PracticalDermatology

Given the dearth of dermatologists in rural areas, the visual nature of this specialty, and all of the advances in technology, many innovative dermatologists thought that telemedicine, or more precisely, teledermatology, would have caught on in a big way by now. But despite all of the promise, telemedicine has not brought dermatology care to the masses…yet. Daniel M. Siegel, MD, Clinical Professor of Dermatology at SUNY Downstate in Brooklyn, NY, and former President of the American Academy of Dermatology, explains why.

Where are we today in terms of teledermatology as an established care model?

Daniel M. Siegel, MD: The technology is here and has been for a decade. The reason it hasn’t caught on is because insurers are not reimbursing for this type of care in a consistent fashion. This is unfortunate, as such care is both time- and cost-effective. Given the paucity of dermatologists in many areas and long wait times to see dermatologists, improved access to dermatologists will result in early diagnoses of skin conditions. It is much more cost-effective to diagnose melanoma early when it is in its most curable stage.

Is there a particular teledermatogy protocol that is most effective?

Dr. Siegel: While live streaming or real-time video appointments may sound appealing, this may not be an efficient use of a patient’s or provider’s time, as it would involve watching the patient undress for an exam while you are staring at a screen while the patient will waste time later watching the dermatologist fill out prescriptions and forms. Store and forward dermatology, with asynchronous contact, allows both patient and physician to use their time in the most efficient fashion.

If not dermatology, what specialty is leading the pack in terms of telemedicine utilization?

Dr. Siegel: Radiologists. A patient can go to any walk-in clinic, and the images as well as any clinical information can be transmitted to a radiologist to read in real time. Radiologists can also embed patient information in the image so that they know the patient’s identity, but the identity is not compromised in any way using Digital Imaging and Communications in Medicine (DICOM) standards.

What is needed to move teledermatology forward?

Dr. Siegel: First, we need insurers to reimburse for this model of care in a consistent manner. Dermatologists take good pictures, but our images are not standardized. Standardized image capture is essential. We need a variety of images. If I am looking at a changing mole or a suspected squamous or basal cell carcinoma, the images need to be well lit and in focus. I want to see an overview of the area as well as close ups to look at lesion morphology. We also need interoperability among electronic medical records so that the images and information look the same regardless of how they are opened. It’s not the technology, but the implemementation of the technology that is the issue, and the US Centers for Medicare & Medicaid Services (CMS) is, in theory, going after data blockers who are standing in the way of such interoperability.

Now that retailers like CVS have in-store clinics that deliver a variety of services, where does dermatology care fit in?

Dr. Siegel: The level of care will vary greatly based on the healthcare provider’s background and training. The ability to transit standardized images to dermatologists in real time with patient identification data embedded would likely result in earlier and more accurate diagnoses of skin diseases.

Tell us about MedX Health Corp. and how this technology will help move teldermatology forward?

Dr. Siegel: I am on the Medical Advisory Board of MedX Health Corp. MedX is a medical device company with a device focused on skin cancer. Their hand-held Siacopes use patented technology utilizing reflected light of different wavelengths to see into suspicious moles and lesions, allowing for a close up dermatoscopy-type surface image, along with images of vascularity, collagen displacement and dermal melanin to evaluate and enhance the ability to differentiate benign from malignant lesions. For example, a pigmented lesion with no dermal melanin, no collagen displacement and normal vasculature is quite likely to be a seborrheic keratosis rather than a melanoma. By contrast, if there is an irregular mole, and collagen under the surface is displaced, the dermal melanin is asymmetrical and vascularity is increased, our index of suspicion for melanoma goes up.