The use of telemedicine in various specialties continues to expand. In fact, telemedicine consultations are expected to reach 158 million per year by 2020, according to a report1 from the market intelligence firm Tractica. Telemedicine often fills a crucial gap in rural areas in the United States and in developing countries, where specialty physicians are lacking. As communication via messaging, apps, and video chat technology continues to emerge, telemedicine is also expanding into urban areas.
“Telehealth video consultations lend themselves to a wide variety of medical treatments,” said Charul Vyas, a principal analyst with Tractica, in a news release.1 “The flexibility and efficiency of video conferencing is helping healthcare providers and payers to achieve tangible value in deploying video-based patient monitoring solutions, both in terms of positive patient outcomes and cost savings.”
As dermatologic care is primarily based on visual cues, teledermatology can be a valuable tool for clinicians and patients.
Types of Teledermatology
Teledermatology in the United States has significantly evolved since the 1990s. Dermatologists began using this technology as a mechanism to provide specialized care to remote populations. However, in the 21st century, teledermatology has expanded to a variety of programs to meet the increasing demand for dermatologic expertise.2
The 3 main teledermatology care delivery platforms are synchronous (ie, video teleconferencing, real-time teledermatology), asynchronous (ie, store-and-forward), and hybrid (ie, mixed, having features of both synchronous and asynchronous forms).3
Synchronous platforms typically use live video conferencing between the patient and the teledermatologist. Asynchronous platforms use the store-and-forward technique, whereby clinical dermatologic images obtained by the requesting clinician or patient are stored and forwarded to the responding dermatologist, who can review the image and clinical history. The hybrid teledermatology platform combines live video teleconferencing and store-and-forward clinical images. This technique, however, is less commonly used, in part because it requires significant bandwidth and storage space and difficulty practicing across time zones.3
In 2016, the American Telemedicine Association (ATA) published updated practice guidelines for teledermatology. In addition to delineating detailed clinical guidelines for the teledermatologic patient encounter and the coordination of remote patient care, the guidelines also outline technical specifications and recommendations to ensure the security and privacy of patient information. Furthermore, the guidelines describe limitations and challenges of teledermatology in certain clinical contexts or in examining particular areas of interest.3,4
The American Academy of Dermatology (AAD) also recently updated its position on teledermatology in a consensus statement.5 Although its key guidelines are similar to those outlined by ATA, the guidelines also underscore patients and referring physicians having a choice of the teledermatologist and access in advance to board certification qualifications of the clinician providing care. The guidelines emphasize maintaining the physician-patient relationship. For direct-to-patient dermatology, the AAD believes that the consulting dermatologist must either have an existing physician-patient relationship (having previously seen the patient in person), or create a physician-patient relationship through the use of a live-interactive face-to-face consultation before the use of store-and-forward technology, or be part of an integrated care delivery system in which the patient is enrolled.3,5 For practices considering adding a teledermatology service, the AAD has identified compliance issues that need to be addressed prior to implementation (Table 1).6
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Advantages and Challenges
A growing body of literature supports the reliability of teledermatology for the diagnosis and treatment of skin disorders compared with standard in-person examination. The majority of studies found diagnostic accuracy rates to be in the mid to high 70th percentile.3 Table 2 lists some of the common conditions that may be appropriate for teledermatology.7 Teledermatology as a triaging tool has also been shown to be highly effective. Studies demonstrated that it can reduce face-to-face referrals by as much as 88%, as well as reduce surgery waiting times and the number of no-shows at face-to-face clinics.7 Additionally, inclusion of dermatoscopic images improves triaging decisions. Naka and colleagues8 looked at the use of electronic consultations and found that this technology increased access to dermatologic care and reduced wait times for patients seeking medical care at community health centers. Other studies have shown that triaging helps reduce the number of cases needed to excise for both melanomas and other skin cancers.7
The provider-to-provider store-and-forward teledermatology service AccessDerm, for example, delivers dermatology care remotely and triages in-person care when needed. Supported by the AAD, this teledermatology platform has connected providers using both a smartphone app and internet interface.
Another benefit associated with teledermatology is clinician and patient satisfaction. One study that looked at the state of dermatology programs in the United States from November 2014 to January 2017 found that both the number of active programs and annual volume of consultations have increased. There were 40 active nongovernmental programs, representing a 48% increase over 5 years. The maximum numbers of consultations increased to 20,000. The researchers also found that academia is the most prevalent practice setting, and store-and-forward is still the most commonly used modality to deliver teledermatology.2
A systemic review of 40 studies on patient or provider satisfaction with store-and-forward and live-interactive teledermatology demonstrated high levels of satisfaction with both platforms. The researchers found 96% and 89% of the studies that evaluated store-and-forward and live-interactive demonstrated patient satisfaction, and 82% and 100% satisfaction among physicians.9 A separate study found that drivers of patient satisfaction included convenience, less travel, shorter waiting times, lower cost, and good quality of health care.7
Telemedicine is not without its drawbacks. “The market still faces a variety of challenges, including the high initial cost of deploying services, inconsistent reimbursement models for telehealth consultations, and some continuing resistance by physicians, patients, and regulatory bodies,” said Ms Vyas.1
A literature review examining the clinical applications and reimbursement policies found that teledermatology was cost-effective and reliable in reducing in-person wait times and allows for faster delivery of care. However, in the United States, reimbursement continues to be a barrier to routine practice.10 While all 50 states and the District of Columbia have telemedicine, law, regulation, and Medicaid policies, telemedicine policy varies significantly from state to state on how it is defined, regulated, and reimbursed.10
“Although in some places Medicaid and Medicare may pay for telemedicine, at least for live interactive video, and parity laws exist, insurance is generally not required to cover this. Many business models have been tried, but for now,…it’s difficult to expand a service, no matter how effective, if the doctors who perform it will not be paid,” stated a dermatologist in a recent article.11
Another challenge is defining who is medically responsible for diagnosis and treatment decisions, which are further complicated if the referring doctor and consultant are in different jurisdictions. Use of smartphones for teledermatology also pose challenges. While smartphones allow patients to take and forward their own images, patient-acquired images have drawback, such as the teleconsultants having difficulty confirming patient identity and coordinating with primary care physicians.7
Poorly-regulated direct-to-consumer (DTC) website and mobile apps is also a concern. Findings from Resneck and colleagues raised doubts about the quality of skin disease diagnosis and treatment being provided by a variety of DTC telemedicine websites and apps. They found major diagnoses were repeatedly missed (eg, eczema herpeticum). Furthermore, regardless of the diagnosis given, treatments prescribed were sometimes at odds with existing guidelines.12
Teledermatology continues to evolve with advancements in telecommunications and mobile phone technology. Its greatest advantage may be as a triage and/or monitoring tool, both in underserved and urban areas. Regulations and policies are still needed to address the reimbursement and privacy issues. Additionally, regulators need to take steps to ensure the quality of DTC telemedicine websites and apps. “The modern era continues to be an exciting time for teledermatology,” according to Yim and colleagues.2 “Future research will continue to redefine ways in which it can best complement the current practices of dermatology as a whole.”
1. Telehealth video consultation sessions to reach 158 million annually by 2020 [news release]. Boulder, CO: Tractica; June 24, 2015. https://www.tractica.com/newsroom/press-releases/telehealth-video-consultation-sessions-to-reach-158-million-annually-by-2020/. Accessed October 15, 2018.
2. Yim KM, Armstrong AW, Oh DH, Mckoy K, Florek A. Teledermatology in the United States: An update in a dynamic era. Telemed J E Health. 2018;24(9):691-697.
3. Lee JJ, English JC 3rd. Teledermatology: A review and update. Am J Clin Dermatol. 2018;19(2):253-260.
4. McCoy K, Antoniotti NM, Armstrong A, et al. Practice guidelines for teledermatology. Telemed J E Health. 2016;22(12):981-990.
5. Position Statement on Teledermatology. American Academy of Dermatology. https://www.aad.org/Forms/Policies/Uploads/PS/PS-Teledermatology.pdf. Accessed October 7, 2018.
6. Compliance guidance. American Academy of Dermatology website. https://www.aad.org/practicecenter/managing-a-practice/teledermatology. Accessed October 7, 2018.
7. Lee KJ, Finnane A, Soyer HP. Recent trends in teledermatology and teledermoscopy. Dermatol Pract Concept. 2018;8(3):214-223.
8. Naka F, Lu J, Porto A, Villagra, Wu ZH, Anderson D. Impact of dermatology eConsults on access to care and skin cancer screening in underserved populations: A model for teledermatology services in community health centers. J Am Acad Dermatol. 2018;78(2):293-2002.
9. Mounessa JS, Chapman S, Braunberger T, et al. A systematic review of satisfaction with teledermatology. J Telemed Telecare. 2018;24(4):263-270.
10. Campagna M, Naka F, Lu J. Teledermatology: An updated overview of clinical applications and reimbursement policies. Int J Womens Dermatol. 2017;3(3):176-179.
11. Rodriguez T. Teledermatology: experts weigh in on benefits, barriers. DermatologyAdvisor. December 13, 2017. https://www.dermatologyadvisor.com/general-dermatology/teledermatology-benefits-barriers-to-success/article/713570/. Accessed October 1, 2018.
12. Resneck JS Jr, Abrouk M, Steuer M, et al. Choice, transparency, coordination, and quality among direct-to-consumer telemedicine websites and apps treating skin disease. JAMA Dermatol. 2016;152(7):768-775.
13. Clinical guidelines. American Academy of Dermatology website. https://www.aad.org/practicecenter/quality/clinical-guidelines. Accessed October 7, 2018.