Teledermatology: An Answer to Managing Chronic Skin Diseases?

Over 140 years ago, The Lancet published an article that discussed conducting doctor’s appointments over a telephone call to reduce the number of unnecessary office visits.¹ The idea of remote care was novel given the newness of telephone system in the mid-1800s, but the concept really took off with the technological advances made in the 20th century.

In 2002, the American Academy of Dermatology issued a position statement on teledermatology.² This statement, most recently amended in March 2016, classifies teledermatology into two specific delivery platforms: live interactive and store-and-forward. Each category is relatively self-explanatory; live interactive teledermatology involves a real-time video conference whereas store-and-forward collects a dermatologic history and set of images for later review. Both methods are growing in popularity at multiple levels, including direct-to-consumer and provider-to-provider models.³

Direct-to-consumer services such as Curology and Apostrophe are trying to revolutionize, and in ways completely replace, the need for in-person visits to the dermatologist. With these subscription-based services, patients submit various photos through a web-based platform for evaluation by a board-certified dermatologist, who then prescribes a personalized treatment to target concerns such as acne, scarring, and wrinkles.^4,5 These services claim to help reduce costs, travel, and patient anxiety—so does teledermatology have a role with patients with chronic and more severe skin diseases?

“I think the climate has finally arrived where everybody is comfortable with the technology and the value proposition of telemedicine,” said Jonathan Cotliar, MD, chief medical officer at Science 37 in Los Angeles, CA. His company aims to make virtual clinical research, and ultimately patient care, more accessible through telemedicine.

A partnership between Science 37 and the Keck School of Medicine of the University of Southern California (USC) in Los Angeles seeks to determine how telemedicine can deliver care equivalent to in-person visits for patients with atopic dermatitis (AD). This particular study received a $3.4 million grant from the National Institutes of Health (NIH), making it the largest teledermatology study ever funded by the NIH.⁶ According to the press release, the study will evaluate telemedicine as a method of delivery care for more than 300 patients with AD.⁶ It builds upon years of previous research that finds teledermatology can be used to provide accurate diagnoses in various practice settings,^7-10 and optimism is high that the future results will indicate a special role for teledermatology in the management of chronic skin diseases.

Partnering Over Quality of Care
“Dermatology is a fitting field for telemedicine. With a qualified provider such as board-certified dermatologists, teledermatology has the potential to provide high-quality care and supplement in-person care. This particular study builds upon a prior pilot study,¹¹” said April Armstrong, MD, MPH, associate dean for clinical research and professor of dermatology at the Keck School of Medicine and the study’s principal investigator. Dr Armstrong also sees patients as a dermatologist with Keck Medicine of USC. “This new study looks at a larger number of patients, but we’re also using validated outcomes, so we have confidence in the data with regards to whether the patients are going to be equivalent in terms of their disease outcome and quality of life.”

She emphasized the research firm’s capabilities as a large draw for the partnership. “Science 37 is very innovative in their approach to research. When I was looking at the different telehealth platforms, I found that Science 37’s philosophy of ‘clinical trials that can be done anywhere’ aligned really well with our motivation for the study,” she said.

“Dr Armstrong has been very progressive and one of the loudest voices within the academic dermatology community about empowering patients,” said Dr Cotliar. “She has previously completed work looking at psoriasis outcomes in patients who have had either online support or telemedicine as the basis of their care.⁷ This particular study was a natural extension of that work that’s she’s done.” Dr Cotliar continued to explain that Dr Armstrong’s previous work made the collaboration with Science 37 a natural fit as the organization attempts to democratize clinical participation in research.

Dr Armstrong expressed similar sentiments. “When we think of patient-centered care, we really put our action where our words are. Many patients with chronic skin diseases are constrained geographically or by poor transportation, restricting their access to quality medical care. We want to ensure that patients, regardless of their geography and access to transportation, receive the same exceptional care as someone who has access to a highly-specialized academic medical center.”

The overall study design, noted Dr Armstrong, has a few different components as part of its validated outcomes. The study will analyze disease severity of AD in addition to effect on patient quality of life. Cost will be considered as well. “Ultimately,” said Dr Armstrong, “the motivation for the study design came from really thinking about patient-centered care. Specifically, for children and adults with eczema, how we can minimize their need to take time away from school and work to obtain specialist care? Telemedicine allows patients to spend less time inside health care facilities while enabling them to receive the same quality of care. In addition, for dermatologists, teledermatology provides them the flexibility to render their expertise from anywhere and at any time. The study also looks like costs associated with telemedicine versus in-person care. This is an important aspect of the study because we need to understand the economic sustainability of such an online model.”

Dr Cotliar further elaborated on overall care for patients with AD. In recent years, clinicians have learned that the care and management of eczema is best provided by a multidisciplinary team. Besides the dermatologist, eczema should be managed concomitantly with primary care physicians, sleep specialists, psychologists or psychiatrists, and other specialties. “We’re learning about quality of sleep in adults with eczema, cardiovascular outcomes, and risk of infection—all the things we used to not necessarily consider holistically when we were treating eczema patients are now, based on what we know in the literature, so important to address,” said Dr Cotliar. 

Technology in Action
This latest research study on teledermatology for the management of AD uses a proprietary platform that completely enables virtual research in the patient’s home. The Network Oriented Research Assistant (NORA) is a comprehensive tool that operationalizes a virtual study by streamlining data collection.

 “NORA has a variety of modules that allow for the execution of clinical research in patients’ homes, with everything from a consent module to a video module that allows us to engage with patients in their homes, in times such as when a mobile nurse or a mobile phlebotomist is visiting, so we can oversee all the activities that are going on during a particular study visit,” said Dr Cotliar. He also explained that NORA can integrate a variety of different biowearbles and sensors into its platform as well as house all of the source documents vital to any clinical research study.

NORA is enabled and coordinated by three separate comparative method validation trials, where Dr Cotliar and other researchers looked at in-person vs remote dermatologic assessment for acne, psoriasis, and AD.^12-14 These trials compared the scoring of dermatologists in person to the scoring of dermatologists on the basis of high-resolution digital photo sets. Results demonstrated a high degree of agreement between the two cohorts, forming the basis to understanding the power of performing studies inside the patient’s home as well as the power of technology to do things remotely that are traditionally performed in clinical or hospital settings.

“This platform has been our tool for coordination of telemedicine-based clinical research for 5 years, so the experience that we can provide Dr Armstrong and her team from a technological standpoint and the way virtual clinical trials take place is valuable,” said Dr Cotliar.

Benefits and Barriers
Teledermatology for patients with AD and other chronic skin diseases may help reduce the burden of care on the patient and their caregiver(s). “It’s true of both standard-of-care medicine and participation in clinical research that the burden of travel for patients, patients’ caretakers, their kids, and their families is just so overwhelming,” explained Dr Cotliar. “Even in cases where they may only be a few miles separating patients from where they live to that clinical center they travel to for care, it can still be so overwhelming and burdensome that giving patients an option to stay at home, again for either care of their disease or participation in clinical research, is something that technology enables.”

In addition to reducing travel, patient and provider satisfaction can improve with teledermatology. Eber et al¹⁵ found that surveyed dermatologists thought telehealth was particularly useful for connecting with experts in a given field or condition of dermatology. Rajda et al¹⁶ and Mounessa et al¹⁷ found that teledermatology was also associated with high levels of patient satisfaction. Further, several studies^16,18-20 demonstrated decreases in wait times and no-shows as well as increased efficiency in triage.²¹

However, despite an overall societal comfort with technology, physicians and patients alike may be resistant to teledermatology. Marchell et al²² found their study population of both dermatologists and patients preferred in-person examinations.

“There are certain doctors and patients who are more comfortable with the traditional, in-person visit. That’s totally understandable and fine,” said Dr Cotliar. “And I think that’s the way it should be. I think in most cases, the goal is not to completely replace those traditional encounters but to maybe find a balance between the need to travel to hospitals or clinics with what can be done at home.

“It’s probably unrealistic to think that multidisciplinary care for all patients with eczema can occur solely with telemedicine. There’s always going to be a need for patients to come to the clinic or hospital, but I do think telemedicine, whether as a treatment modality or as a mechanism for participating in clinical research, is still very powerful to the extent that it can reduce the burden of travel on patients and their families, which is a real concern, and we should take advantage of that as [telemedicine] does not compromise the quality of care or quality of scientific clinical research that needs to be conducted.”

Dr Armstrong took her considerations of challenges to teledermatology a step further. “One of the [barriers] is reimbursement and if the path is clear for telemedicine for Medicare and insurance. It is important that we consider similar reimbursements for teledermatology visits as in-person visits if the outcomes are similar and the dermatologists take on the same medicolegal risks. Number two remains to be the technology: how easy it is to capture an image, the completeness of the image, the relevance of the images, and how easy it is to communicate with the patients through the portal. Number three is really thinking about those medicolegal issues: identifying legal liability issues and ensuring that we implement appropriate safeguards for both the patients as well as the providers.”

To address the medicolegal issues, clinicians can take a few important steps before engaging or adding teledermatology to their practice. Dermatologists should review their personal medical liability insurance policy covers telemedicine services, especially if the clinician is providing teledermatology over state lines.² In addition, dermatologists should pay close attention to policies set by the payor. Medicare provides coverage in certain circumstances (eg, traditional fee-for-service beneficiaries in rural areas may receive videoconferencing and remote therapy monitoring), and Medicaid also provides coverage that varies widely between states.^23,24 Similarly to Medicaid, private insurers also cover telehealth, though the terms of coverage vary by state.^2,23,24  

Dermatologists interested in researching telehealth guidelines can review current state laws and reimbursement policies on the National Telehealth Policy Resource Center website.²⁵

Next Steps in Teledermatology
Dr Cotliar expressed excitement at the future of teledermatology and telehealth in general. “We’ve been super excited about not just dermatology but unleashing the capabilities of telemedicine-based model for virtual research in general. We’re always looking for partners to continue to explore and increase the adoption of a telemedicine-based model for standard-of-care medicine and for research,” he said.

Logically, Dr Armstrong hypothesized, virtual visits and teledermatology are similar to traditional in-person visits. “Online patients are still having interactions with the physician, but these interactions are just online. These visits occur in the natural frequencies as they would in person, but the only thing different are the visits are occurring online.” 

Furthermore, patient demographics continue to change. Younger generations have grown accustomed to carrying a piece of tech with them at nearly all times, and older generations have assimilated technology into their everyday lives. Dermatologists, said Dr Armstrong, may consider integrating technological advances into their practice as a supplement traditional in-person appointments. 

“It’s a dynamic time,” she said. “We are constantly thinking about how we can improve our models of providing care for our patients. Teledermatology can be a useful adjunct to in-person care if we ensure that we are putting the appropriate safeguards for high-quality care for our patients.”

References
1. Gaydos J. The audio-visual connection: a brief history of telemedicine. Today’s Wound Clinic. 2019;13(4):26-29.

2. Position statement on teledermatology. American Academy of Dermatology. https://server.aad.org/Forms/Policies/Uploads/PS/PS-Teledermatology.pdf. Published March 7, 2016. Accessed January 31, 2020.

3. Teledermatology: benefits and challenges. Dermatology World. https://aadmeetingnews.org/2018-summer-meeting-wrap-up/teledermatology-benefits-and-challenges/. Published August 3, 2018. Accessed February 5, 2020. 

4. Our story. Curology. https://curology.com/our-story. Accessed January 31, 2020. 

5. Our mission. Apostrophe. https://www.apostrophe.com/mission/. Accessed January 31, 2020.

6. Keck school of medicine of USC and Science 37^® collaborate on largest ever NIH-funded, telemedicine-based dermatology study [press release]. Los Angeles, CA: Science 37; October 1, 2019. https://www.prnewswire.com/news-releases/keck-school-of-medicine-of-usc-and-science-37-collaborate-on-largest-ever-nih-funded-telemedicine-based-dermatology-study-300928105.html. Accessed October 5, 2019.

7. Ford AR, Gibbons CM, Torres J, et al. Access to dermatological care with an innovative online model for psoriasis management: results from a randomized controlled trial. Telemed J E Health. 2019;25(7):619-627. doi:10.1089/tmj.2018.0160

8. Whited JD. Teledermatology research review. Int J Dermatol. 2006;45(3):220-229. doi:10.111/j.1365-4632.2004.02427.x

9. Sharma P, Kovarik CL, Lipoff JB. Teledermatology as a means to improve access to inpatient dermatology care. J Telemed Telecare. 2016;22(5):304-310. doi:10.1177/1357633X15603298

10. McKoy K, Antoniotti N, Armstrong A, et al. Practice guidelines for teledermatology. Telemed J E Health. 2016;22(12):981-990. doi:10.1089/tmj.2016.0137

11. Kornmehl H, Singh S, Johnson MA, Armstrong AW. Direct-access online care for the management of atopic dermatitis: a randomized clinical trial examining patient quality of life. Telemed J E Health. 2017;23(9):726-732. doi:10.1089/tmj.2016.0249

12. Singer HM, Almazan T, Craft N, et al. Using network oriented research assistant (NORA) technology to compare digital photographic with in-person assessment of acne vulgaris. JAMA Dermatol. 2018;154(2):188-190. doi:10.1001/jamadermatol.2017.5141

13. Hughes ME, Aralis H, Bruhn KW, et al. A reliability study using network-oriented research assistant (NORA^®) to evaluate the use of digital photographs in the assessment of atopic dermatitis [published online January 28, 2019]. J Am Acad Dermatol. doi:10.1016/j.jaad.2019.01.043

14. Jeong D, Aralis H, Bruhn KW, et al. A reliability study using network oriented Research assistant (NORA^®) examining the use of digital photographs in the assessment of psoriasis. Br J Dermatol. 2019;181(1):214-215. doi:10.1111/bjd.17702

15. Eber EL, Janda M, Arzberger E, Hofmann-Wellenhof R. Survey on the status of teledermatology in Austria. J Dtsch Dermatol Ges. 2019;17(1):25-31. doi:10.1111/ddg.13729

16. Rajda J, Searly MP, Fernandes J, et al. Impact of direct to consumer store-and-forward teledermatology on access to care, satisfaction, utilization, and costs in a commercial health plan population. Telemed J E Health. 2018;24(2):166-169. doi:10.1089/tmj.2017.0078

17. Mounessa JS, Chapman S, Braunberger T, et al. A systematic review of satisfaction with teledermatology. J Telemed Telecare. 2018;24(4):263-270. doi:10.1177/1357633X17696587

18. Ragui GJ, Nelson W, Miethke M, et al. Teledermatology implementation in a VHA secondary treatment facility improves access to face-to-face care. Telemed J E Health. 2016;22(1):12-17. doi:10.1089/tmj.2015.0036

19. Bezalel S, Fabri P, Park HS. Implementation of store-and-forward teledermatology and its associated effect on patient access in a veterans affairs dermatology clinic. JAMA Dermatol. 2015;151(5):556-557. doi:10.1001/jamadermatol.2014.5272

20. Coates ME, Albers LN, Sargen M, Chen SC. Diagnostic accuracy of teledermatology for nonmelanoma skin cancer: can patients be referred directly for surgical management? [published online September 22, 2017]. J Am Acad Dermatol. doi:10.1016/j.jaad.2017.09.029

21.Peracca SB, Jackson GL, Weinstock MA, Oh DH. Implementation of teledermatology: theory and practice. Curr Dermatol Rep. 2019;8:35-45. doi:10.1007/s13671-019-0252-2

22. Marchell R, Locatis C, Burgess G, Maisiak R, Liu WL, Ackerman M. Patient and provider satisfaction with teledermatology. Telemed J E Health. 2017;23(8):684-690. doi:10.1089/tmj.2016.0192

23. Telehealth basics. American Telemedicine Association. https://www.americantelemed.org/resource/why-telemedicine/. Accessed February 3, 2020. 

24. Ogbechie O. The legal landscape of teledermatology. AJMC Managed Markets Network. https://www.ajmc.com/contributor/oluwatobi-ogbechie-md-mba/2017/02/the-legal-landscape-of-teledermatology. Published February 1, 2017. Accessed February 5, 2020.

25. Current state laws & reimbursement policies. Center for Connected Health Policy. https://www.cchpca.org/telehealth-policy/current-state-laws-and-reimbursement-policies. Published October 15, 2019. Accessed February 5, 2020.