Some dermatologists may be surprised to hear that the concept of teledermatology originated 25 years ago, and has slowly increased in usage, primarily for the purpose of providing care to those in underserved areas.1 The challenges created by the COVID19 pandemic has rapidly accelerated both interest and usage of telemedicine by dermatologists, with the American Academy of Dermatology and other dedicated groups responding quickly to provide guidance on how to integrate teledermatology into real-world dermatology practice effectively, and hopefully with avoidance of technical, medicolegal, and financial pitfalls.2 Despite differences in opinion on whether teledermatology is beneficial to the specialty, it does provide some positive aspects for patients such as decreased travel time, faster access to care, and ability to reach underserved geographic areas. On the other hand, there are many challenges related to completeness of the visit, quality of images, legal considerations, individual state regulations, security issues, lack of a true sense of connection between the patient and clinician, and conflicts in management due to patients who independently seek care from multiple clinicians simultaneously. Marked efforts are also being made to assure proper education on coding and billing for teledermatology services.2,3
Of major importance is whether or not the tele-interaction is primary (direct between patient and clinician), secondary (between GP and dermatologist), or tertiary (between dermatologist and consultant dermatologist), and whether it is “store and forward” (SAF) or ‘real-time interactive (live)” (RTI).1,4 Live interactive teledermatology (RTI) has been correlated with higher consultative quality and improved clinical outcomes as compared to a SAF visit, where patients upload static photos and information in advance. There are several obvious reasons for RTI being superior in quality, an obvious one being that SAF often requires that the patient “play doctor” and decide what is significant to show and ask about. In addition, the optimal accuracy and value of RTI depends on follow-up over multiple visits.4
A thorough review of teledermatology pros and cons is beyond the scope of my discussion here and is not my objective. My objective is to stress that even in the best case scenario of teledermatology, it can never offer the same as a live in-person visit by a patient with a clinician and their staff. Of course, this statement assumes that both options are being employed with competence and high quality. I have heard it said on some recent webcasts on teledermatology that acne and rosacea are perfectly amenable to telemedicine, and also that the Center for Medicare and Medicaid (CMS) deems teledermatology to be equivalent to an in-person visit. I was not aware that CMS is to be considered as a reference for guidance on standards of care on patient and disease management. That is not the role of CMS. I agree that patients with acne and rosacea can be selectively managed at times via a telemedicine approach, especially where travel distance is a factor. However, I suggest each clinician evaluate their comfort level regarding how often and when you need to see a patient in person. As Nickolas Ashford and Valerie Simpson wrote, and Marvin Gaye and Tammi Terrell so fantastically sang in 1968, “Ain’t Nothing Like the Real Thing” was true back then, and still remains true today. Be careful to not cut corners on how you believe is the optimal way to manage your patient, which is not always the easiest way, including in this era where telemedicine is being somewhat forced upon us. As a specialty, dermatology has put a lot of effort into emphasizing the importance of the dermatologist as the primary clinician for diagnosis and management of all skin diseases. I really do not want to see us devalue our specialty by minimizing our importance in caring for some of our more common diseases like acne and rosacea, and turning it over to devices, cameras, and “apps”.
James Q. Del Rosso DO
JDR Dermatology Research/Thomas Dermatology
Las Vegas, NV
References
1. Tensen E, Van der Heijden JP, Jaspers MWM, Witkamp L. Two decades of teledermatology: current status of integration in national healthcare systems. Curr Derm Reports. 2016;5:96-104.
2. Oakes K. COVID-19: coronavirus resources from AAD target safe office practices, new telemedicine guidance. Dermatology News. 2020;51(4):1-7.
3. Campagna M, Naka F, Lu J. Teledermatology: an updated overview of clinical application and reimbursement policies. Int J Women’s Dermatol. 2017;3:176-179.
4. Lamel S, Chambers CJ, Ratnarathorn M, Armstrong AW. Impact of live interactive teledermatology on diagnosis, disease management, and clinical outcomes. Arch Dermatol. 2012;148(1):61-65.
Of major importance is whether or not the tele-interaction is primary (direct between patient and clinician), secondary (between GP and dermatologist), or tertiary (between dermatologist and consultant dermatologist), and whether it is “store and forward” (SAF) or ‘real-time interactive (live)” (RTI).1,4 Live interactive teledermatology (RTI) has been correlated with higher consultative quality and improved clinical outcomes as compared to a SAF visit, where patients upload static photos and information in advance. There are several obvious reasons for RTI being superior in quality, an obvious one being that SAF often requires that the patient “play doctor” and decide what is significant to show and ask about. In addition, the optimal accuracy and value of RTI depends on follow-up over multiple visits.4
A thorough review of teledermatology pros and cons is beyond the scope of my discussion here and is not my objective. My objective is to stress that even in the best case scenario of teledermatology, it can never offer the same as a live in-person visit by a patient with a clinician and their staff. Of course, this statement assumes that both options are being employed with competence and high quality. I have heard it said on some recent webcasts on teledermatology that acne and rosacea are perfectly amenable to telemedicine, and also that the Center for Medicare and Medicaid (CMS) deems teledermatology to be equivalent to an in-person visit. I was not aware that CMS is to be considered as a reference for guidance on standards of care on patient and disease management. That is not the role of CMS. I agree that patients with acne and rosacea can be selectively managed at times via a telemedicine approach, especially where travel distance is a factor. However, I suggest each clinician evaluate their comfort level regarding how often and when you need to see a patient in person. As Nickolas Ashford and Valerie Simpson wrote, and Marvin Gaye and Tammi Terrell so fantastically sang in 1968, “Ain’t Nothing Like the Real Thing” was true back then, and still remains true today. Be careful to not cut corners on how you believe is the optimal way to manage your patient, which is not always the easiest way, including in this era where telemedicine is being somewhat forced upon us. As a specialty, dermatology has put a lot of effort into emphasizing the importance of the dermatologist as the primary clinician for diagnosis and management of all skin diseases. I really do not want to see us devalue our specialty by minimizing our importance in caring for some of our more common diseases like acne and rosacea, and turning it over to devices, cameras, and “apps”.
James Q. Del Rosso DO
JDR Dermatology Research/Thomas Dermatology
Las Vegas, NV
References
1. Tensen E, Van der Heijden JP, Jaspers MWM, Witkamp L. Two decades of teledermatology: current status of integration in national healthcare systems. Curr Derm Reports. 2016;5:96-104.
2. Oakes K. COVID-19: coronavirus resources from AAD target safe office practices, new telemedicine guidance. Dermatology News. 2020;51(4):1-7.
3. Campagna M, Naka F, Lu J. Teledermatology: an updated overview of clinical application and reimbursement policies. Int J Women’s Dermatol. 2017;3:176-179.
4. Lamel S, Chambers CJ, Ratnarathorn M, Armstrong AW. Impact of live interactive teledermatology on diagnosis, disease management, and clinical outcomes. Arch Dermatol. 2012;148(1):61-65.
