How Can Telemedicine Best Access the Inaccessible?

Telemedicine, in general, and teledermatology, more specifically, came into their own during the COVID-19 pandemic, but the healthcare divide became even more apparent across many underserved areas during these trying times.

To help bridge these gaps, my colleague Adam Friedman, MD, chair of dermatology and residency program director at the George Washington University (GW) School of Medicine and Health Sciences (SMHS) in Washington, DC, implemented a telehealth help desk at the Temple of Praise Church in a residential area of Ward 8 in Washington, DC, an area that does not have any practicing dermatologists.

The program was so successful that GW and Pfizer Global Medical Grants are collaborating to offer a grant opportunity focused on the broad implementation of this model in underserved areas across the United States.

Dr. Friedman and I sat down to talk about the program’s inception, reach, and impact.

Why did you start this program?

Adam Friedman, MD: As healthcare practitioners, our ability to access our patients was certainly undermined by stay-at-home or shelter-in-place declarations. We recognized, especially in dermatology, the value of telemedicine and its ability to keep things somewhat normal so that we were able to still follow up on patients who need to be seen, especially those who are on longstanding therapies. Fortunately, telemedicine was no stranger to us. We’ve been using telemedicine for the last several decades. We have been limited in terms of our ability to employ it because of licensure requirements and reimbursements. But with the declaration of a Public Health Emergency (PHE), we were able to receive pay parity for these visits, and other restrictions were also eased.

We came up with some best practices in terms of ensuring the patient had the link, calling before the visit, and having our staff all in one place which allowed us to quickly act when things didn’t work. Of course, this happened frequently in the beginning, allowing for smooth workflows and really great communication. We wrapped up and banked a lot of experience using telemedicine early on and even published on that experience with respect to patient satisfaction. One of the things I noticed from our satisfaction data, in terms of demographics, was that there was a very small subset of patients from an area of DC that we know as a dermatology desert, who weren’t benefiting from this pivot.

What did you do?

Dr. Friedman: Serendipitously, Pfizer released a request for proposals for projects that addressed this very issue. I was very fortunate to have two amazing collaborators at GW,  Gigi El-Bayoumi, Director of the Rodham Institute, MD, and Neal Sikka, MD, co-chief of the section of Innovative Practice and professor of emergency medicine, both of whom paved the way for what became this program. Dr. El-Bayoumi's incredible connectivity and partnerships with community stake holders enabled us to engage the church where we ultimately held the clinic, and Dr. Sikka set the stage with his telehealth help desk model where doctors went into the community and trained residents on telehealth best practices. They didn’t undertake clinical visits but rather taught the residents how to use telemedicine. We expanded this successful program by both continuing the tradition of teaching individuals how to use telemedicine and what it’s all about and adding education on high-impact and common skin conditions like atopic dermatitis. We also facilitated a free clinic visit using the skills they just acquired. We brought these different pieces together to create this grant and turned the idea into a solid physical breathable thing that has now been working for more than two years and is in its second iteration at a church in Ward 8.

Tell us about the patient’s experience.

Dr. Friedman: Patients come in and can learn all about these amazing things. They learn about atopic dermatitis through posters and by interfacing with medical students who really are the lifeblood of this program. They undergo a telemedicine visit with an iPad and are armed with a telehealth helper or ambassador to show them how to best utilize the technology. These patients are also integrated into our system, and they can make a follow-up visit in person at GW, using telehealth at GW, or for another free telehealth clinic visit.

Now that PHE is over, where do you see teledermatology fitting in?

Dr. Friedman: We need to be purposeful. There are certainly many visit types that would not be amenable to telemedicine. For example, skin cancer surveillance via telemedicine is not a good idea. If you’re really concerned, you can’t do a biopsy through a screen. There are, however, many visits that can be done using telemedicine including isotretinoin follow-ups or other medication monitoring. This is one of many examples where telemedicine could make us more efficient and make it easier for patients to adhere to their treatment regimens.

What are some of the barriers to dermatologic care?

Dr. Friedman: There are very simple things that stop someone from being able to make an appointment or even show up on the day of their appointment. Socioeconomic factors can play a role and can really impact one’s ability to access a dermatologist.

It’s more than just being able to get somewhere. It’s the actual ability, wherewithal, and knowledge to pursue care. It’s not enough to say, “Hey, we’re offering this.” If you build it and you advertise it in a purposeful way to those who need it most, and prepare that population as best as you can, they will come. It’s not enough to just talk about it. You need to be thoughtful and inclusive when designing a program to ensure success and impact. It’s providing the technology, the bandwidth, space, and teaching the skillset of how you do it and how you optimize the visit itself that matters.