Effectively engaging geriatric patients via teledermatology

To the Editor: In response to the coronavirus disease 2019 (COVID-19) pandemic, the Centers for Medicare and Medicaid Services expanded telemedicine access for Americans aged older than 65. Although shifting to non-face-to-face encounters is important to protect vulnerable older patients,¹ dermatologists may face challenges when providing care virtually to a generation that did not grow up in the internet age.

Prior studies indicate teledermatology can be a reliable method of care for geriatric patients,^{2 , 3} but some found implementation of virtual care difficult for older populations,⁴ especially via direct-to-patient workflows. As they shelter at home, with some under lockdown in long-term care facilities, many older patients will need to engage with dermatologists without the assistance of advocates who normally accompany them at in-person visits.

We provide suggestions for optimizing virtual care for older patients who remain in need of dermatologic care (Table I ).

Table I.

Suggestions for optimizing virtual care for older patients

Suggestion for optimizing care	Helpful tips
Present all available options∗	•Do not assume a patient's age will dictate willingness or ability to engage in virtual care. •Many older patients are familiar with video chat. •For patients uncomfortable with a live video visit, consider digital photographs complemented by telephone discussion. •For those without internet/smartphone access, telephone-only encounters can still be effective.
Reduce the steps to connect	•Ensure there is a simple workflow alternative. •Avoid apps that require patients to sign up for an account and enter excessive information. •Look for telemedicine platforms that can be accessed directly within browsers patients may already use. •Send invitations at the appointment time via text message or e-mail containing a direct link to the encounter.
Provide clear, step-by-step instructions	•Swap ambiguous/technical jargon for descriptive terms. •More words or pictorial instructions may be required, because this leaves less room for missteps. •A brief demonstration video or screenshots can also be helpful.
Offer a trial run	•Trained staff members familiar with the platform can prepare patients for virtual visits. •Briefly testing the platform in advance of the appointment will build patient confidence and prevent technical delays during live virtual visits.
Encourage ergonomic device use	•Larger touchscreen tablets can make visual acuity less of a barrier. •For those with limited dexterity or tremor, a mounted webcam that can be detached may be better than a handheld device. •Encourage use of speakerphone, which frees the patient's hands to write down recommendations.
Use multiparty encounters	•Use teledermatology platforms that permit simultaneous communication between more than 2 parties, so older patients can conduct virtual visits with a trusted advocate. •Advocates may offer assistance with historical information and record treatment instructions.

^∗No matter the platform used, patient privacy and data security should remain a priority, and limitations of these methods should be discussed with the patient.

All options for a virtual visit should be presented to patients. Although some older patients may have less experience with modern telecommunication devices, many are familiar with video chat to connect with loved ones. For patients uncomfortable with a live video visit, consider accepting digital photographs via a simple online platform and discuss them with the patient by telephone. As an alternative, telephone-only encounters can be effective for managing established patients with known diagnoses.

Telemedicine through patient portals and secure apps can be effective for delivering care, but simpler alternatives are available. Requiring patients to download an app, sign up for an account, memorize a password, and type in demographics can be significant barriers for those experiencing cognitive decline. Many telemedicine platforms can be accessed directly within web browsers that patients use regularly. Some platforms can send a direct link to the telemedicine encounter at the appointment time via a text message or e-mail.

Swap ambiguous/technical jargon for descriptive terms. For instance, “click the button to connect” may be confusing for those using a tablet, which does not have a mouse or buttons. “Tap the square that says ‘connect’” offers clearer direction. Likewise, “flipping the camera” should be explained as not a literal movement, but perhaps by showing a picture of the icon to press. More words or pictorial instructions may be required. A brief demonstration video or screenshots can also be helpful.

Larger touchscreen tablets can make visual acuity less of a barrier. For those with limited dexterity or tremor, a mounted yet detachable webcam may be better than a handheld device. A webcam atop a computer monitor allows for camera stability; some models can be detached and pointed at the body area of interest to help with maneuverability. Encourage use of a speakerphone, which frees the patient's hands to write down recommendations, especially for those struggling with memory.

While health care has been rapidly transitioned to virtual delivery to prioritize patient safety, we must not allow technical hurdles or suboptimal workflow to leave older patients without quality access to our visually oriented specialty. Dermatologists can use these strategies to help bridge the gap separating us from older patients while they must remain at a distance.