Takeaway: Best practices for telemedicine in dermatology

Using telemedicine in dermatology

Dermatology Times editorial advisor, Elaine Siegfried, M.D., talks with Carrie Kovarik, M.D., associate professor, department of dermatology, University of Pennsylvania, Philadelphia, about her path into teledermatology, best practices, and the future of telemedicine.         

Elaine Siegfried, M.D. Dr. Siegfried: I recognize that you’ve been a champion of teledermatology for many years now. How did you become interested in this tool?

Dr. Kovarik: I had done quite a bit of global health work before attending medical school. When I began studying dermatology, I started work in Africa, which was in the middle of the HIV epidemic. I had the opportunity to see what a large role skin disease plays in HIV. There are a lot of manifestations of skin disease with HIV. With that in the background, I started working with the Baylor Internatioanl Pediatric AIDS Initiative BIPAI) in 2006 after I finished my fellowship. They were just starting to get their pediatric HIV clinics going in Africa and they needed help with dermatology. I traveled to all of their clinics giving lectures to their clinicians on the ground in Africa. So within about a year and a half, I went to Uganda,

Malawi, Lesotho, Swaziland and Botswana. In order to really sustain the relationship so that their clinicians could continue to get assistance, we started building bridges using telemedicine. That’s really how I started with my work in telemedicine.

Carrie Kovarik, M.D.Then when I came to the University of Pennsylvania, I realized that its major global health initiative was in Botswana on the grounds of Princess Marina Hospital in Gaborone, which is where Baylor’s clinic was. So, it was the perfect place for me to start building my major global health initiative.

Dr. Siegfried: You said that you began building bridges by using telemedicine. What year was that, and what kind of telemedicine were you doing at that point?

Dr. Kovarik: That was in 2007. And you’d think that wasn’t that long ago; but in technology years it really was. We really started with Internet-based telemedicine. When I was in Uganda, I virtually met Steven Kaddu, M.D., who was a Ugandan dermatologist and is now practicing in Austria. He wanted to build a connection back to Uganda to help using teledermatology, and together we have built up the Africa teledermatology program, which is still running today. It’s a very simple web-based portal where people can submit consults online. Over the years we’ve added the mobile platform; but initially it was just a very simple portal that could be used with dial-up Internet because there were many countries that still had that method of Internet connectivity.

Next: Confidentiality

The future of teledermatology and how to make it work for you

Dr. Siegfried: At that point did you have to worry about confidentiality? Was it all encrypted?

Dr. Kovarik: HIPAA is a very American standard, but there are security principles involved in the website. The website is developed by an experienced group in Austria who has other e-health initiatives. They have encrypted the data and it is secure. People have logins, and we encourage our submitting physicians not to submit any personal health information, so they’re not including names or dates of birth. We also discourage them from taking full facial photos. The patients also are educated on what we’re doing, and they have the right to decide whether they want their information sent to an expert in another country. In general, patients want an answer for what’s going on with them.

Dr. Siegfried: Can you talk about your current telemedicine activities in the United States and abroad in terms of the technology - the equipment is expensive and it has to be funded - and so considering that telemedicine isn’t well-funded, how do you adapt with new technology? Where do you get the funding for that?

Dr. Kovarik: Yes, so my vision all along has been to use what we have available. I never really thought that telemedicine would be sustainable by using any special equipment. In all of the Philadelphia City Health Centers, the physicians use their own smart phones for consults in a HIPAA-compliant manner. There is no special equipment required, which is completely sustainable in my eye. If the physicians don’t have a smart phone and don’t have an unlimited data plan, we can supply them with a digital camera. We received a $1K grant from the University or Pennsylvania, and we were able to buy ten digital cameras.

The city health clinic physicians use an app called AccessDerm, which we developed with the American Academy of Dermatology and a company called Vignet. Our program is strictly voluntary right now, and it’s aimed specifically at providing access to patients in the city of Philadephia who are underserved through the city health clinics.

We’ve been through many iterations of the workflow since 2009. I think we’re finally to a point where physicians can take out their phones, open the app, answer a list of questions that provide us the history we need, and then take the photos of the patients.

When the physicians first get their logins, they go through PowerPoint presentations that explain what we need from them in terms of what to photograph on the patient.

If the physician is linked to the University of Pennsylvania as their pool of dermatologists, when they submit their case there are about 12 of us here that would get an email. Whoever picks up the case first will answer it. If a resident picks up the case, they can answer it and then it would go back to the pool of attending’s for one of them to edit it, and then it will go back to the doctor that sent it.

Dr. Siegfried: So once you introduce this possibility, what percentage of the docs in these city health service clinics become users?

Dr. Kovarik: It was like the floodgates opened. We had 85 clinicians register in about two months. The interest was high; however not all of those who registered used the service. We found that there are the super users. I think what happens is that those people end up being sort of the “dermatology Primary Care Physicians” in the clinic. If there is a dermatology case in that clinic it tends to go to that physician. If the physician needs help, the teledermatology case comes to us. They really learn a lot from this, and so the physician continues to become a better dermatology expert in each of these clinics.

NEXT: How do you conduct telemedicine consults?

Dr. Siegfried: Are you conducting this as strictly store and forward? Do you have any real time consults? 

Dr. Kovarik: It’s all store and forward. I really think that’s also the future of teledermatology. I think video teledermatology has its place, but it’s going to probably become less utilized for many reasons: one, the equipment; two, the logistics; and three, it requires each person to be in the same place at the same time. You also need to write another record about the visit, because you’re not recording the video.

The beauty of dermatology is the fact that we were partially trained to recognize diseases through pictures, which is essentially what you are doing with store and forward teledermatology. If you talk to people that do a lot of video, you have to have specialized cameras for close-up as well. You end up having to get that special equipment that you were trying to avoid in the beginning and so for triage and treatment, it becomes logistically more difficult with the video.

Dr. Siegfried: I have not been very successful giving one-on-one tutorials on optimal digital images. How do you think your PowerPoint has worked in that regard, and have you had to make updates to it?

Dr. Kovarik: The way that our program is structured right now is that it’s an ongoing dialogue. The doctor sends us the case, we may send them back recommendations or questions, and they can send us back answers. So if we have to send the pictures because can’t see anything in the pictures, we’ll give them feedback on what’s wrong. I think the feedback is more valuable than a PowerPoint, because we do see improved quality over time.

The clinicians are very engaged. Part of our questionnaire tells us when the patient is coming back, so we can advise them to take pictures of specific things as well as what lab work they should get done. This way we can keep the patient workup moving.

RELATED: The virtual cosmetic consult

Dr. Siegfried: How does record keeping for your e-consultation services work?

Dr. Kovarik: Right now, it’s written within the web portal and stored in the cloud within our mobile teledermatology system. This is a medical record within itself.

Dr. Siegfried: Does this interface with your hospital EMR?

Dr. Kovarik: At this point no; however, we do have a new initiative that we’re planning. We’re currently in discussions with a private insurance carrier as well as our EPIC group to add a teledermatology workflow.

Right now our peripheral primary care offices can send a Consult to Dermatology as an order through EPIC. It comes into our office, we look at it and we try and decide what to do with the patient.

I have colleagues at the University of Texas Southwestern Medical Center in Dallas who have taken that Consult to Dermatology and turned it into a teledermatology consult, similar to our AccessDerm program.

They added the AccessDerm questions that we currently use with Philadelphia and into the Consult to Derm form in EPIC. They’ve added the ability to insert photos into EPIC and create that teledermatology workflow.

Here, at the University of Pennsylvania, we want to do the same thing, but integrate a mobile workflow. So if you’re a PCP and you’re in one of the Philadelphia Penn affiliates and you want to send a consult, you’ll pull up the Consult to Derm form and fill in a few more questions. Then, to add the pictures, we’re hoping to create a mobile interface that will directly integrate into the patient record. So the PCP can use his or her mobile device to take the photos and then send the record as a teledermatology consult. We can then answer the consult and help you treat your patients or we’ll have more information to actually get them into the right clinic.

I think using teledermatology as triage and/or treatment through EPIC would really help us enhance our services here. So that is our next project.

NEXT: What can you use telemedicine for? What are the limitations?

Dr. Siegfried: What distinguishes an issue that you can treat or triage with teledermatology and one that you can’t? Are you aware of anyone who’s actually trying to quantify or study that? Have you come up with parameters to distinguish between those cases?

Dr. Kovarik: Most studies show that about 15 percent of cases need to be seen in person. That’s about what we’ve found in our Philadelphia clinics; whether it’s for biopsy, further evaluation or the case is too complex. We also don’t want PCPs doing full skin exams and then picking out the lesions to take pictures of and send to us.

There are studies saying that it can be difficult to screen for malignancies, however there are also good studies showing that dermoscopy works really well. So, if you have the ability to receive dermoscopic photos of pigmented lesions, you can actually screen individual pigmented lesions if you’re skilled at looking at these.

You need to know when to search for more; you need to know what you’re limitations are.

Dr. Siegfried: It seems to me that teledermoscopy and teledermatopathology may be more amenable than teledermatology, to global use, because the image is two-dimensional and with relatively limited number of views?

Dr. Kovarik: Pathology, in general, is very amenable to telemedicine. Its very much like radiology, where you have an image and you interpret the image. Same with dermoscopy: you get that image; you interpret it.

Dr. Siegfried: So does your system in Africa or Philadelphia incorporate teledermoscopy and teledermatopathology at this point?

Dr. Kovarik: We’ve had a wide telepathology system in Botswana since 2009, and I’ve read about 500 cases. In fact we just published a paper on robotic teledermatopathology.[1]

Next: Difference from standard dermatopathology

Dr. Siegfried: How do you find that different from standard dermatopathology?

Dr. Kovarik: It’s all limited by the technology. I use a live system, which is really going out of style, because it’s all going to slide scanners. But in 2009 en vogue was live robotic telepathology where you put the slide on the scope. The difference is that for live telepathology you need a nice fast Internet connection. Because it’s a live streaming connection, I’m moving the slide and I’m seeing it move as the pathologist in his office is watching his microscope move.

So, I can actually move the stage and move the objective in Botswana, and I can take pictures of it up to 40X. I get great resolution and take beautiful pictures. The limitation is often the slide processing, it’s not the microscope. It’s the fact that I may get thick sections or fragmented tissue.

What a slide scanner does is that it scans the slide and it generates this massive 60-100 megabyte image, and so to upload that to me from Botswana on that Internet would take all night long. In addition, these slide scanners are really expensive. We are actually working with a hospital in Ethiopia that just bought a four-slide, slide scanner. They have a pretty fast connection; so for the first time we’re going to help their hospital to do telepathology using a slide scanner.

Dr. Siegfried: Now there are all kinds of little things that you can hook on to your iPhone. Do you have a favorite one? I would imagine that the technology is very similar to doing teledermatology?

Dr. Kovarik: The group in Austria who is actually the group that did the Africa telederm website with has published some very nice studies on teledermatocopy.[2] They have several iPhone adaptions. It can be done; particularly if you’re working in a place where you can’t biopsy a lot of lesions and you are good at looking through a dermatoscope.

Dr. Siegfried: It seems to me that successful e-consultation from a dermatoscopic digital image taken by a non-dermatologist may be easier than from a clinical image.

Dr. Kovarik: It would be helpful; particularly if they’re worried about a certain segment of a lesion.

NEXT: Thoughts on future incentives to cover cost

Dr. Siegfried: There’s a new code for remote e-consultation, and several states are considering reimbursements for telemedicine. Do you envision future incentives to cover the cost, technology and who will be performing teledermatology once it’s well accepted?

Dr. Kovarik: I’m part of a few committees where we’re working on reimbursement for telemedicine services. I think as our health care reimbursement models change, telemedicine may not be fee-based reimbursement everywhere, but certainly we’re still working towards that.

It’s reimbursable in many states right now. There are bills up in the majority of states right now to have it reimbursed.

I think in the end it‘s going to be a part of value-based care. I think people are going to use it, like we talked about Penn using it for triage, to add value to services, to get patients evaluated and to the right clinic faster.

I think people are getting tired of waiting many months to have dermatologic conditions evaluated, and telemedicine is a great way to be triaged or to get an urgent consult. I think it could be bundled into payments for these services. So I think, in the end, it’s going to become a very useful part of our healthcare system and certainly patients accept this technology and patients will drive this forward because they like the instant answers.

Dr. Siegfried: Reimbursement, I think, is a big barrier to success. Do you see any other barriers to future success?

Dr. Kovarik: Right now some of the barriers are people’s anxiety around new technology. I think more education about what telemedicine is would help people understand how it works, how it can be helpful, how it can save money and benefit patients. Right now people think it’s heavy technology and expensive equipment and they don’t feel they have time for it.

Other barriers: doctors worry about the liability. But, telemedicine has been done for 20 years, and there are less lawsuits percentage-wise that have come up in telemedicine than in other medical care settings.[3] It’s definitely not more lawsuit ridden; it’s a different way to deliver health care, but these fears need to be addressed in order for people to engage.

Dr. Siegfried: So how did you introduce it? Do you provide in-service education? Do you send emails? How do you introduce users to the benefits?

Dr. Kovarik: The best way is one-on-one: showing people the app. Other ways that work seem to be in a conference with the residents or a lecture with attendings; showing screenshots and showing them what it’s about.

Dr. Siegfried: Do you have any suggestions for dermatologists who are interested in setting up a system of teledermatology locally, or getting involved in anyway?

Dr. Kovarik: The first thing is figuring out if they’re in a state where it reimburses. If they’re not, we do have the AccessDerm program through the AAD which they can use for volunteer services. The AAD will help with setting it up. Dermatologists have been using that for some interesting services. In Iowa, for Mohs patients who are elderly and have difficulty coming in for follow up, it has been used to engage the patient’s PCP to follow-up with wound care. Dermatologists are welcome to use that platform with patients that may have difficulty with access.

We also have another initiative with the AAD for in-patient teledermatology. We have about 16 groups that are providing in-patient teledermatology services around the country right now. This program is encouraging these groups to set up some type of business contract; so if there’s no reimbursement in the state, there are actually many groups that have set up independent contracts to reimburse for telemedicine.

For example, the University of Pittsburgh has set up service agreements with local hospitals in which they provide inpatient and emergency department consultations, home-based primary care consultations, outpatient consultations, and dermatologic education.[4]

References

[1] Michelett R.G., Steele K.T., Kovarik C.L. Robotic teledermatopathology from an African deratology clinic. J Am Acad Dermatol. 2014;70(5): 952-954

[2] Kroemer S, Frühauf J, Campbell TM, et al. Mobile teledermatology for skin tumour screening: diagnostic accuracy of clinical and dermoscopic image tele-evaluation using cellular phones. Br J Dermatol. 2011;164(5):973-9

[3] Marsch A, High WA. Teledermatology, teledermatopathology, interstate dermatopathology and the law. Semin Cutan Med Surg. 2013;32(4):224-9

[4] English JC, Gehris R, Leyva W. Add Pittsburgh teledermatology "with a twist" to the map!. J Am Acad Dermatol. 2013;68(6):1042