To the Editor: In the era of COVID-19, dermatology practices have rapidly adopted teledermatology.1 , 2 Prepandemic research showed physician and patient satisfaction; however, these studies included groups who chose the telemedicine medium.3 , 4 Pandemic-related restrictions on in-person care catalyzed a broader adoption of telemedicine among both physicians and patients. This study examines the experiences of both groups with teledermatology during the COVID-19 pandemic.
We surveyed the clinical faculty in the Department of Dermatology at Yale School of Medicine and patients seen via Epic MyChart (Epic, Verona, WI) synchronous video visits from mid-March to mid-May 2020. We performed an ordinal logistic regression using the polr package in R, version 3.6.1 (R Foundation for Statistical Computing, Vienna, Austria) to compare patient and physician perceptions. We excluded all unable to answer responses from the regression analysis.
Faculty were amenable to managing many skin conditions solely by telemedicine or by telemedicine in conjunction with in-person visits. However, 23 of 24 faculty members (96%) believed that total body skin examination should only be managed through in-person visits (Fig 1 ).
Fig 1.
Faculty management preferences for managing various dermatologic conditions via telemedicine versus in-person visits.
Table I summarizes physician and patient perspectives on virtual care; 50% of faculty reported prior experience with teledermatology, although the majority had used only store-and-forward.5
Table I.
Patient and physician perspectives on telemedicine care
| Question posed to patients and/or physicians | Patients, n (%) (N = 548) |
Physicians, n (%) (N = 24) |
Odds ratio | 95% CI | P value |
|---|---|---|---|---|---|
| The MyChart App made it easy to have a video visit | 4.46 | 2.05-9.71 | .001 | ||
| Strongly agree | 365 (67.1) | 7 (30.4) | |||
| Agree | 137 (25.2) | 11 (47.8) | |||
| Disagree | 14 (2.6) | 2 (8.7) | |||
| Strongly disagree | 21 (3.9) | 3 (13.0) | |||
| Unable to answer | 7 (1.3) | 0 | |||
| The video visit picture and audio quality were good | 18.05 | 8.56-38.75 | <.001 | ||
| Strongly agree | 324 (59.2) | 0 (0) | |||
| Agree | 169 (30.9) | 9 (37.5) | |||
| Disagree | 24 (4.4) | 10 (41.7) | |||
| Strongly disagree | 16 (2.9) | 5 (20.8) | |||
| Unable to answer | 14 (2.6) | 0 | |||
| Patient received/I am able to provide the same quality of care during our video visit as an office visit | 48.28 | 19.55-128.40 | <.001 | ||
| Strongly agree | 234 (42.8) | 1 (4.2) | |||
| Agree | 213 (38.9) | 2 (8.3) | |||
| Disagree | 61 (11.2) | 11 (45.8) | |||
| Strongly disagree | 7 (1.3) | 10 (41.7) | |||
| Unable to answer | 32 (5.9) | 0 | |||
| I am interested in using video visits for future appointments | 1.33 | 0.62-2.85 | .47 | ||
| Strongly agree | 223 (40.8) | 8 (33.3) | |||
| Agree | 238 (43.6) | 13 (54.2) | |||
| Disagree | 53 (9.7) | 3 (12.5) | |||
| Strongly disagree | 10 (1.8) | 0 | |||
| Unable to answer | 22 (4.0) | 0 | |||
| My family member or I would be more likely to choose a provider who offered video visits | — | — | — | ||
| Strongly agree | 195 (35.8) | — | |||
| Agree | 233 (42.8) | — | |||
| Disagree | 72 (13.2) | — | |||
| Strongly disagree | 9 (1.7) | — | |||
| Unable to answer | 35 (6.4) | — | |||
| How much time did you save by having a video visit? (includes travel, wait, time off of work) | — | — | — | ||
| Less than 1 hour | 192 (35.0) | — | |||
| 1-2 hours | 267 (48.7) | — | |||
| 2-4 hours | 67 (12.2) | — | |||
| More than 4 hours | 22 (4.0) | — | |||
| My patients appreciated the ability to have a video visit | — | — | — | ||
| Strongly agree | — | 14 (60.9) | |||
| Agree | — | 9 (39.1) | |||
| Disagree | — | 0 | |||
| Strongly disagree | — | 0 | |||
| Unable to answer | — | 0 | |||
| Offering video visits during the pandemic allowed me to feel that I was participating in the overall effort to decrease the need for in-person care | — | — | — | ||
| Strongly agree | — | 18 (78.3) | |||
| Agree | — | 5 (21.7) | |||
| Disagree | — | 0 | |||
| Strongly disagree | — | 0 | |||
| Unable to answer | — | 0 | |||
| Patients were generally understanding of the situation and our effort to conduct care using telemedicine | — | — | — | ||
| Strongly agree | — | 12 (50) | |||
| Agree | — | 12 (50) | |||
| Disagree | — | 0 | |||
| Strongly disagree | — | 0 | |||
| Unable to answer | — | 0 | |||
| I believe that some of my patients' skin cancer, or skin disease, has progressed as a result of avoiding interaction with the medical system during the COVID-19 pandemic | — | — | — | ||
| Strongly agree | — | 5 (21.7) | |||
| Agree | — | 15 (65.2) | |||
| Disagree | — | 2 (8.7) | |||
| Strongly disagree | — | 1 (4.3) | |||
| Unable to answer | — | 0 | |||
| Did you have experience offering teledermatology services before the COVID-19 pandemic? | — | — | — | ||
| Yes, store-and-forward, physician-to-physician (eConsults) | — | 9 (38) | |||
| Yes, live synchronous (video visits) | — | 2 (8) | |||
| Yes, store-and-forward, direct-to-patient | — | 1 (4) | |||
| No | — | 12 (50) |
CI, Confidence interval.
All physician respondents believed that teledermatology allowed them to contribute to efforts to reduce in-person care; however, 87% of physicians responded that some patients' skin cancer or skin disease likely progressed because of COVID-related avoidance of interaction with in-office medical care (Table I).
Finally, most patients reported that teledermatology was time saving. Including travel, wait time, and time off from work, 65% of patients reported saving at least 1 hour of time (Table I).
Patients were nearly 50 times more likely than faculty to agree or strongly agree that the quality of care during a telemedicine visit was equal to an in-office visit (odds ratio, 48.28; 95% confidence interval, 19.55-128.40; P < .001). Patients were nearly 20 times as likely as faculty to agree or strongly agree that the picture and video quality during the video visit were good (odds ratio, 18.05; 95% CI, 8.56-38.75; P < .001). The majority of both patients and physicians reported future interest in video visits (P = .47) (Table I).
Our study indicates that patients and physicians are overwhelmingly interested in teledermatology in the future. Although most physicians had limited previous experience, the majority believed that teledermatology allowed them to contribute to COVID-19 control efforts and that many conditions could be managed by telemedicine alone or by telemedicine in conjunction with office visits. However, our study highlights important discrepancies between physician and patient perceptions and emphasizes significant concerns among physicians regarding the quality of virtual care provision. They also suggest that patients, compared to physicians, value convenience when thinking about quality. These insights represent opportunities for technologic innovation but also indicate a need for caution as we integrate this care modality. Our study is limited by our sample size of 572 and the fact that patients who did not schedule video visits could not be included. Larger, multi-institutional studies are needed to better understand the limitations of, and opportunities afforded by, teledermatology during the public health crisis and beyond.
Acknowledgments
Author Asabor would like to thank the Black Health Scholars Network for their support of this work.
Footnotes
Drs Cohen and Perkins contributed equally to this article.
Funding sources: None.
Disclosure: Dr Perkins is a clinical advisor for Hims/Hers. Dr Bunick is a consultant for Teladoc. Author Asabor and Dr Cohen have no conflicts of interest to declare.
IRB approval status: Reviewed and approved by Yale University Institutional Review Board (protocol ID 2000028082).
References
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