Snap an image of a skin rash or growth from your smartphone, forward it to a dermatologist for a virtual consultation and voila: Within a day or two, you receive the evaluation and recommendation. Welcome to the world of teledermatology.
At costs ranging from about $40 to $99 for app-based services, teledermatology is pretty affordable. And with dermatology practices in short supply in many parts of the U.S., teledermatology helps fill a gap. But virtual dermatology has its limits.
Teledermatology comes in different types. At one end of the spectrum are teledermatology services embedded within traditional health networks. Models like these allow dermatologists to collaborate with your primary care providers.
In contrast, many direct-to-consumer services rely on images from your cellphone and your written skin-problem description. Quality can be uncertain when you’re getting medical advice from unseen, unknown providers. If your condition turns out to be skin cancer, for instance, you want to make sure that clinicians get it right.
[See: 7 Ways to Prevent Skin Cancer.]
Telemedicine is nothing new to Dr. Karen Edison, a professor and chair of the dermatology department at the University of Missouri School of Medicine in Columbia. She’s been been practicing teledermatology for more than 20 years, throughout rural Missouri.
Videoconferencing allows Edison to weave teledermatology patients into her regular patient schedule. These patients travel to locations such as rural health centers and doctors’ offices, where clinicians use iPad minis to photograph skin trouble spots.
“We see patients the same way — just at a distance,” Edison says. “It’s real-time. You can ask follow-up questions. You look patients in the eye for their issues. There’s a back-and-forth discussion; a history of their present illness and a review of [organ] systems.”
When it comes to anonymous, direct-to-consumer online services, Edison has misgivings. She is concerned about quality of care, lack of transparency and the lack of connection to a patient’s medical records or local providers.
People with medical problems and multiple medications need coordinated care rather than turning to internet-only services, Edison says. However, she says, they might be OK for the “worried well.”
Quick Turnaround
As one of the worried well, I recently did my own teledermatology test run. Because the skin growth was located on my back, my husband took the two pictures — a close-up and an overview shot — using the virtual dermatology provider’s smartphone app.
Registering and filling out the case request took a few minutes. The app asked for age, city and country; how long I had the skin problem (months) and to include a brief description. Providing so little information was disconcerting: What about my medical history or current medications?
Within 24 hours, the results came back. Based on the information and images, the growth was possibly a seborrheic keratosis, which is not contagious and very common in adults, according to the response. Potential treatments were listed. If I noticed any of several skin changes, I was advised to see a dermatologist for an in-person examination.
Dermatology for the Underserved
In the U.S., a persistent shortage of practicing dermatologists makes teledermatology a virtual necessity. According to a September 2017 study on the dermatology workforce supply, the latest estimate is 36 practicing dermatologists for every 1 million people.
Several years ago, the U.S. Department of Veterans Affairs put a telemedicine program in place including teledermatology services to increase access for veterans living in remote areas, among others.
One method used in the VA program is “store-and-forward” teledermatology. Rather than taking place in real time, the primary care provider sends a consult electronically to the dermatologist after the patient’s visit, then waits for results to come in.
For vulnerable populations, teledermatology can increase access to dermatologists on a large scale, says Lori Uscher-Pines, a policy researcher at the RAND Corporation. A study led by Uscher-Pines and published in the August 2016 issue of JAMA Dermatology focused on teledermatology for people enrolled in Medicaid, who may have limited access to traditional in-office treatment.
Among more than 380,000 patients under a large California Medicaid managed care plan, which began offering teledermatology in April 2012 as a covered service, the number of patients who had at least one visit with a dermatologist nearly doubled by the end of December 2014.
Patients newly enrolled in Medicaid may benefit most from this greater availability. “Those patients can have a hard time establishing a relationship with specialists,” Uscher-Pines says. “They can often confront long wait times.” Often, she adds, busy providers won’t even take on new patients.
Direct-to-Consumer Options
In the realm of direct-to-consumer teledermatology, models of care still vary. Within health systems, it may take the form of patient portals leading directly to online dermatologists with access to patients’ electronic medical records.
This represents a high-quality form of teledermatology, Edison says — one that promotes accountability, complements in-person care and keeps primary care providers in the loop. Where she practices, she says, direct-to-consumer teledermatology is most popular with parents of pediatric patients.
In other cases, web-only providers may offer secure platforms with live videoconferencing and advanced imaging technology. Other providers depend solely on your smartphone camera skills .
[See: 11 Items to Protect Your Health.]
While emerging research supports patient satisfaction and accuracy with more-established forms of teledermatology, evidence on online-only virtual dermatology is scarce.
“Like anything else, teledermatology can be deployed well or poorly,” Dr. Jack Resneck Jr., a professor and vice-chair of the dermatology department at the University of California, San Francisco, wrote in an email. “When telemedicine allows patients to follow up more easily with a dermatologist who knows them and their history, it can be incredibly convenient and provide highly coordinated care.”
By allowing for quick second opinions from one clinician to another, teledermatology can be “incredibly useful,” says Resneck, who is also the chair-elect of the American Medical Association’s board of trustees. Some patients will require additional testing or treatment in person, he adds, and telemedicine can facilitate that process.
However, patients should proceed with great caution before venturing online independently to seek care, Resneck emphasizes: “Some of the other uses patients might find on the internet are providing fragmented, low-quality care for convenience.”
To highlight the pitfalls, Resneck points to research that he, Edison and others conducted last year. In this “secret-shopper” study, team members contacted teledermatology services by posing as dermatology patients and submitting online images of standard skin problems. The study, published in the July 2016 issue of JAMA Dermatology, evaluated 62 clinical encounters from 16 direct-to-consumer telemedicine websites. Websites that offered live, interactive video were excluded.
None of the providers asked the faux patients for identification, according to the study. Most patients were assigned a clinician without any choice. Only about one-quarter of sites asked consumers to name an existing primary care physician and only 10 percent offered to send records. Roughly one-quarter of sites disclosed information about clinician licensure.
Diagnoses or likely diagnoses of skin conditions were given in 77 percent of encounters, with prescription medicine ordered in about two-thirds of those cases. The diagnoses were more likely to be correct for conditions where visual symptoms in photos were sufficient.
However, diagnostic performance was poor when additional elements like fever or menstrual status were significant and follow-up questions would have helped. Major conditions like polycystic ovarian syndrome, or PCOS, were repeatedly missed. Whatever the diagnosis, “treatments prescribed were sometimes at odds with existing guidelines,” researchers noted.
[See: 10 Seemingly Innocent Symptoms You Shouldn’t Ignore.]
If you develop a skin problem and are considering going online to seek care, check on these items first:
Who is your clinician? Do you have a choice? “When new clinicians are involved in a patient’s care via telehealth, patients should always have the choice of the clinician who will care for them and know the credentials of the person providing that care,” Resneck says. Is the physician licensed in your state? Make sure that clinician is a board-certified dermatologist, Edison emphasizes.
Will your virtual dermatology results exist in a vacuum? “The site should offer coordinated care, sending records to a patient’s existing local doctors,” Resneck says. “That coordinated care must include having ties to the local area to facilitate any needed in-person follow-up care.”
When drugs are prescribed, does the clinician discuss side effects or pregnancy risks? In Resneck’s study, only 32 percent of clinicians discussed relevant adverse effects when prescriptions were provided.
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What to Know About Virtual Dermatology originally appeared on usnews.com
