Canadians have longer waits to see a medical specialist than most other industrialized nations.That’s according to a report by the Canadian Institute for Health. A virtual dermatologist and a smart phone just might be one way to bridge the gap.

Health Plan of San Joaquin is a managed care plan that serves more than 380,000 people living in California’s Central Valley.  In 2012, the plan began offering virtual dermatology referrals through a company called Direct Dermatology.  In the beginning, GPs and internists referred patients to a virtual dermatologist  complete with background information about the patient plus photos of the rash or skin lesion – both uploaded to a secure web site. The virtual dermatologist would give an opinion about the rash to the referring doctor within a few days

More recently, patients have been referred to a bricks and mortar building where they are interviewed and photographed first by a nurse.  If necessary, a skin biopsy can be done there too.

So far, the program has been quite successful.  Researchers from Rand Health  the largest independent health policy research program in the U.S.  crunched the numbers. Of close to 400,000 patients in the plan, 8614 were referred a dermatologist.  Overall, half the patients saw a dermatologist in person, and half had a virtual appointment.  After the U.S. Affordable Care Act came into effect in 2014, more than 108,000 new patients entered the plan.  Of the newbies referred to a dermatologist, one quarter saw one in person and three quarters had a virtual appointment.

That means access to virtual dermatologists enabled the plan to keep with a huge increase in the demand for dermatology referrals. It did so despite the region having far fewer dermatologists than the national average.

Like other specialties in medicine, virtual dermatology has attracted its share of critics.  They maintain that no one – not even a dermatologist who often makes spot diagnoses based on the typical appearance of a skin lesion –  can diagnose a patient without seeing them in person.  Texas and other states in the U.S. have tried to put the breaks on virtual appointments.

I like the way Health Plan of San Joaquin adapted its virtual dermatology program to anticipate that objection. The bricks and mortar clinic I told you about also serves as the place where the virtual dermatologist can refer patients with more complex skin and other conditions for a more complete assessment by a dermatologist in person. The use of the physical clinic is reassuring.  In the study, those who received a virtual appointment only were younger and more likely to have minor skin problems like acne and warts; those seeing a dermatologist in person were older, had more serious skin problems like cancer, and tended to have other serious medical problems.

I imagine that some of these critics would be dermatologists who might feel threatened by this.  I think dermatologists enjoy being in scarce supply in Canada.  They get to schedule delayed appointment – by which time the skin rash has either gone away, or is so easy to diagnose that even a medical student can offer a correct opinion.  If dermatologists lose significant business to virtual colleagues, then more and more of them will go the virtual route themselves.

Smart phones work surprisingly well with virtual appointments.  A 2015 study by researchers at the University of Pennsylvania found that a smart phone app can help doctors prioritise referrals to a virtual dermatologist.  In another recent study, researchers in Sweden and South Africa recruited subjects to rate the quality of photos taken by various smart phones – and compared them to photos taken by a digital camera.  The image quality generated by the smartphones was just as good.  Add-on devices are being developed that can enhance today’s smart phones to the point where they might be able to help detect cancer.

It’s tempting to say that what happens in health care in the U.S. is not applicable to Canada.  In this case, I think that’s incorrect.  Virtual access to a dermatologist under the Health Plan of San Joaquin is not a marketing gimmick to generate income.  The Health Plan of San Joaquin is not for profit.  Like Canada, it provides publicly funded health care – in this case – under contract to California’s Department of Health Care Services.

What is different to me is that the U.S. is more willing to try new ideas.  In Canada, we let fears of breaching patient privacy act as a break on the development of virtual medicine.  That’s changing, but not as fast as I’d like and, as we need to keep up with an ever-increasing demand for services.

TELEDERMATOLOGY CAN HELP: A RAND/Harvard study shows that skin-doctoring-at-a-distance makes it easier for patients to get specialized care. The researchers studied a collaboration between Palo Alto, Ca.-based Direct Dermatology and Health Plan of San Joaquin, a Medicaid managed care plan with nearly 300,000 enrollees in an area where immigrant farmworkers get their share of skin conditions. “Patients covered by Medicaid have traditionally been one of the groups with limited access to dermatologists, but teledermatology is making it possible for patients to receive the care they need through a network of primary care physicians, teledermatologists and local dermatologists,” said Dr. David Wong, CEO of Direct Dermatology (now DirectDerm).

Why has teledermatology never taken off? Technically, we’ve been able to do it for years, yet most providers have been unwilling. This year, however, I expect we will cross the tipping point. The convergence of digital health records, expanding reimbursement, and consumerization of health care have led to a surge in demand, and now a supply of teledermatology services.

Much of this growth is from direct-to-consumer teledermatology providers. These are telehealth services marketed to patients where they access a dermatologist directly, paying out of pocket or with insurance. One such company is the aptly named Direct Dermatology.

Founded in 2009, it is an online dermatology clinic that provides 24/7 access to board-certified dermatologists. It is experiencing rapid growth and is currently looking to expand its network of dermatologists. For this month’s column, I share an interview with Dr. David Wong, cofounder of Direct Dermatology and clinical associate professor at Stanford (Calif.) University. I have no financial or other conflicts of interest to disclose.

Initially, telehealth was designed to serve rural communities with limited access to health care. Today it is used more widely. Would you share some examples of its use?

Dr. Wong: Much of the initial telehealth efforts and success have been in rural communities because telehealth solves a major problem of access to medical care in underserved areas. But it can be extremely valuable in all geographic areas, not just rural communities. Access is a problem even in urban areas, where wait time for a dermatologist appointment averages over 1 month. Telehealth has the potential to not only improve access, but also to improve quality of care and deliver care more efficiently for the patient, provider, and overall health system.

Teledermatology is being used by several employers as a benefit to their employees to provide convenient and timely access to dermatologists and decrease employee time away from work. There are several direct-to-consumer online teledermatology services that are being used by patients in all communities, especially urban communities.

The fact is that the majority of dermatology cases are seen by primary care physicians. If teledermatology can provide rapid, efficient, and reliable access to experienced dermatologists, the quality of dermatology care in the country will improve.

Please share some of the tangible benefits of teledermatology, such as triage, reducing the disparity in access to dermatologists, employer benefits, etc.

Another factor is that dermatology problems don’t occur only during business hours – we are seeing a growing number of cases submitted from our own patients over the weekend or in the evening. The ability to evaluate acutely developing skin problems within a few hours, such as rashes in children, can alleviate a lot of anxiety and avoid unnecessary emergency room costs.

Teledermatology also is beneficial to dermatologists in allowing us to provide care from anywhere on a flexible schedule. We don’t have to go into the office to “see” our patients. Both patient and provider satisfaction in our office’s teledermatology practice is very high.

Reimbursement has been a major drawback with telehealth. For example, Medicare reimburses for telemedicine services in some states, but others have restrictions. There are also more restrictions on the “store-and-forward” format than for the live, interactive format. Would you shed some light on this?

Dr. Wong: Yes, reimbursement has been a barrier to telehealth. But that is changing. A total of 22 states and the District of Columbia have passed parity laws for private insurance coverage of telemedicine, and 10 states have pending legislation. But whether telemedicine is actually covered by each health plan varies even in those 22 states. And coverage can vary depending on whether it is store-and-forward or live interactive teledermatology. Medicare still only covers store-and-forward teledermatology under a federal demonstration program in the states of Hawaii and Alaska. We believe that the ultimate driving force – delivery of high-quality and cost-effective specialty care to more patients – will continue to support the current trend in expanded telemedicine coverage.

What type of liability do dermatologists face when using telehealth?

Dr. Wong: The good news is that there have not been any malpractice lawsuits related to teledermatology to date. But physicians performing telehealth services should ensure that their malpractice liability insurance policy covers the exact form of telehealth that will be provided (just as it covers any other medical services that physicians provide), prior to starting to provide those services. Most medical malpractice insurance does not automatically cover telehealth services. In addition, be sure to understand state regulations about licensing, informed consent, and online prescribing.

How do patients feel about teledermatology? Do you notice any differences regarding patients’ gender and age?

Dr. Wong: I’m going to specifically speak about “store-and-forward” teledermatology, which is the predominant mode of teledermatology being used today. Store-and-forward teledermatology is an asynchronous mode where pictures of the skin problem and medical history are sent to the dermatologist. In general, patients love teledermatology. It is convenient; they don’t have to take time off from their busy schedules. They don’t have to wait for the next available appointment in my clinic. They can get answers and are placed on treatment that same day. In our practice, there is an opportunity for rapid, secure communication exchange with the dermatologist during the consultation as well. Of course, there are skeptics who wonder whether dermatologists can really make an accurate diagnosis with a picture. But once patients experience the service, they are typically very satisfied with what our dermatologists can do and with the quality of care. Anecdotally, we’re seeing a nearly equal distribution of male and female consumers seeking care through teledermatology. Individuals in their 30s comprise the largest age segment, but we see patients from all age groups, even pediatric cases sent by parents.

What do you say to physicians who are concerned that teledermatology will eventually replace in-person visits and erode the doctor-patient relationship?

Dr. Wong: Teledermatology will never completely replace in-person visits. But it will become an important component of our practices. Teledermatology can actually improve the doctor-patient relationship because it allows for increased connectivity between doctor and patient. It is important for dermatologists to define how teledermatology enhances our existing practices by improving the quality of care and actually strengthening our relationship with our patients.

What advice do you have for dermatologists who are considering implementing teledermatology in their practice?

Dr. Wong: Speak with other dermatologists who have had experience with providing teledermatology services in their practices. Learn from their best practices. In addition to adopting a new technology, think through how it incorporates into your clinic operations. And pay attention to regulatory and legal compliance in an environment where there is constant change.

What are your predictions for the future of teledermatology?

Dr. Wong: The future of teledermatology is exciting. It is now an important tool to provide even better care to our patients. The technology for high-quality photography from mobile devices has rapidly advanced, and in most cases, when done properly, the resulting images are as good as – or better than – what you can see with the unaided human eye in an exam room. Because of the way our field has thoughtfully implemented teledermatology alongside traditional dermatology, teledermatology will very soon become a standard of care. The term “teledermatology” will no longer be used because it will simply be a standard part of dermatology practice.

For more information and contacts, please visit DirectDermatology.com.