosed disseminated histoplasmosis, but tissue analysis took some time, because it was unavailable locally and had to come to her via courier. Her patient, who made a full recovery, was a young girl in rural Tanzania, some 7500 miles away.  

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Victoria Williams, MD, pictured with her patient in the outpatient dermatology clinic at Princess Marina Hospital.

Dr Kovarik is an associate professor of dermatology at the University of Pennsylvania in Philadelphia, and the founder of the Penn Dermatology Global Health program. The program has been growing steadily over the last 12 years and is focused on sustainable solutions that improve clinical care, education, and patient outcomes in global communities. One of the facets of the program includes the American Academy of Dermatology supported Residents International Grant (RIG), which has been providing continuous dermatology care to the citizens of Botswana for more than a decade, in conjunction with local health care providers within the Ministry of Health as well as trainees at the University of Botswana. Since the induction of the program, Dr Kovarik and her faculty collaborators, including Victoria Williams, MD, assistant professor of dermatology, have trained hundreds of health care providers in person throughout Africa in the care of skin disease and have seen thousands of patients in collaboration with them. Dr Kovarik has participated in thousands of teledermatology consults from more than 15 African countries and read over 500 telepathology cases in order to provide relevant diagnoses for patients.  

Humble Beginnings

In 2001, Botswana, an African country with no medical school and few doctors, was losing the HIV/AIDS epidemic. With almost 40% of the population affected, Botswana’s president called for international aid. The University of Pennsylvania responded.

The Center for Global Health at the Perelman School of Medicine partnered with the African nation and the University of Botswana to train and educate local healthcare personnel and improve access. That collaboration, known as the Botswana-UPenn Partnership, has trained thousands of healthcare professionals at Princess Marina Hospital and others in the region, local clinics, and the University of Botswana.

In 2007, Dr Kovarik began sending a few of her residents to Botswana, and gradually, the program grew. With the support of the RIG grant, 15 residents from US and Canadian programs are able to participate every year.

Dr Kovarik also began a Telemedicine and Informatics program within the Botswana-UPenn Partership in 2009, in order to further the reach of dermatology clinical care and education. Technology had improved since her first visit to Africa in 2001, when internet connections were still dial-up and cell phones were nonexistent. But the infrastructure was still lacking, as was dermatologic training among the local medical professionals. In 2007, she had helped to develop a simple internet-based telemedicine system for many sites throughout Africa, and Botswana was the perfect place to continue development of telemedicine technology, including mobile-based systems. The Telemedicine and Informatics team grew from one employee to 15 over the years, with development of experience in mobile telemedicine, electronic medical records, Internet security, and integration. This experience integrated with the dermatology clinical team in order to assist with teledermatology development in Botswana and other countries. 

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Victoria Williams, MD, teaching University of Botswana medical students during their clinical rotation through Princess Marina Dermatology Clinic. 

Distant Diagnoses

The physicians working on the ground in Botswana were often seeing dermatology at its most complex: disseminated fungal infections, parasites, complications of HIV and AIDS. And those diseases were far from the only challenges. 

“Telemedicine is heavily limited by who is on the receiving end of the consults, particularly when you are providing care to a developing country,” said Dr Williams. “The person responding to the consults must understand what disease pathologies are prevalent, what local resources are available for treatment, and, most importantly, the local cultural norms.”

Early in her experience working as the full-time local dermatology site director in Botswana, Dr Williams recalled her consternation when a patient with albinism who had been newly diagnosed with squamous cell carcinoma became hysterical and refused treatment. “Global health can be incredibly complex,” Dr Williams said. “What seems like an easily solution is often not so simple. Psychosocial factors play a huge role in patient care, particularly in stigmatizing diseases like albinism. Access to a diagnosis and treatment isn’t always the whole solution. Similarly, you can make a diagnosis of atopic dermatitis, but it is not going to be much benefit to the patient unless you understand the local bathing customs and provide education on how to adjust skin care practices.”

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Carrie Kovarik, MD (middle), and Victoria Williams, MD (right), with Karen Mosojane, MD (left), Botswana’s dermatology medical officer, at Princess Marina Infectious Disease Care Clinic. 

Reaping the Rewards

Despite the many challenges the program faced, it has yielded terrific results. Approximately 5000 patients are now seen per year in person in the Botswana clinics. Teledermatology has allowed extension of specialty care to many African countries; however, all global health sites participating in teledermatology needed to have local hospital staff trained to take a good patient history and get clear, high-resolution photos. The process educates clinicians, said Dr Kovarik. “The submitting clinicians are asking questions about patients and the next time someone comes in, they can recognize that condition and know what to do for it,” she said. “They are learning about their own patients. So the cases we see in consultation are getting harder and harder because now they know how to take care of the easy ones.”

It has been a learning experience for the US-based faculty as well. Dr Kovarik co-authored several papers related to new staging criteria in children with Kaposi sarcoma because of a cluster of pediatric cases she saw in Malawi. 

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“What I’ve learned doing telemedicine in Africa, I’ve brought back to the United States,” she said. “It’s been way more progressive and accepted there than it is here because of geography and how people are spread over large distances, with specialists only in city centers, when they are available at all. We have that same issue here in the rural United States, especially with dermatology. There are areas where you can’t get to a specialist.” Telemedicine, she believes, could be solution. “Decision and policy makers don’t always see a need for it yet. But there is a need for it.”

The personal impact of teledermatology and global health work, though, is harder to measure. “I am much more patient-focused and I absolutely think I am a better physician and dermatology clinician because of my global health work,” said Dr Williams.  

“The essence of what we do … it’s not clean, it takes place in a hospital with dirty walls, with sick patients, and little resources,” said Dr Kovarik. “But we reach out and touch our patients, and we teach each other.” One of the things that makes her most memorable case, the young girl with the large scalp ulcer, so memorable, is a follow up photo they sent of her celebrating her birthday in the hospital, despite a long and difficult recovery. “It was so great to see that progress,” said Dr Kovarik. “Thank goodness we could get her that.” 

 

Drs Kovarik and Williams would like to thank the UPenn Department of Dermatology, UPenn Center for Global Health, Mike and Peg Kramer, and other supporters that have contributed to the success of Penn Dermatology Global Health.

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