PracticalDermatology

What are barriers to traditional in-office dermatology consults?

Camille Introcaso, MD: There are a number of barriers of access to specialty dermatology care. I think those barriers can vary depending on where our patients are and what their resources are, but certainly one significant barrier is geographic location. There are large parts of the world and then certainly of our own country where there are not many specialty providers, particularly in dermatology.

Financial resources warrant consideration—most basically just being able to have access to health insurance that covers specialty visits. Other kinds of resources like access to transportation to a dermatologist or the ability to have either time off from work or child care influence whether a patient can go to a dermatologist in person.

How and why did you get involved in teledermatology?

Dr. Introcaso: I have worked with AristaMD for about a year now. AristaMD reached out to me through the Doximity platform to let me know about their telehealth platform. My own background involves quite a bit of telemedicine through volunteer work. I've had the opportunity to work internationally as a dermatologist, both in Africa and South America.

On what types of cases do you consult? Do cases differ from typical practice?

Dr. Introcaso: My experience has really run the gamut. Sometimes the consults that I get are very straightforward. For example, a primary care provider may send a picture of a mole asking if it requires biopsy or could be monitored. That's the same type of thing that I see in my own practice day in and day out.

Quite a few straightforward rashes, irritations, and contact dermatoses come up. I definitely see the day-to-day things that I would see in my practice. I also see, and to a much greater degree than I see in my own practice, patients who have conditions that have been neglected because they didn't have the resources to address them earlier. I certainly see through the consult platform more advanced skin cancers. I see people who have skin manifestations of internal disease that has not been well controlled, such as diabetes, vascular disease, and more complicated conditions like lupus.

Overall the consults that I receive through the AristaMD platform are patients who have more serious dermatologic conditions than what I typically see in my day-to-day practice. I think that's a reflection that those are patients who haven't really been in regular care.

My interactions with consults are all generated by, then sent back to, the patient's primary care provider. That could be a physician's assistant, a nurse practitioner, or an MD or a DO. These are patients who are mostly at institutions, including prisons or federally qualified healthcare centers—places where people are either living under the poverty line or have state Medicaid services and get their care at a primary care doctor.

The primary care provider will decide that they would like to ask for specialty consult services, or the clinic's workflow is such that all referrals are reviewed for e-consult eligibility. The providers then communicate with me directly and send a store-and-forward telehealth consult.

I review everything then type up my answer, and through the same platform send that information back to the primary care provider. AristaMD asks us to commit to answering within 24 hours. That has never been a problem.

What's the best part of providing e-consults? What's the worst part?

Dr. Introcaso: I would say there are two “best” parts: one is a bit selfish and one is more altruistic. Selfishly, I really learn a lot from the consults. Unlike in clinic when I have to come up with an answer and a plan right away, if I have an e-consult, I have a little more time and I can do some reading. I can think about the treatment approach a little bit more in depth, and I really take the opportunity to give myself some more education and then craft answers that are not only going to answer the question for the primary care provider, but hopefully provide some education about the condition, as well.

It's very meaningful to be able to see these pictures of somebody who has not had the opportunity to get care and know that you're going to be able to make some suggestions that won't cost them anymore. They won't have to go someplace else for a visit. It will help to strengthen their relationship with their primary care providers and will really provide excellent care for them.

I don't have much negative to say. In particular, working with this company has been very easy and convenient.

What do you think is the future of teledermatology?

Dr. Introcaso: I think the next five years are probably going to be a growing period for telehealth in general and certainly for dermatology. I think more and more patients are going to be expecting to be able to communicate with their dermatologist via mobile platforms. I think payers are going to be trying to figure out what could be covered, what the appropriate payments for telehealth are going to be, and doctors are going to be figuring out how to work that into their regular schedule.

I do think it's the future of medicine. Looking out 10 or 20 years, I think that we'll have figured out how to make this a regular part of our healthcare system, both for convenience for patients as well as health costs saving. It could be a potential major cost savings to the healthcare system as a whole, if patients are able to be triaged by their primary care providers or even do direct interfacing with specialists on their own. But it's going to take us a little while to figure that all out, especially since the healthcare system is changing rapidly in other ways.