The new normal: An approach to optimizing and combining in-person and telemedicine visits to maximize patient care

To the Editor: In response to the COVID-19 pandemic, our department transitioned to an almost entirely teledermatology practice.¹ As the country begins to reopen safely, we and many dermatologists across the United States will continue using teledermatology while integrating in-office care.

Telemedicine visits, in the correct clinical context, can often function as efficiently as their in-person counterparts.² However, more work is required to prepare patients for visits, and without this, many patients spend their entire visit troubleshooting various technical issues. Notably, in our experience, lack of access to technology has not been a significant barrier; most patients have access to a capable device, but many require coaching to effectively use it. To address these issues, our department provides patients with an electronic message before telemedicine visits with written instructions and instructional videos to ensure readiness. This allows the patient to seek technical assistance in advance, if necessary. The patient is also asked to reply to the message with photographs of the skin problem to enhance evaluation, thus combining the advantages of store-and-forward and synchronous telemedicine visits. There are many patients who decline teledermatology visits, but information on the motivation for declining is unknown.

To integrate telemedicine efficiently, the encounter workflow must replicate that of an in-person visit. Before the start of a visit, the rooming process, which involves confirmation of medical history, medications, allergies, and pharmacy, is critical for both patient care and practice efficiency. For telemedicine visits, patients are virtually roomed by a member of the clinical staff. This replicates in-office rooming and ensures that the patient is in the virtual waiting room ready for the physician, who is alerted through the medical record to begin the video visit. In our practices, the dermatologist can have a member of the clinical staff join for the entirety of the video visit to assist as they would during an in-person visit.

Looking forward, we devised a system in which the dermatologist alternates between a telemedicine “room” and an in-person room to streamline the integration of the 2 modalities (Fig 1). The combination prevents waiting room crowding, maintains safe distancing between in-person visits with adequate time for disinfecting protocols, and maximizes access to care while using the full capacity of our staff. Additionally, we found that triaging patients before any in-person visit with telemedicine can allow for optimal in-office scheduling. Patients with lesions or eruptions who are believed to need more immediate attention are evaluated in the office in an expedited way.

Fig 1.

Algorithm for integrated practice during the COVID-19 pandemic.

As dermatologists enter the next phase in the COVID-19 pandemic, providing the highest quality of care while ensuring patient and staff safety remains paramount. Our generalizable strategies and workflows can be adopted across academic and private practices to facilitate the use of teledermatology in tandem with in-office care to achieve these goals. This pandemic has enlightened us to the benefits of virtual care in certain contexts while simultaneously reinforcing the value of in-person care in others. Dermatologists will need to use and integrate both modalities as we move forward with this new normal.