COVID-19 and a Transition to Teledermatology

CMS defines telehealth, telemedicine, and related terms as the exchange of medical information from one site to another through electronic communication to improve a patient’s health. Numerous barriers have delayed the implementation of telemedicine in the US. For example, health care organizations have identified cost, reimbursement, and legal liability as the most frequently listed limitations for implementation of telemedicine. For patients, the most commonly listed barriers include age, level of education, and computer literacy.¹

A 2016 article in JAMA reported there are fewer than 3.4 dermatologists for every 100,000 people in the US, highlighting a need for alternate delivery of care to these patients.² As skin cancer is the most common tumor in humans and as there is a growing aging population, there is a need for additional systems for dermatology care in the US. The delivery of dermatological care through information and communication technology is termed teledermatology. One of the greatest strengths of teledermatology is its role as a triage and/or monitoring tool to help reduce unnecessary referrals as well as wait times for patients. In addition to medicolegal responsibility, reimbursement of teledermatology services has long been a barrier for many providers to adopt this form of care.³ For example, a 2018 review of teledermatology services revealed self-pay as the most frequently accepted payment method and academic institutions as the most common practice setting for delivery of teledermatology.⁴

The 2020 spring spike in COVID-19 cases in the US meant numerous health care offices had to decrease or halt in-person care. The passage of the CARES Act allowed CMS and the federal government to lift many restrictions on the use of telemedicine. These changes greatly expanded access to telehealth and expansion of telehealth services.⁵ Additionally, numerous states have taken action to suspend or waive certain practice requirements for physician assistants (PAs) in response to the COVID-19 pandemic. In a letter in the May 2020 issue of JAAD, recommendations for the delivery of dermatology care via telemedicine include using existing EMR systems, identifying highest-risk or urgent patients and scheduling them for telemedicine visits, deferring all nonessential visits until a later time, and developing an established pathway for contact and evaluation for urgent patients while ensuring patients know there is a clear line of communication to minimize emergency department overuse for noncritical issues.⁶ Ahead is the summary of physician assistant Justin Love’s personal account of the adoption of teledermatology during COVID-19.

Embracing Teledermatology

“Can you hear me okay?”—this is a phrase I never thought I would have to repeat so many times in a given day, week, or year for that matter. The office in which I practice had discussed the use of telemedicine prior to the pandemic, however, reimbursement issues and EMR software were our biggest hurdles. In addition, as time is limited in a busy dermatology office, there always seemed to be a more important and pressing issue. Previously, many of us considered teledermatology a resource for patients that allowed increased access, however, once COVID forced the closure or decreased capacity of most medical offices in the US, teledermatology became a necessity for delivery of timely care to our patients.

The transition to teledermatology has revealed numerous challenges with our current system of health care delivery. For example, how can providers best visualize a condition through a lens they may not be able to control? Technological issues include the reliability of internet connection and patient familiarity of platforms. Further considerations include medico-legal implications and the guarantee of patient privacy. Fortunately, the US government was able to assuage some of these concerns when they temporarily lifted restrictions on Medicare to allow access to telehealth services early in the pandemic.

In my experience as one of two PAs in our office, I felt the need to become the “go-to” person to learn and implement telemedicine in our office. Adaptability is an important trait for physician assistants—we are trained to not only adapt to practice within different fields of medicine but also within varying roles of a team. It was my hope that my ability to transition quickly to adopt telemedicine would illustrate my value to our office during this challenging time.

Early on, I found myself using telemedicine as more of a triage to determine if we needed to see a patient urgently. As our office became more familiar with telemedicine, we implemented the use of pandemic billing codes and compliance phrasing, which helped with our documentation and billing of services. It has been my experience that telemedicine has worked best for established patients and/or patients with established conditions. Delivery of a full body skin exam, on the other hand, has become more challenging, and at times requiring a sense of humor as patients attempt to do this from home.

Celebrating small victories, such as a patient’s ability to navigate new technology while in their 70s-90s, has been a glimpse of hope for my office and patients. For many of us, we find ourselves asking why we had not implemented this technology sooner. Several months in, while I still find frustration with conducting teledermatology visits and having to navigate possible audio-visual issues, I do find some comfort when I now ask, “can you hear me?” and a patient’s response is a resounding “yes!”

1 Scott Kruse C, Karem P, Shifflett K, Vegi L, Ravi K, Brooks M. Evaluating barriers to adopting telemedicine worldwide: A systematic review. J Telemed Telecare. 2018;24(1):4-12.

2 Glazer AM, Farberg AS, Winkelmann RR, Rigel DS. Analysis of Trends in Geographic Distribution and Density of US Dermatologists. JAMA Dermatol. 2017;153(4):322–325.

3 Lee KJ, Finnane A, Soyer HP. Recent trends in teledermatology and teledermoscopy. Dermatol Pract Concept. 2018;8(3):214-223. Published 2018 Jul 31.

4 Kaitlyn M. Yim, Aleksandra G. Florek, Dennis H. Oh, Karen McKoy, and April W. Armstrong.Telemedicine and e-Health.Sep 2018.691-697.

5 https://www.ama-assn.org/delivering-care/public-health/cares-act-ama-covid-19-pandemic-telehealth-fact-sheet

6 Lee I, Kovarik C, Tejasvi T, Pizarro M, Lipoff JB. Telehealth: Helping your patients and practice survive and thrive during the COVID-19 crisis with rapid quality implementation. J Am Acad Dermatol. 2020;82(5):1213-1214.