As we finally say goodbye to social distancing and isolation, one thing we may not say goodbye to is the pandemic-prompted expansion of seeing your doctor remotely via video or phone, also known as telemedicine. Dermatology practices across the country rapidly adopted telehealth protocols in spring 2020 to continue providing care for their patients, as did most other medical providers.
“Initially we started offering teledermatology because we had to, because there were no alternatives after shutting down our practice last March,” says Elizabeth Buzney, MD, associate vice chair of clinical affairs for the Department of Dermatology at Brigham and Women’s Hospital and assistant professor of dermatology at Harvard Medical School. “Now we offer teledermatology as an adjunct for people who want it or for people who need it.”
Insurance claims in the U.S. for telehealth visits were more than 8,000 percent higher in April 2020 than in April 2019. And while about 15 percent of dermatologists reported some teledermatology use in 2016, more than 80 percent offered some form of it during the height of the pandemic in summer 2020. But will a return to something closer to “normal” mean a return to the low, pre-pandemic levels of virtual visits?
It depends. While the “public health emergency” declaration from the Department of Health and Human Services is still active, temporary legislation passed by Congress is active too. This legislation expanded Medicare and Medicaid reimbursements for virtual visits and relaxed restrictions on who can be served by a virtual visit and how, allowing dermatologists to widely offer telemedicine services. (Many private insurance companies adopted these rules too.) For many reasons, dermatologists want these temporary expansions made permanent.
A Picture’s Worth a Thousand Words
Dermatology is well situated to benefit from the continued use of telemedicine: Since your skin is visible on the outside of your body, a physician should, hypothetically, be able to evaluate it on camera, whether it’s in a photograph or a video chat.
When you, or a health-care provider, send a dermatologist a photo of your skin to review, you’re engaging in “store-and-forward” teledermatology. This is an example of an “asynchronous” visit, because you and your provider aren’t interacting in real time. A video visit or a phone call is a “synchronous” visit, because you are “syncing up” with your physician and chatting live.
Every practice did things a bit differently over the past year. But for Dr. Buzney, who used both synchronous and asynchronous teledermatology, it was particularly helpful to combine the two and have a patient send a photo ahead of a video visit. “This allowed the patient to focus on what they wanted to, and show us what was going on,” she says.
For dermatologists across the country, one silver lining of the pandemic was the rapid learning experience with teledermatology. Physicians now have a better understanding of when teledermatology provides care equivalent to being seen in person, and when it doesn’t. “The last year really allowed us to discover what the advantages of teledermatology are and what the limitations are,” says Dr. Buzney.
According to Dr. Buzney, teledermatology works great for managing already diagnosed cases of inflammatory conditions, such as acne and rosacea, and for conducting follow-up visits after a procedure. Asking people about their symptoms and evaluating how they’re using their medication is about the same virtually and in person, she says. Diagnosis of a new condition is more tricky, but may be possible in some cases, she says, although there is no substitute for a thorough, in-person evaluation.
Teledermatology can also be helpful in managing patient volume in the office. During the pandemic, when social distancing and conserving personal protective equipment (PPE) was key, both store-and-forward and synchronous teledermatology were extremely important tools for “triage” — determining who could be managed remotely and who needed to be seen in person.
But some physicians were already triaging patients with telemedicine before COVID-19. Referring physicians, in certain hospital systems or rural areas, for example, could send photos and other electronic records or notes to a dermatology department or practice. Then the specialists could evaluate the condition and recommend a treatment plan, which could be managed through the referring physician. This saved the patient another visit to a doctor.
When using teledermatology, patients and providers can save time and money, and care becomes more efficient and convenient. Studies from before and during the pandemic show that using store-and-forward teledermatology decreases patient wait times (both from referral to appointment and literally waiting in the office to be seen), leads to faster diagnoses and care, reaches people from more diverse backgrounds and more people on Medicaid than in-person visits do. Fewer people miss their virtual appointments, and patient and provider satisfaction with virtual appointments is high. If teledermatology remains widespread, even when we don’t need to stay six feet apart, dermatologists and their patients could continue to reap these benefits and probably even see them grow.
Addressing the Limitations
However, while not everyone has equal access to dermatologists, there is similar concern about equitable access to teledermatology. Not everyone has a smartphone or computer with a camera that they can use in a private place for a doctor’s appointment, and not everyone has high-speed internet that can support those visits. Language barriers can be harder to overcome virtually, and some elderly patients who did not grow up with this technology may be reluctant to use it. Others may have concerns about the privacy of using the Internet to conduct a potentially exposing doctor’s visit. “How secure it is and how comfortable someone feels showing their skin over one of these platforms — it’s a legitimate concern,” Dr. Buzney says. “As far as I know, there have not been issues with the video platforms. In my practice, we use a hospital-approved platform, which makes me feel more secure.”
There are limits on what can be done using telemedicine. Many dermatologists, Dr. Buzney included, learned the hard way that skin cancer screenings and full-body skin exams are not easily adapted to virtual platforms. “We can be rash-focused. We can be problem-focused or lesion-focused, but we can’t do a virtual full skin exam. We realized that it just doesn’t work. When it comes to skin cancer, I worry more about teledermatology. It doesn’t provide a substitute for in-person evaluation and care.”
And although a high-resolution, well-lit photograph of a lesion can compensate for poor video connection, it’s still not the same. “Cameras don’t make up for what I can see with my eyes,” Dr. Buzney says. “There is something that you get in person, a sense of scale and texture, a sense of three-dimensionality, a sense of the lighting and contrast that you don’t really have the context for when the photo is taken at home.”
However, she stresses, “Care is better than no care. The truth is that there are exceptions to everything because of personal circumstances. We, as providers, have to meet patients where they are in so many ways and consider all of their needs.”
This was especially true during the pandemic, when, even if something looked concerning on camera, many patients were reluctant to be seen in person. Dr. Buzney recalls doing a video visit with a patient who had what she clearly identified as a squamous cell carcinoma (SCC) on her leg. The elderly patient, however, didn’t want to risk being exposed to COVID-19 by going into the office. She agreed to send a photo in two weeks so Dr. Buzney could see if the lesion was growing. It was. “I was able to convince her that because I was noticing a change, that this was rapidly evolving on us, that she really needed to come in immediately. And she did. We skipped the biopsy all together. I sent her directly to Mohs and she was able to have it removed.”
That time, Dr. Buzney was confident about what she was looking at. But she admits that she isn’t always this confident, and that is when having a patient come in can be really important. “This is where it got tricky last spring, because I felt like I didn’t have an out when I couldn’t tell. Now I feel very comfortable telling someone I really can’t tell.” She’s looking forward to being able to use teledermatology not as a necessity but as another tool in her dermatologist’s toolkit.