Where Teledermatology is Today: Expanding Access and Navigating Limits

Telemedicine use among patients has expanded dramatically in recent years, and the practice’s ability to expand access to patients regardless of location has shifted the way medicine is practiced.1

Despite the explosion of telemedicine’s implementation, especially during the COVID-19 pandemic, concerns have arisen regarding the value of this practice as opposed to the value of in-person interactions with clinicians.1,2 While the practice may have expanded access to care, the limits of telemedicine and telehealth in general have become increasingly more apparent.

Dermatology, a visually dependent subfield of medicine, is uniquely suited for the virtual health care model, and its integration has been dubbed ‘teledermatology.’ This technological advancement in the field of medicine, commonly involving virtual appointments and app-based instructions, can allow a diverse patient population access to dermatology care.

In this feature, the editorial team reached out to 3 speakers in the field of dermatology to provide commentary on the evolution of teledermatology. One speaker was Harrison Nguyen, MD, MBA, MPH, a double board-certified dermatologist, Mohs micrographic surgeon, and clinical researcher in Houston, Texas. Nguyen also serves as a clinical assistant professor of dermatology at the Baylor College of Medicine.

HCPLive also spoke with Sylvana A. Brickley, DNP, FNP-BC, DCNP, a dermatology certified nurse practitioner (NP) at Lahey Health, and Avery Dinallo, DNP, FNP-C, DCNP, a dual board-certified family NP, a dermatology NP, and the president-elect of the Society of Dermatology Nurse Practitioners (SDPA).

These 3 leaders in the dermatology space provided several helpful insights on the ever-changing topic of telemedicine and teledermatology, highlighting the strengths and weaknesses of the practice and describing where improvements can be made to the practice to ensure adequate care.

Teledermatology’s Evolution

Although teledermatology exploded in use during the COVID-19 pandemic, the practice predates 2020, with the term initially appearing in medical literature in 1993 and gaining traction in Norway.2 However, the first formal guidelines regarding teledermatology were issued by the American Telemedicine Association in 2007.

As innovations related to home computer use and smartphone adoption increased dramatically in the late 2000s and early 2010s, telemedicine became more and more of a reality. The COVID-19 pandemic was, undoubtedly, the inflection point for teledermatology’s use.

The aforementioned guidelines, when updated in 2016, began referring to 3 forms of consultation typically seen in teledermatology: real-time videoconferencing, store and forward, and a hybrid of these 2 methods.2 Store-and-forward is known to be the most widely utilized, involving taking photographs or videos, which are then evaluated at a different time and location.

In his interview, Nguyen explains how, despite technological advances, inconsistent reimbursement practices kept adoption fragmented in the period before 2020. He also highlights Medicare's reliable reimbursement during the pandemic, describing the move as setting a precedent followed by commercial insurers.

“It had been in existence before, but we had very inconsistent reimbursement, and adoption varied among practice types and varied among regions,” Nguyen explained. “But with COVID, it became a necessity. We started to really use it across more practice types, and we had very strong reimbursement from that, which started when Medicare was reimbursing very, very reliably.”

In their interview with HCPLive, Brickley and Dinallo both provide a practitioner's impression of what the COVID-era rush into telehealth actually looked like from within a clinic.

"It did explode,” Dinallo expressed. “It exploded during COVID, when everybody was forced to enter into these telehealth spaces.” Brickley concurred with Dinallo, describing the increasing adoption of telemedicine practices as a ‘mad rush’ in light of the pandemic.

The Benefits of Teledermatology

Telemedicine has been used for a variety of aims: those working in healthcare settings can use the practice to monitor patient health, to provide clinical services to patients, to consult with other providers, and to allow patients to have access to various educational resources. Perhaps most significantly, in the dermatology world, telemedicine practices can allow for efficient diagnoses of diseases such as psoriasis, rosacea, atopic dermatitis, and skin cancer.

Skin cancer, for example, is a uniquely important condition for dermatologists to diagnose, given the increasing incidence and real concerns over morbidity among patients.3 Multiple studies have demonstrated high concordance between teledermatology and in-person diagnoses, with 1 finding 91% concordance.4

Patients have also reported a high level of satisfaction with teleconsultations, with increased savings related to travel, diminished wait times, and time efficiency being cited specifically.5 In his interview, Nguyen generally concurred with these views, outlining the conditions well suited to telehealth and noting medication and biologic monitoring, as well as post-procedure follow-up, are strengthened by the practice.

Brickley and Dinallo reinforced this view as well from their own clinical experience and practice focus, highlighting evidence supporting telemedicine for acne and rosacea specifically. Both also touched on the value telemedicine has brought to underserved communities

"Many dermatology practices, you're waiting three months, six months to get seen, or they live so far away they don't want to make that commute,” Dinallo said. “It's a lot easier just to pop on a call."

Brickley agreed, describing virtual consults as helping to decrease the number of referrals to dermatology practices. Such consults can free up in-person appointments for individuals who more urgently need to be seen by a dermatology provider, she highlighted.

The Limits of Teledermatology

An important consideration of adopting any new technological innovation is awareness of downsides. As tools such as smartphones have become more widely accepted in everyday life by most Americans, for example, the negative effects of their implementation related to emotional and cognitive health have become more apparent.6

In the same vein, the limits of teledermatology require exploration to better understand the practice’s long-term impact on the medical field and on patients’ lives. Additionally, understanding these limits can help to improve the different facets of teledermatology’s use, allowing for improvements to the practice.

Despite the previously cited successes of virtual lesion assessments, research suggests in-person diagnostic accuracy remains approximately 11% greater than teleconsultations.7 Additionally, while diagnosing various conditions such as acne, psoriasis, and different skin cancers can be improved by teleconsultations, full body skin exams, melanocytic lesion assessments without dermoscopy, new or unclear rashes, and anything requiring a biopsy or procedure still necessitate in-person meetings.

During her interview, Brickley noted that still photos outperform video for diagnostic purposes. Nevertheless, she noted, modern smartphone cameras fall short of in-person evaluation for anything past classic presentations. Both Brickley and Dinallo note providers practicing solely through telemedicine carry a responsibility to refer patients to in-person care when necessary.

Nguyen frames most issues with telemedicine as a deployment problem, as much as a technology problem. He describes such practices as not inherently flawed, pointing to the placement of teledermatology in the wrong clinical context as producing redundant visits at best and missed diagnoses at worst.

"It falls short whenever it's being deployed under the wrong clinical context, when there's not the right triaging or workflows to identify the appropriate patient and appropriate care processes,” Nguyen expressed.

The ‘Prescription Mill' Problem

One of the more pointed critiques emerging from the interview with Dinallo and Brickley was regarding the proliferation of telemedicine platforms described by the 2 speakers as ‘prescription mills,’ wherein individuals can select a treatment, submit a photo or intake form, and be prescribed a medication without clinical conversation.8

"There are companies out now where you just go, you click the drug you want, you text someone about it, and they mail it to your house,” Dinallo noted. “That's where it's been for the last 10 years, and it's gone too far in that direction."

Brickley concurred, noting that clinicians “want to satisfy the consumer, but also want to practice good medicine.” Practicing good medicine, Brickley added, is not always giving an individual who is asking for something exactly what they want. In other words, a commitment to scrupulous prescription practices is vital where telemedicine adoption is concerned, and this includes dermatology.

Brickley and Dinallo noted the founding rationale for their own telehealth clinic, AllMe Health, as correcting the market’s tilt toward convenience at the expense of genuine care. Examples include patients given tretinoin without guidance on how to use it, or ordering unnecessary labs with no clinician to interpret the data. Their clinic, they assert, will help to address these types of situations while still providing access to dermatologic care for underserved communities.

Obstacles to Teledermatology’s Expansion

Some of the most important issues related to teledermatology as a practice in today’s world lie not in its implementation, when warranted, but in the obstacles preventing its implementation.

Specifically, teledermatology reimbursement has been less than optimal for some dermatology clinicians, attributed to inconsistent payment parity between in-person consultations and teleconsultations. Reimbursement, Nguyen noted in his HCPLive interview, is the single biggest barrier to teledermatology’s more widespread use among those who need it.

"Teledermatology often takes as much time and resources to be able to do it as in-person visits,” Nguyen said. “It is not so different from a time and resource perspective."

Prior to the COVID-19 pandemic, inconsistent reimbursement kept teledermatology use limited, with fewer than 4% of dermatologists utilizing live video conferencing.9 During the pandemic, the Centers for Medicare & Medicaid Services (CMS) expanded payment parity under public health emergency waivers, a move driving 43 US states to adopt permanent coverage parity laws and 22 states to initiate explicit payment parity legislation.

Nevertheless, given the benefits cited by Nguyen and a significant amount of available data on telemedicine’s implementation, the appropriate reimbursement for asynchronous teledermatology assessment services remains a concern for many clinicians.

Adding to the discussion of obstacles to teledermatology, Brickley and Dinallo described an NP-specific licensure issue: the lack of a multi-state compact for NPs and the current presence of individual state licensing for every jurisdiction where NPs see patients. This, they note, is a time-consuming and expensive process.

“We don't have a compact for nurse practitioners where we can,” Brickley highlighted. “We have to get every single state license individually. You can only see a patient [for whom] you're licensed in the state where the patient is located."

Such obstacles remain a concern among dermatology clinicians and, in the coming years, may need to be addressed by US public health organizations.

Looking Toward the Future of Telemedicine

The demand for dermatology clinicians is high, due to population aging and increasing skin cancer rates. Teledermatology is uniquely positioned as a necessary response to such concerns and concerns over financial costs among patients.

The geographic maldistribution of clinicians is not likely to self-correct, making sustained teledermatology infrastructure a significant long-term priority for policymakers. Additionally, the value of maintaining the patient-centric nature of medicine has been described by clinicians as vital to medicine’s future.10

Brickley and Dinallo’s interview concluded with a prediction of what is to come for teledermatology practices, with Brickley predicting a trend toward niche, specialized teledermatology services rather than broad general platforms. Dinallo echoes this sentiment, framing passion-driven specialty care as the model most likely to provide genuinely improved outcomes.

“The future is going to be similar to what we're doing, where we're focusing more on specialty care, where people that are really passionate about this one specific topic [are] then providing it to more people,” Dinallo concluded in her interview.

Nguyen concluded his discussion of teledermatology by, first and foremost, reiterating his pro-telemedicine views. He describes such practices as an important tool in the modern medical world for maintaining access among underserved patients, provided it is used efficiently and with the patient’s best interests in mind.

“Efficiency depends on whether the practice, the health system, or the clinician has the infrastructure set up so that telemedicine is done in an efficient manner,” Nguyen explained. “I would say that access is something that has been demonstrated to improve with telemedicine. How do we continue to maintain the viability of it? We come back to the reimbursement aspect, making sure that clinicians are reimbursed appropriately for their efforts in teledermatology.”

Teledermatology's future may not be determined by the innovation itself, but by whether the policymakers, the payers, and the clinicians involved ensure its success. The screen is likely not to fully replace the exam room, but its helpfulness as a tool for clinicians may increase over time.

References

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