To the Editor: Rural dermatological access is negatively impacted by a shortage of dermatologists and a disparity in their geographic distribution.1 In the United States, Georgia ranks poorly in dermatologist and primary care availability.2,3 The combination of telehealth and dermoscopy facilitates timely expert evaluation of skin lesions, prioritizing referrals to specialists for patients with lesions worrisome for skin cancer while reassuring those with benign-appearing lesions.4 Dermoscopy training for primary care providers (PCPs) improves their confidence in skin cancer screening.5 Reports of teledermoscopy in association with distance learning are scarce. We developed a dual approach of distance learning and teledermatology assessment of suspicious lesions to address major barriers to specialty healthcare access in underserved rural areas.
The ongoing Teledermatology in Rural Georgia program provides PCPs with a dermatoscope attached to a smartphone and training on its use. Dermoscopic photographs, clinical images, and patient history sent by PCPs are securely transmitted using a teledermoscopy platform to dermatologists, who then return diagnostic and treatment recommendations (Fig 1). The Augusta University Institutional Review Board determined this project did not meet the definition of human subject research.
Fig 1.
Teledermatology in Rural Georgia schematic. (1) Ten rural primary care providers (PCPs) from 8 clinics indicated on the map of Georgia were enrolled in the program. (2) Using the dermatoscope, PCPs send dermoscopic images of concerning lesions to dermatologists at the Medical College of Georgia at Augusta University and the Georgia Cancer Center (The Hub). (3 & 4) The dermatologists provide a diagnosis and treatment plan via the secure teledermoscopy platform to rural PCPs. (5) Monthly virtual TeleECHO TeleDerm Sessions are held. Sessions include a 20-minute didactic presentation regarding dermoscopy, 2 case presentations, and a discussion.
To improve participating PCPs' abilities to identify lesions requiring expert care, the Project ECHO (Extension for Community Healthcare Outcomes) model of distance learning was implemented. “TeleECHO TeleDerm” sessions consist of didactic presentations by dermatologists (eg, introduction to dermoscopy, diagnostic algorithms, and features of benign and malignant lesions) and case presentations.
Thirteen months after project initiation, 10 PCPs from 8 clinics were enrolled, trained, and subsequently submitted 76 consultations from 42 patients (median age 61 years, range 21-89 years). Of these patients, 8 (19%) reported a personal history and 13 (31%) a family history of skin cancer. Dermatologists suggested a malignant diagnosis in 67% of consults, including squamous cell carcinoma (n = 15) and basal cell carcinoma (n = 3). A diagnosis was provided within the same day for 52 (68%) consults and the next day for 15 (20%) with one outlier (110 days) due to erroneous data entry. There were 15 (20%) concordant and 26 (34%) discordant diagnoses between PCPs and dermatologists. PCPs recommended a biopsy for 14 (18%) lesions and dermatologists for 27 (36%), with concordance between dermatologists and PCPs occurring in 19 (25%) cases (Table I). Seven TeleECHO TeleDerm sessions have occurred with 78.2% attendance from the rural clinics.
Table I.
Demographics of patients receiving a teledermatology consult and their consult results
| Teledermatology patient demographics | No. (%) |
|---|---|
| (N = 42) | |
| Average age | 61 y |
| Sex | |
| Female | 21 (50) |
| Male | 21 (50) |
| Race/ethnicity | |
| African American | 2 (5) |
| Hispanic/Latino | 5 (12) |
| White | 32 (76) |
| Other/unknown | 3 (8) |
| Personal history of skin cancer | |
| Yes | 8 (19) |
| No | 32 (76) |
| Unknown | 2 (5) |
| Personal history of melanoma | |
| Yes | 2 (5) |
| No | 38 (90) |
| Unknown | 2 (5) |
| Family history of skin cancer | |
| Yes | 13 (31) |
| No | 27 (64) |
| Unknown | 2 (5) |
| Family history of melanoma | |
| Yes | 8 (22) |
| No | 32 (76) |
| Unknown | 2 (5) |
| Teledermatology consult results | No. (%) |
|---|---|
| N = 76 | |
| Dermatologist diagnosis | |
| Squamous cell carcinoma | 15 (9) |
| Basal cell carcinoma | 3 (4) |
| Actinic keratosis | 7 (9) |
| Seborrheic keratosis | 26 (34) |
| Nevus-benign | 9 (12) |
| Other/Retake image | 16 (21) |
| Concordance with PCP | 15 (20) |
| Dermatologist biopsy recommendation | |
| Yes | 27 (36) |
| No | 42 (55) |
| Retake image | 7 (9) |
| Concordance with PCP | 19 (25) |
These results demonstrate that combining teledermatology, teledermoscopy, and distance learning facilitates skin cancer screening while reducing barriers to dermatologic care. Our project has limitations. Rural Georgia has a majority black population, and we identified low knowledge regarding self-screening and skin cancer in nonwhite skin among patients and PCPs. Further, PCP visits are limited by time and resistance to new technology. These limitations are being addressed by providing educational materials to the general public in the clinics, educating PCPs through our TeleDerm TeleECHO sessions with a focus on lesion identification in skin of color, and facilitating the incorporation of the new technology into PCP workflow. Overall, Teledermatology in Rural Georgia is addressing healthcare disparities by increasing access to dermatologic care, expediting appropriate biopsies, and saving patients time, money, and travel for unnecessary referrals.
Conflicts of interest
Harold Rabinovitz, MD is a consultant for MetaOptima. All other authors state no conflict of interest.
Footnotes
Funding sources: Sponsored by the Georgia Cancer Center and the Department of Dermatology, Medical College of Georgia at Augusta University, through a grant from the United States Department of AgricultureRural Utilities Service, Distance Learning and Telemedicine Grants Program.
IRB approval status: The Augusta University Institutional Review Board determined that this project did not meet the definition of human subject research; #1863939-1.
References
- 1.Coustasse A., Sarkar R., Abodunde B., Metzger B.J., Slater C.M. Use of teledermatology to improve dermatological access in rural areas. Telemed J E Health. 2019;25(11):1022–1032. doi: 10.1089/tmj.2018.0130. [DOI] [PubMed] [Google Scholar]
- 2.Explore primary care providers in Georgia: 2021 annual report. America's Health Rankings. https://www.americashealthrankings.org/explore/annual/measure/PCP_NPPES/state/GA
- 3.Feng H., Berk-Krauss J., Feng P.W., Stein J.A. Comparison of dermatologist density between urban and rural counties in the United States. JAMA Dermatol. 2018;154(11):1265–1271. doi: 10.1001/jamadermatol.2018.3022. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Uppal S.K., Beer J., Hadeler E., Gitlow H., Nouri K. The clinical utility of teledermoscopy in the era of telemedicine. Dermatol Ther. 2021;34(2) doi: 10.1111/dth.14766. [DOI] [PubMed] [Google Scholar]
- 5.Seiverling E.V., Stevens K., Dorr G., et al. Impact of multimodal dermatoscopy training on skin biopsies by primary care providers. J Am Acad Dermatol. 2022;87(5):1119–1121. doi: 10.1016/j.jaad.2022.01.027. [DOI] [PubMed] [Google Scholar]