PracticalDermatology

As the numbers of the infected rose and the world went into quarantine, medical offices had no choice but to become innovative to provide care to their patients. The shift to teledermatology left many questioning if this would be feasible and able to maintain the level of quality of in-person visits while avoiding contact. How did this shift affect academic centers compared to private practices? A study involving 4 clinical sites in New Haven, CT assessed their transition for 3 weeks from ambulatory care to teledermatology visits. The number of teledermatology visits increased by 191% within the first week of the transition. By the third week, 41% of the pre-pandemic patient volume was being seen as teledermatology visits.

Increased Use and Availability of Teledermatology

So how useful was teledermatology during this time? An American Academy of Dermatology (AAD) survey took a look at dermatologists’ perspectives of the adaptations made during the surge of COVID-19. Before COVID-19, out of the 4,356 responses received, 14.1% used teledermatology compared to 96.9% during the COVID-19 pandemic—a 7-fold increase. The most common barrier described was technology/connectivity issues during the visits (223 of 570).

From the financial aspect of the visit, 357 of 419 dermatologists (85%) thought reimbursement for teledermatology visits was too low. As far as assessing how effective body examinations were using this technology to assess lesions, acne, rashes, and moles, 512 of 535 dermatologists (96%) felt skin checks still required in-person examination.

In the US, the use and availability of teledermatology visits increased substantially in dermatology offices. A majority (86.5%) of dermatology practice websites offered teledermatology as opposed to in-person visits. Within these practices, 42.6% used video consultation. In addition, restrictions on practicing across state lines were lifted, increasing accessibility to those who many have not been able to attend in-person visits due to issues such as transportation, childcare, social anxiety, and challenging work schedules.

Concerns were raised about the effect of teledermatology visits on practice income and finances. However, as an attempt to encourage physicians to use teledermatology during COVID-19, insurance companies allowed payment parity for these visits to help compensate for decreased visits and procedures. Moreover, teledermatology visits proved to be shorter, eliminating waiting and visit times, which permitted clinicians to schedule a greater number of patients, at least in some practices. Asynchronous teledermatology allowed clinicians to review photos and history before each appointment, helping to compensate for poor video quality issues.

In an online survey conducted in early May 2020, 186 of 480 members of the Professional Association of German dermatologists used some form of video consultation or store-and-forward teledermatology, 4 times as many as before COVID-19.

Is Teledermatology a Good Thing? The Good and the Bad

The use of teledermatology has been beneficial to both health care practitioners (HCPs) and patients. HCPs have found that using teledermatology for initial consultations is a great resource and can allow for more efficient triaging, but there are clearly situations when an in-person visit is deemed necessary, such as when a procedure would be indicated.

Teledermatology is also ideal for patients who are known or suspected to have COVID-19 who need care and can provide services while patients are isolated and/or awaiting test results.

As with all innovations, there are challenges that must be considered to improve teledermatology. While this type of visit may be excellent for acute concerns, the limitations of telemedicine can mean missing things that could be captured by dermatologists during a live, in-person examination. Furthermore, technological malfunctions and limitations on bandwidth can cause video and audio issues in teledermatology visits, making an already non-ideal situation worse. Moreover, the lack of access to procedures with teledermatology consultations is still a problem that leads to care gaps.

Privacy concerns are another disadvantage of teledermatology use. Many patients and HCPs do not believe this service is personal and confidential because there is no standardized system to protect the confidentiality of patients, with reports of offices even using off-the-shelf messaging software during these times. While CMS waived HIPAA regulations during the first years of the COVID-19 pandemic, this was meant to be temporary and, for some at least, may reduce confidence in privacy.

Finally, while there are enough pros to suggest that telemedicine should be available as a service for all, there is a lack of access to technology for certain populations such as the elderly, urban communities, and those who do not have access to the internet can limit its use. While the future of teledermatology remains promising, addressing the challenges will be able to refine this technology and allow greater access for patients seeking care.

Conclusion

Although there are many challenges with teledermatology, this service has proven to be beneficial in increasing access to dermatologic care, decreasing transportation times, and eliminating unnecessary in-person visits. The future of teledermatology is promising as it redefines routes of health care and the ability to reach more patients who are in need. From the perspectives of dermatologists, there is a need for reimbursement, regulation for privacy, and solutions to technological difficulties i.e. connectivity and access to the Internet. In addition, refining what types of visits are best-suited for teledermatology seems to be something that HCPs believe will help to improve the use of these types of visits.

For further reading:

Elsner, P. (2020), Teledermatology in the times of COVID-19 – a systematic review. JDDG: Journal der Deutschen Dermatologischen Gesellschaft, 18: 841-845. https://doi.org/10.1111/ddg.14180

Farr, M.A., Duvic, M. & Joshi, T.P. Teledermatology During COVID-19: An Updated Review. Am J Clin Dermatol 22, 467–475 (2021). https://doi.org/10.1007/s40257-021-00601-y

Gupta, R., Ibraheim, M. K., & Doan, H. Q. (2020, April 22). Teledermatology in the wake of COVID-19: Advantages and ... - jaad.org. jaad.org. Retrieved July 4, 2022, from https://www.jaad.org/article/S0190-9622(20)30696-4/abstract

Perkins, S., Cohen, J. M., Nelson, C. A., & Bunick, C. G. (2020, April 16). Teledermatology in the era of COVID-19: Experience of an academic ... Retrieved July 4, 2022, from https://www.jaad.org/article/S0190-9622(20)30661-7/fulltext

Kennedy J, Arey S, Hopkins Z, et al. Dermatologist Perceptions of Teledermatology Implementation and Future Use After COVID-19: Demographics, Barriers, and Insights. JAMA Dermatol. 2021;157(5):595–597. doi:10.1001/jamadermatol.2021.0195

Zakaria, A., Maurer, T., Su, G., & Amerson, E. (2019, August 12). Impact of teledermatology on the accessibility and efficiency of dermatology care in an urban safety-net hospital: A pre-post analysis. Journal of the American Academy of Dermatology. Retrieved July 4, 2022, from https://www.sciencedirect.com/science/article/abs/pii/S0190962219325630