To the Editor: Teledermatology enhances the practice of dermatology by improving efficiency, cost-effectiveness, and access to care without compromising patient satisfaction.1, 2, 3 As medicine anticipates future adoption of technology in practice,4 tailoring the choice of the teledermatology model based upon the condition can improve practice implementation.
This is a retrospective cross-sectional single-institution study of 2984 synchronous teledermatology visits performed by 11 dermatologists using the Epic platform from March 14, 2020, through March 31, 2021. The visits’ first-listed International Classification of Disease (ICD-10) code was categorized by a board-certified dermatologist into 3 categories: acneiform, inflammatory, or lesion-specific. The first or index visit (n = 2064) was categorized as “hybrid,” if at least 1 photo was uploaded within 4 days before or after the encounter, or “video-only”. Two reviewers deemed photos unusable if the subject could not be adequately visualized.
Video-only visits comprised the majority of teledermatology visits (1797, 87%) as compared to hybrid visits (267, 23% with 827 photos). Inflammatory conditions were most often assessed (49.0%) followed by acneiform conditions (31%) and lesions (20%) (Table I). Chi-squared analysis revealed significant differences in use of hybrid versus video-only visits across the diagnostic categories (P < .001). Acneiform conditions were treated more frequently with video-only visits, while lesion-specific conditions were treated more frequently with hybrid visits. Inflammatory conditions were treated comparably with both models.
Table I.
Number of visits by teledermatology (TD) model and primary diagnosis
| Primary diagnosis | Hybrid | Video only | All TD |
|---|---|---|---|
| Acneiform | 37 (14%) | 593 (33%) | 630 (31%) |
| Inflammatory | 145 (54%) | 874 (49%) | 1019 (49%) |
| Lesion | 85 (32%) | 330 (18%) | 415 (20%) |
| Total index encounters | 267 (13%) | 1797 (87%) | 2064 |
Demonstrates trends in use of teledermatology models across diagnostic categories. Telephone visits, exclusively store-and-forward encounters, or incomplete visits were excluded. The average patient age was 40 years with sex distribution as 68.5% female and 31.5% male. The patient sample was 61% White, 18% Black, 8% Asian or Pacific Islander, 4% Hispanic or Latino, and 9% other or unknown.
Within the hybrid model, photos were uploaded for inflammatory (N = 520, 63%), followed by lesion-specific (N = 209, 25%), and acneiform conditions (N = 98, 12%). For hybrid encounters, a high rate of photo usability (95%) was similar to prior studies5 and a low rate of anatomically sensitive photos (5% groin/buttocks) was noted. The mean number of photos per encounter for inflammatory (3.41), acneiform (2.66), and lesion-specific (2.44) conditions were statistically different by one-way ANOVA (P < .01). By post hoc unpaired t-tests, inflammatory conditions averaged significantly more photos per encounter than lesions (P < .01), but other pairings did not differ significantly. Most photos featured a diagnosis assigned to the encounter (91%) versus a pregnancy test or other.
Nearly half of the uploaded photos were requested by the physician (46.8%), followed by patients (39.5%), and office staff (2.2%) or unknown initiators (9.7%) (Fig 1).Chi-squared analysis revealed that initiator and condition were statistically dependent (P = .004). Only for lesion-specific conditions did physicians more commonly request photos as compared to patients or staff/other. (30% vs 19%). This study is limited as a retrospective study comparing only 2 modalities of teledermatology within a single institution with a single Epic based platform during the pandemic.
Fig 1.
Skin diagnosis and photo uploading initiators. Proportion of images submitted by patients or their representatives, physicians, and staff or unknown sources across acneiform, inflammatory, and lesion-specific diagnoses in the hybrid teledermatology model. The electronic medical record workflow provided no standardized patient instructions regarding uploading photos through patient portal messages before or after a visit. Patients could upload 3 photos per message with the ability to send multiple messages in a hybrid encounter.
Within a teledermatology workflow that lacks standardized patient instruction, this study demonstrates an advantage of hybrid over video visits for lesion-specific conditions. Hybrid visits were used at a higher rate with physicians more frequently requesting photos for lesions as compared to other diagnoses. Inflammatory conditions demonstrated the highest photo upload rate per encounter. As a result, the hybrid model demonstrate higher utility in treating lesion-specific and inflammatory conditions via teledermatology while video-only visits suffice for acneiform conditions.
Conflicts of interest
None disclosed.
Footnotes
Funding sources: None.
Patient consent: Not applicable.
IRB approval status: Reviewed and exempt by Thomas Jefferson University; #21E.409.
References
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