Teledermatology for remote communities
Store-and-forward technology allows access to expert dermatologic advice for remote communities and can aid primary care education (1,800 words, 9 minutes)
Teledermatology works exceptionally well for patients who cannot easily travel to a dermatology centre, including individuals living in remote communities such as those of First Nations peoples. Consults can be either real-time or “store-and-forward,” according to Dr. Jaggi Rao, speaking at the 7th annual Skin Spectrum Summit on Nov. 6.
Dr. Rao is a clinical professor in the faculty of medicine and dentistry at the University of Alberta in Edmonton, and the founder of ConsultDerm, a Canadian national teledermatology project.
In addition to living in a community far from a major medical centre, other factors that could be an obstacle to patients reaching a dermatologist's office include imposed social isolation, such as the lockdowns associated with the Covid-19 pandemic, or comorbid illness or injury that keeps them at home, Dr. Rao said.
As an example of a successful store-and-forward teledermatology program, Dr. Rao described ConsultDerm. He said that this program is web-based and does not require specialized software while remaining secure and confidential. At the time of his talk, ConsultDerm was available to physicians or patients in Alberta, British Columbia, Ontario, the Yukon, and the Northwest Territories in Canada.
In a ConsultDerm consultation, "a referring physician or nurse practitioner will see a patient in their clinic, take a digital photo or two of their patient, and then log into ConsultDerm and upload the images and provide a very brief history," said Dr. Rao. "That [information package] is then sent to the teledermatologist who will review the images and history and provide an impression, an educational note, and a management strategy. Sometimes a management strategy might be a prescription. Sometimes it might be a diagnostic or therapeutic intervention." In other cases, the patient will be referred to a dermatologist who will take over their care.
Dr. Rao said ConsultDerm has set up teledermatology clinics for more remote communities.
“In remote areas where there is no dermatologist, we have selected family physicians or nurse practitioners that act as our hands. We are the eyes, and they are the hands. [The nurse practitioners] will take photos and history and send it to [the ConsultDerm dermatologists].” The dermatologists will then instruct the nurse practitioners on a program of care for the patient.
He said there is also a similar program for emergency rooms in Edmonton called er.consultderm.com.
With this sort of store-and-forward teledermatology, “rapid access to board-certified dermatologists can occur, and it functions in any location, any environment,” said Dr. Rao.
In addition to supporting patient care, Dr. Rao said these dermatology consults have also improved the medical education of the non-dermatologist referring physicians. This provides those caregivers with confidence in managing their patients' skin conditions and improves the overall quality of care, he said.
ConsultDerm has also developed a program to support dermatology patients outside Canada, Dr. Rao said. Volunteer dermatologists work with agencies such as Canadian Physicians for Aid and Relief and the Foundation for African Medicine and Education to provide expert consultation to underserved populations worldwide.
Whatever is causing a need for teledermatology, the two broad categories of how this type of care is delivered each has strengths and weaknesses:
Real-time
Live communication between the dermatologist and the referrer or the patient directly
Can aid in building rapport with patients
Can support interactive conversations
Consultations may take more time than store-and-forward approaches
Image quality may be poorer, complicating diagnosis and monitoring
All parties need to coordinate schedules
More susceptible to language barriers
Patients may be hesitant to reveal some anatomical areas of their body on live camera
Store-and-forward
Dermatologists, referrers and patients can interact with the system at times convenient to them
High-quality images can be used, aiding diagnosis and monitoring
No need for the patient to travel to a site with video equipment
Amateur photographs may not be framed to show a lesion in an adequate context or have other deficiencies
Dr. Rao said another question is whether teledermatology should be between the consultant and the referrer or between the consultant and the patient. He said he prefers to consult with the other physician because they know the patient well, and this approach can avoid language barriers or trust issues.
Bottom Line: Teledermatology can help patients in any community, urban or rural. It can be very efficient in terms of time. Rapid access to board-certified dermatologists can occur, and it improves medical education and confidence not only for patients but also for the referring physicians.
From the literature on teledermatology
A desperate need for psoriasis health care in remote regions as revealed by a live interactive teledermatology program serving Penghu Islands in Taiwan Strait
This study investigated the seasonal and geographical distribution of different skin diseases in remote regions of Penghu Islands in Taiwan Strait to assess medical needs in remote islands. The authors also compared the cost differences among three dermatology care models.
The three most common skin conditions identified among the 145 included patients were eczema (33%), dermatophytosis (13%), and psoriasis (11%).
Geographical analysis showed that for psoriasis, there were relatively higher case numbers, more visits per case, with cases living at greater distances from medical facilities. Patient satisfaction was good (>95%). Among the three dermatology care modes examined, the estimated costs of interactive teledermatology and in-person clinics were similar yearly (2.4-2.9 million New Taiwan Dollars, roughly Cdn$105,000-112,000.)
The authors conclude that there is a strong need for health care for psoriasis in remote regions, and this care can be delivered with quality and high patient satisfaction by interactive teledermatology.
Implementation and impact of a store-and-forward teledermatology platform in an urban academic safety-net health care system
The authors of this paper note that minority and low-income patients disproportionately experience dermatologic access challenges. With this paper, they aimed to evaluate patterns of utilization and overall impact after implementing a store-and-forward (SAF) teledermatology program in a safety-net health care system.
This retrospective review of 3,285 teledermatology consultations from 2014 to 2017 found that 1,680 (51.2%) patients were referred for inflammatory/rash conditions and 967 (29.5%) for skin lesions. The teledermatologistbrecommended in-person evaluation in 1,199 encounters (36.5%). Patients then waited a median of 36 days for a subsequent appointment. Some 237 patients (26.4%) underwent skin biopsy on an in-person visit after referral. The no-show rate after a referral was 11.8%.
The median wait time for dermatology appointments through standard referral was 64 days, with a no-show rate of 18.6%. Only 10.9% of patients referred directly from primary care providers underwent skin biopsy.
The authors write that implementing SAF teledermatology in a safety-net health system resulted in the avoidance of 63.5% of potential dermatology visits. These consultations typically resulted in a change in suspected diagnosis or management plan. There was a high agreement rate between the in-person and tele-consults, and both median wait times and no-show rates were reduced with the remote consultations.
Attitudes and perceived barriers toward store-and-forward teledermatology among primary care providers of the rural Mississippi
The authors of this paper conducted a survey to assess perceived obstacles and attitudes about store-and-forward teledermatology among primary care providers in Mississippi's rural areas.
They found that most providers were very interested in the telehealth program. Two barriers to engagement in teledermatology were identified. The first of these was primary non-adherence, rooted in misconceptions about teledermatology, the investment in time required to master the technology and establish digital links between primary care provider and consultant. The other was secondary non-adherence, related to the time required to submit a teledermatology consult, potentially disrupting workflow in already busy offices.
The authors conclude that emphasizing the benefits of teledermatology to primary care physicians and simplifying the teledermatology consult submission process may increase the use of teledermatology in rural Mississippi and serve as a model for other academic teledermatology programs throughout the United States.
Rise of teledermatology in the Covid-19 era: A pan-world perspective
The authors of this study reached out to dermatology professionals through social media and the WhatsApp application. Professionals who had worked with teledermatology between March and June of 2020 were asked to complete an online survey.
Data on respondent demographics and the preferred platforms for digital consultations were collected and data on the most common diagnoses and rates of referral for further evaluation. Participants were also asked about their own and their patient's perspectives on the advantages and operational challenges of teledermatology.
A total of 653 individuals participated from around the world. They reported that Facebook and WhatsApp services were the most popular mediums for digital consultation and that acne, eczema, and skin-related infections were the most common diagnoses. Both practitioners and patients reported personal benefits from adopting teledermatology, but they also had concerns about data privacy and the levels of technological literacy required.
VIDEO: Tele-Derm National: Ten years of store-and-forward teledermatology for rural and remote Australia
At the intersection of skin and society
An Indigenous woman in Fort Smith, N.W.T., is seeking an apology from Parks Canada after receiving a letter requesting she stop collecting salt from Wood Buffalo National Park, contrary to her treaty rights to harvest, reports CBC News.
Melissa Daniels is a Athabasca Chipewyan First Nation (ACFN) member. She uses the salt from Wood Buffalo's salt plains in a bath product for her skincare products.
"Canada is trying to extinguish my treaty rights to harvest from my traditional territory, something agreed upon with the Crown since 1899 but has, in practice, been in place since time immemorial," she told CBC Trailbreaker host Loren McGinnis.
According to the CBC report, the letter from a Parks Canada warden congratulates her on her business success and then requests she stop harvesting from the salt plains. The letter cites a national regulation and Parks Canada's duty to protect the "ecological integrity" of the area.
The article notes that Daniels said the letter illustrates why her community has been pushing for an apology and reparations from Canada for the historical displacement and denial of their harvesting rights since the park's creation and that the letter made no reference to the fact that she's a member of the Athabasca Chipewyan First Nation, adding she has “constitutionally affirmed and inherent Indigenous and treaty rights to use this land that supersede any park regulations.”
A statement from Parks Canada says that commercial harvesting of the salt from the park, a World Heritage Site, is not permitted.
The CBC reports that Daniels objects to the term "commercial," as her business and harvesting practices are based in Dene law, and her products will never be mass-produced. Her products are a way to reconnect people with the land, including Dene who cannot harvest medicine for traditional use themselves.
"The implication that my land-based, hand-harvested practice is a threat to the natural environment is insulting to me, our nation, our ancestors and the land itself," she said.
This week
April is Rosacea Awareness Month in the US
April 24-30 is World Immunization Week
April 28 is World Day of Safety and Health at Work
Something to think about in the week ahead…
Kobe Bryant (1978-2020) played for the Los Angeles Lakers basketball team
Next week
Nickoo Merati, a fourth-year medical student at McGill University in Montreal, spoke at the seventh annual Skin Spectrum Summit on an anti-racist review undertaken of the school's dermatology curriculum. She also spoke more broadly on skin of colour in dermatologic education.