Journal of Dermatology for Physician Assistants

The official journal of the Society of Dermatology Physician Assistants

Increasing Dermatology Access Via Teledermatology

By Jason E. Quicho, DMSc, PA-C

Jason E. Quicho, DMSc, PA-C, graduated from Samuel Merritt University’s Physician Assistant program in 2015 and completed his Doctor of Medical Science degree at the University of Lynchburg, Lynchburg, Virginia, in 2020. He has worked in both county and large hospital dermatology based practices during the last three years and is currently working full time with the dermatology group at Kaiser Permanente in San Francisco, California. He is a member of the Society of Dermatology Physician Assistants (SDPA) and the American Academy of Physician Assistants (AAPA).

ABSTRACT
Purpose: The purpose of this article is to identify if teledermatology is a viable approach compared to traditional in-office dermatology visits for effective and increased access to dermatologic care in underserved populations and within resource limited hospitals. Method: A literature search was conducted with search terms “teledermatology,” “underserved,” “dermatology,” and “hospital.” Seventeen pertinent articles were retrieved that serve as the basis for this review. Results: While recent literature has shown teledermatology may increase access to dermatology providers and improve treatment of cutaneous diseases in under-resourced health centers, further studies are needed to explore the benefits and challenges when implementing teledermatology in wider practice settings. Conclusion: Dermatological issues are common chief complaints many primary care providers encounter. While some issues are benign, others require referral to dermatology providers to rule out worrisome pathologies. Given the shortage of dermatology providers in the United States, many patients in underserved populations and resource-limited hospitals often wait weeks or months to be seen. Use of teledermatology combats the shortage of dermatology providers by providing access to patients who are unable to receive dermatological care in a timely, efficient, and cost-effective manner.

INTRODUCTION
Access to dermatology providers in underserved populations and hospitals with limited resources is in high demand.1 Many patients have urgent dermatological needs that may have not been addressed by their primary care providers (PCPs). Further, numerous complex cutaneous pathologies often present in patients who lack medical resources as well as those in hospitals with limited resources. Since patients often face multiple barriers in accessing dermatology providers, patients often wait weeks or months to be seen.1 Due to the shortage of dermatology providers in the United States, different approaches to healthcare delivery must be considered in order to provide efficient and increased access to care within these patient populations.

With the advent of new technological capabilities and breakthroughs in medicine, patients now have increased options to provider access. An example of new technological access is through teledermatology. Teledermatology is a subspecialized field within dermatology that aims to provide increased access to patients through digital platforms via audio, visual, and data communication.2 Since teledermatology is a recent subspecialty within dermatology, further research is needed to determine if teledermatology provides effective and increased patient access compared to traditional in-office dermatology.

DISCUSSION
Establishment of Telemedicine. Telemedicine began around the 1950s starting with hospitals sharing images along with information via telephone. Overtime, it slowly developed from sending radiographic images to connecting physicians with patients and specialists remotely.3 With the establishment of telemedicine, a larger geographical reach, especially for individuals in rural regions without access to specialist care, was quickly realized. Further advances through other technological means, such as portable computers and smart phones, improved access, paving the way for modern telemedicine. The ability to transmit high-quality videos and audio in real-time resulted in cost-effective measures and enabled care for patients who were unable to visit specialists otherwise. While many medical specialties recently incorporated telemedicine within their practice, dermatology has been utilizing telemedicine for quite some time.

Beginnings of Teledermatology. Teledermatology has increased in utilization during the last few years. Given the demand of dermatological care and shortage of dermatology providers, teledermatology has allowed for increased and timely access to patients who need dermatological care. One of the greatest benefits of teledermatology is the increased access to care in rural and remote settings. One of the more common uses in teledermatology is in skin cancer screenings, diagnosis, and treatment management. This has been an active area within teledermatology and numerous studies in the literature have shown a reported accuracy in diagnosis rates of around 80 percent.4 Dermatologists performing teledermatology were able to correctly diagnose 36 of 38 (95%) cases with an average confidence level of 7.9 of 10.5. The average time to consultation was 0.8 days with patients reporting high levels of satisfaction.5 Teledermatology has greatly increased access to dermatological care and continues to refine its processes to better streamline services while providing cost-effective care.

Access to Dermatology Providers. Dermatology access is provided through teledermatology and in-office dermatology settings. Unfortunately, there is a shortage of dermatology providers in the United States, especially in resource-limited settings (RLS). RLS are classified by limited access to providers; few healthcare professionals; less developed infrastructure; and reduced availability of medications, supplies, and equipment. Dermatologists in RLS are fewer in number and generally work in urban areas, rarely traveling to rural communities.6 Patients who live in rural areas often lack access to seeing specialists due to cost of transportation and services. Further, healthcare professionals in rural areas may lack sufficient dermatology training. This limits effective dermatological care for patients who do not have access to dermatology specialists.

Access Via Teledermatology. Teledermatology is a cost-effective way to deliver dermatological care to underserved areas.7 Further, teledermatology reduces in-person visits allowing for patient convenience and quicker delivery of care. There are currently two main modalities in use for teledermatology—”store-and-forward” and “live interaction.” Store-and-forward handles digital pictures uploaded by a referring provider while live interaction typically involves a video interaction with a provider and a dermatology provider. Teledermatology increases patient care while decreasing the access gap by mitigating patients’ cost and time concerns. Importantly, teledermatology can be implemented in rural or resource-limited hospitals where providers are familiar with endemic diseases and local healthcare delivery.6 A telephone survey of 148 patients who were randomly selected out of 1,030 patients who had been seen by store-and-forward teledermatology sought to measure patient satisfaction with teledermatology providers and services. When asked how satisfied responders were with their teledermatology providers, 87 percent rated their providers as excellent or good and 83 percent rated the explanation, they received about the teledermatology service as excellent or good.

In-office Dermatology. In many PCP practices, skin diseases are present in 30% of all office visits. Chronic skin diseases lead to decreased quality of life and financial consequences. In the U.S., patients living in remote and underserved areas have difficultly accessing dermatology providers for initial and follow up care.8 As the U.S. population and average life expectancy continues to increase, there exists a need for dermatology providers. With the increased incidence of skin cancers and complex skin disorders, there is a high demand for dermatological providers.9 In 2014, dermatology mean appointment wait times were 18 days for established patients and 29 days for new patients. Wait times for new and established patients in rural areas were longer than those in urban areas. Further, travel time for rural patients seeking dermatology care were longer than those residing in urban and metropolitan areas.

BILLING AND PRIVACY CONCERNS
Teledermatology allows for quicker access to providers and plays a large role in delivering dermatological care. One of the greatest strengths of teledermatology is its role in triaging by reducing the number of unnecessary referrals resulting in decreased wait times for patients.10 While teledermatology allows for increased access to patients, concerns such as billing, insurance and privacy issues must be accounted for in order better understand the benefits within this subspecialty of dermatology.

Billing and Insurance. Teledermatology provides benefits to the healthcare provider and patient by improving access to care. While few studies found teledermatology to be more expensive than conventional care, most studies show teledermatology as equivalent or more economical than face-to-face visits. The economic benefits for healthcare systems resulted in fewer face-to-face specialist referrals, reduced travel time, reduced costs, and decreased time away from work for patients leading to quicker assessments and treatments.11 Real-time video consultation in teledermatology tends to be more expensive than store-and-forward modalities but can be cost effective, particularly if patients live far from dermatological specialists. Further, reimbursement can be an issue when integrating teledermatology into healthcare systems. Teledermatology reimbursement depends on the modality used (store-and-forward versus real-time versus hybrid), consultation costs, follow-up, and referral processes. If implemented within the appropriate setting, teledermatology can increase quality of care while decreasing costs.12

Privacy. Patient privacy must be considered when establishing new modalities of healthcare delivery. Privacy can be achieved by requiring secured login details and consent before information is delivered between healthcare provider and patient. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects patients’ medical records and health information. To successfully implement teledermatology, appropriate navigation of HIPAA is crucial.13 There are many systems in place ensuring the protection of patient privacy. These include electronic billing to minimize fraud and devices that protect the security of information by utilizing passwords preventing unauthorized individuals from accessing patient information. Overall, teledermatology is safe and secure but can always be further improved upon to ensure patient privacy and protection.

OUTLOOK OF TELEDERMATOLOGY
Teledermatology has successfully increased access to dermatology care for many patients. Teledermatology has proven to be accurate in diagnosis, management, and clinical outcomes when compared to in-office visits. It has decreased many barriers patients faced prior to initiation of teledermatology.14 Teledermatology can be applied to many medical settings such as hospitals, outpatient clinics, nursing homes, and in underserved and remote settings to deliver care. Further, teledermatology has decreased patient wait times for patients seeking care for their cutaneous concerns.

Impact on Rural and Underserved Populations. Many underserved areas receive minimal to little exposure to dermatological specialists. It is important to note that cutaneous conditions may be the initial manifestation of more worrisome medical diagnosis, cancer syndromes, and other conditions.15 Given the shortage of dermatology providers in the U.S., finding access in rural or underserved hospitals continues to be a challenge. Fortunately, the advent of teledermatology resulted in community outreach and improved access to dermatologic care. Using photographs, PCPs are able to send digital images to remote dermatologists who then evaluate the cutaneous concerns without being physically present. Uninsured patients, those living in rural areas, and those who seek care in underserved or safety net hospitals tend to have decreased access to dermatologists. Teledermatology has reduced barriers to care among disadvantaged populations.

Future Implications of Teledermatology. Teledermatology helps fill a crucial void given the shortage of dermatology providers. This is shown in the effective deliverance and efficacy of teledermatological care provided in rural and underserved communities that often lack specialists. Newer and more sophisticated technologies such as smart phones and virtual phone apps have further increased access to dermatology providers. For example, mobile teledermatology (such as smart phones), are a cost effective and triaging tool useful for PCPs in underserved and remote areas and has effectively reduced wait times for patients seeking dermatology care.16 With quickly developing technological advancements and demand for dermatology services, teledermatology has paved the way for efficient and cost-effective care.

CONCLUSION
Dermatology access and care is in demand. Due to limited and difficult access especially in rural and underserved patient populations, new and novel approaches are needed for patients seeking consultation for dermatology services.17 In recent years, there have been discussions of telemedicine, in particular in dermatology, to meet the growing needs of patients seeking dermatological care. Teledermatology involves delivering dermatological care via communication technology such as live interactive and store-and-forward. Some organizations utilize a hybrid model where images are used in combination with videoconferencing.2 Others incorporate mobile teledermatology such as smart phones to better deliver and increase access to dermatology care.16 Technological access via teledermatology helps decrease the need to be seen in person for certain dermatological concerns, especially for patients in rural or safety net hospitals where care by specialists is often difficult to obtain. By utilizing teledermatology, increased access and decreased wait times will provide patients with quicker appointments for their dermatological conditions and concerns.

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