To the Editor: With more than 16 million newly insured individuals since the implementation of the Affordable Care Act, dermatologists are challenged to improve access to care. Teledermatology is rapidly emerging as one solution and has been shown to provide high diagnostic accuracy and reproducibility.1–3 Although traditionally there has been limited literature on teledermatology in safety-net health systems, a recent prospective study of 196 teleconsults4 in an underserved outpatient setting found that the system improved care through dermatologist-recommended management modifications. Our group builds upon this knowledge by investigating whether the Los Angeles County Department of Health Services (LAC-DHS)—a large safety-net health system—was able to use teledermatology to “tele-triage” and manage a proportion of consults solely via telemedicine.
This was a retrospective descriptive study involving manual review of teleconsults in the LAC-DHS system placed by primary care providers (PCPs) to 1 of 8 DHS-affiliated dermatologists between July 2012 and May 2014. After 99 exclusions for duplicate or canceled consults, 9499 consults were included (Table I). PCPs suspected any type of cutaneous malignancy in 22% of consults and specifically melanoma in 7%, while dermatologists suspected any malignancy in 9% and melanoma in 2% of consults.
Table I.
Teledermatology consult characteristics
| n (%) | |
|---|---|
| Age | Mean: 47.0 (SD: 16.6) |
| Gender | |
| Female | 5683 (60%) |
| Male | 3816 (40%) |
| Consult reason | |
| Lesion | 6171 (65%) |
| Rash | 2829 (30%) |
| Lesion and rash | 229 (2%) |
| Unknown/other | 263 (3%) |
| Photo included at any point | |
| No | 1976 (21%) |
| Yes | 7523 (79%) |
| Photo included initially | |
| Yes | 7337 (98%) |
| No | 186 (2%) |
| Photo adequate | |
| Yes | 7160 (95%) |
| No | 363 (5%) |
| Length of dialogue exchange | |
| ≤1000 characters | 5902 (62%) |
| >1000 characters | 3596 (38%) |
| PCP suspects malignancy | |
| Yes | 2072 (22%) |
| No | 7427 (78%) |
| Dermatologist suspects malignancy | |
| Yes | 860 (9%) |
| No | 8639 (91%) |
| PCP suspects melanoma | |
| Yes | 663 (7%) |
| No | 8836 (93%) |
| Dermatologist suspects melanoma | |
| Yes | 182 (2%) |
| No | 9317 (98%) |
PCP, Primary care physician.
Primary outcome was the percentage of consults referred for a dermatology appointment versus those that addressed the patient’s concerns without in-person evaluation. When adequate photographs were included (defined by inclusion of a photograph and absence of comment by the dermatologist that the photograph was inadequate), 68% of consults were referred face-to-face, while 31% were managed exclusively via telemedicine (Table II). Without adequate photographs, 24% of consults were managed by telemedicine, and the dermatologist requested a photograph before making recommendations in 11%. Consults that lacked adequate photographs but were managed via telemedicine were primarily requesting treatment advice for previously established dermatologic diagnoses. Consults were managed by telemedicine more frequently for rashes than lesions (38% vs 25%). With adequate photographs, in-person visits were deemed unnecessary by the dermatologist in 21% of consults for which the PCP suspected any malignancy and in 29% for which the PCP suspected melanoma.
Table II.
Teledermatology consult outcomes
| Referred face-to-face % (n) |
Addressed via telemedicine % (n) |
Requested a photograph % (n) |
|
|---|---|---|---|
| Total | 68 (6429) | 29 (2765) | 3 (305) |
| Photo included | |||
| Yes | 68 (5147) | 31 (2299) | 1 (77) |
| No | 65 (1282) | 24 (466) | 12 (228) |
| Adequate photo included | |||
| Yes | 68 (4887) | 31 (2219) | 1 (54) |
| No | 66 (1542) | 23 (546) | 11 (251) |
| Length of dialogue exchange | |||
| ≤1000 characters | 78 (4608) | 19 (1097) | 3 (197) |
| >1000 characters | 51 (1821) | 46 (1667) | 3 (108) |
| Referral Reason | |||
| Lesion | 72 (4435) | 25 (1535) | 3 (201) |
| Rash | 59 (1671) | 38 (1080) | 3 (78) |
| Lesion and rash | 69 (158) | 28 (63) | 3 (8) |
| Unknown/other | 61 (160) | 32 (85) | 7 (18) |
| Primary care physician (PCP) suspects malignancy | |||
| Yes | 78 (1607) | 19 (392) | 4 (73) |
| With adequate photo | 78 (1248) | 21 (334) | 0.5 (8) |
| Without adequate photo | 74 (359) | 12 (58) | 13 (65) |
| No | 65 (4822) | 32 (2373) | 3 (232) |
| PCP suspects melanoma | |||
| Yes | 71 (469) | 24 (159) | 5 (35) |
| No | 67 (5960) | 29 (2606) | 3 (270) |
| Dermatologist suspects malignancy | |||
| Yes | 96 (828) | 4 (31) | 0 (1) |
| No | 65 (5601) | 32 (2734) | 4 (304) |
| Dermatologist suspects melanoma | |||
| Yes | 96 (174) | 4 (7) | 0.5 (1) |
| No | 67 (6255) | 30 (2758) | 3 (3034) |
The use of teledermatology in medically underserved populations can assist in maximizing the number of patients with access to specialist care. This is largely accomplished by tele-triaging, or using telemedicine to prioritize in-person clinic visits for patients with the most urgent complaints associated with greater morbidity or mortality. The LAC-DHS teledermatology system managed benign rashes and suspicious lesions through its platform. Although total percentage of remotely managed consults (29%) is lower than in many other teledermatology programs,5 this likely reflects limitations of a safety-net system. In particular, there were concerns about inadequate follow-up, pharmacy restrictions, and limited resources to perform basic dermatologic interventions in the busy community clinics. Overall, we believe that teledermatology has the potential to increase access to care for some of the country’s most underserved populations and can function successfully even in health systems with significant functional limitations. It is important to continue assessing its use in such settings in order to provide the highest level of care.
Acknowledgments
Funding source: None.
Footnotes
Conflicts of interest: None declared.
REFERENCES
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