Where: Hospital of the University of Pennsylvania, a 784-bed academic medical center in Philadelphia.
The issue: Providing timely dermatology consultations for inpatients.
The Hospital of the University of Pennsylvania (HUP) has an inpatient dermatology service. But dermatologists there know that most inpatients at other institutions don't have such ready access to dermatologic care.
Even hospitals with affiliated dermatologists don't get them every day. “The dermatologist comes in when it's necessary to see inpatients. That's the standard of practice at most places in this country,” said Misha A. Rosenbach, MD, assistant professor of dermatology at the University of Pennsylvania.
Hoping to improve inpatients' access to dermatologists, he and his colleagues recently conducted a proof-of-concept study of inpatient teledermatology.
How it works
Their study included 50 inpatients at HUP who needed dermatology consults between September 2012 and April 2013. A fourth-year medical student visited each patient, collected relevant information and photographs, and entered the information into a smartphone app. The app data were then reviewed by 2 attending dermatologists, who independently triaged the patients, developed diagnoses, and determined whether any biopsies were needed.
One of the main goals was to see whether the remote dermatologists could accurately triage patients to immediate attention, a later visit, or outpatient care. “Could they say, ‘Oh my gosh, that is something I really need to come see today, like Stevens-Johnson toxic epidermal necrolysis'…or if it's a Tuesday and the dermatologist plans on coming Thursday… [and it] looks like... poison ivy, [it] can wait,” said Dr. Rosenbach.
To test the accuracy of the remote triage, Dr. Rosenbach also provided an in-person consult for the 50 studied patients. His diagnoses and care plans were similar to those of the remote dermatologists, according to results published by JAMA Internal Medicine on Feb. 12. “Ninety to 95% of the time, there was basically agreement over the acuity, when to triage, whether it would need a biopsy,” said Dr. Rosenbach.
When the consultants disagreed about treatment, the differences seemed to result from normal variation in practice styles, rather than any incorrect diagnoses. The study also found that about 60% of the patients could wait at least a day to be seen in person by a dermatologist, and at least 10% could have waited until after discharge.
Challenges and benefits
Although the results were encouraging, the participating doctors weren't ready to switch over to totally remote practice. While one of the consultants would have been comfortable treating 90% of the patients entirely through teledermatology, the other said the same about only 58% of cases.
That problem could potentially be remedied in practice by allowing the teledermatologist to ask questions and follow up on patients, Dr. Rosenbach suggested. The study protocol required them to make decisions based on the initial information provided.
There are a number of other obstacles to widespread implementation of teledermatology in U.S. hospitals, including reimbursement, malpractice coverage, patient privacy, and the interest of dermatologists.
“If someone takes a picture of a patient, that picture should become part of their medical record, but there are many places where you can't have a digital image in the medical record,” said Dr. Rosenbach. “You need to have secure messaging. Even if every ER doc or hospitalist in the whole country has some sort of app and can take a picture and upload it, you still need to have dermatologists on the other end who can review it in appropriate time. Until teledermatology is reimbursed, and potential malpractice issues are addressed, that will be a real barrier.”
Benefits Dr. Rosenbach cited include: “Decreased mortality, length of stay, costs—many of our consults are for issues like ‘Cellulitis not improving on day 7 of vancomycin and cefepime’ and it turns out that they have poison ivy or stasis dermatitis. If you could intervene or provide support for cases like that, you could potentially show that having that access would make a difference,” he said.
To see whether the intervention makes a difference in the real world, HUP researchers are now conducting a trial of teledermatology consults for affiliated hospitals that don't have on-site dermatologists, he said.