Teledermatology is an effective strategy for eliminating unnecessary dermatology referrals and increasing access to specialty care for underserved populations.
It is possible to diagnose serious and life-threatening skin conditions on the basis of simple images taken in primary care offices and reviewed remotely by dermatologists.
Teledermatology saves money for the health care system and enables primary care providers to better coordinate and manage care for patients with skin concerns. However, insurance reimbursement remains a major challenge.
Telemedicine technology does not have to be complicated or difficult to use, and thoughtfully designed workflows can facilitate the smooth integration of telemedicine into a primary care practice.
In its most recent publication on the burden of skin disease in the United States, the American Academy of Dermatology reported that skin disease caused almost 23,000 deaths in 2013 (representing 0.9% of approximately 2.6 million total deaths). The estimated direct cost related to skin diseases was almost $75 billion, of which $46 billion was related to medical costs. Furthermore, there was an opportunity cost of about $11 billion resulting from lost time at work due to interaction with the health care system.
Early detection and timely treatment of serious skin conditions can prevent negative health outcomes and death. However, many patients, especially those from underserved communities, face significant barriers in accessing specialty dermatology care. Although some minor skin conditions such as acne, eczema, and contact dermatitis could be managed within the primary care setting, primary care providers (PCPs) typically are not trained to diagnose or triage skin conditions and sometimes unnecessarily refer patients to dermatologists.
This factor, combined with a shortage of dermatologists, creates a situation in which many dermatology appointments are filled by patients who do not need specialty care, thereby limiting the availability of such appointments for those who do. The net effect is that patients with urgent skin conditions such as cutaneous T-cell lymphoma, melanomas, or infectious rashes face lengthy delays in receiving diagnosis and treatment and are at risk for poor health outcomes, whereas those with minor conditions face cost and travel burdens related to unnecessary visits to a dermatologist.
A group of seven community health centers (CHCs) serving low-income communities in Massachusetts collaborated to eliminate unnecessary dermatology referrals, improve access to care for patients with serious skin conditions, and reduce overall dermatology spending.
The CHC collaborative was led by Edward M. Kennedy Community Health Center. The other partners were Family Health Center of Worcester, Harbor Health Services, Charles River Community Health Center, Lynn Community Health Center, Manet Community Health Center, and South Boston Community Health Center. This group of CHCs, with 22 primary care locations across eastern and central Massachusetts, serves a vulnerable population in which 44% of patients are enrolled in Medicaid or CHIP insurance plans and 17% are uninsured.
South Boston CHC is the only health center in the group that provides dermatology services in-house; the others refer patients requiring dermatology services to other institutions. For CHC patients in Massachusetts, the average wait time for a dermatology appointment is 16 weeks (data from a telephone survey of Massachusetts dermatologists conducted by 3Derm Systems, Inc., in 2018).
In October 2015, the CHC collaborative received a grant to pilot a telemedicine solution for remote dermatology consultation and triage and selected 3Derm Systems, Inc., as the technology partner. 3Derm Systems offers a skin imaging system that enables primary care staff to take clinical-quality 2-D and 3-D images and upload them for remote review by a dermatologist. The imaging system involves the use of simple handheld imaging devices and a HIPAA-secure software interface. 3Derm Systems provided data and input to the authors during the preparation of this article; however, the authors do not have any financial or other interest in 3Derm Systems.
3Derm Systems and the CHCs jointly developed workflows for primary care and remote dermatologist offices and devoted significant attention to identifying common workflows that worked for all entities with minor customizations. In addition, the collaborative identified and contracted with three specialty dermatology sites that provided dermatologists to perform remote readings, and each CHC identified local dermatology offices that agreed to ensure appointment availability for patients with urgent skin concerns.
The teledermatology workflows were rolled out to the seven CHCs in a staggered manner over a period of 8 months, allowing the collaborative to pilot test, troubleshoot, and refine the process. With the finalized workflows, the typical teledermatology process involves three major steps: (1) imaging in primary care, (2) remote dermatology consult and triage, and (3) in-person evaluation.
- Imaging in Primary Care:
- After CHC staff confirm the patient’s insurance eligibility for teledermatology coverage, the PCP places an order in the electronic health record (EHR).
- A medical assistant takes images and closes the order, and the data are automatically uploaded to the 3Derm system.
- The medical assistant or a medical records staff person sends insurance information to 3Derm Systems, which manages invoicing for the remote dermatologist’s office.
- Remote Dermatology Consult and Triage:
- Using a remote reading station, the dermatologist reviews the images and enters the triage time line and treatment suggestions.
- A consult report is then autogenerated and uploaded. The consult report is standardized and includes the information provided by the dermatologist as well as any patient and condition-related information provided by primary care.
- At the remote dermatologist’s office and the CHC, a medical records staff person adds the consult report to the EHR.
- In-Person Evaluation:
- At the CHC, the PCP reviews the report, and, if needed, the referrals team makes a dermatology appointment, which is expedited according to the dermatologist’s determination of urgency.
With this program, remote dermatologists were reimbursed by insurers at a reduced rate of $32.40 per consult on average (compared with $180 for an in-person visit), and CHCs paid 3Derm Systems a subscription cost of $20 per consult. Primary care was reimbursed at the standard rate and did not receive additional reimbursement for the inclusion of the teledermatology imaging as part of the visit.
The collaborative hired a program manager to coordinate efforts across all participating centers and sites, and 3Derm Systems collaborated closely with the group of CHCs throughout all stages of project planning and implementation.
In preparation to go live with the teledermatology workflows, each CHC held a kickoff meeting with the executive leadership team to build buy-in and to coordinate internal communications. Each CHC also assembled an implementation team that typically included a project manager, provider lead, medical assistant lead, referrals lead, EHR expert, and medical records lead. In some cases, the project manager was a CHC executive such as the Chief Operating Officer, whereas in other cases the project manager was a clinical or information technology leader.
The Institute for Community Health was the external evaluator for the grant program that funded this project and worked with the collaborative to define evaluation metrics.
Metrics and Results
Overall, 850 teledermatology consults were completed between November 2016 and May 2018. On average, CHCs received consult results within 0.5 to 3.0 calendar days after taking images. Forty-four consults (5%) were deemed high priority, with the patients receiving expedited dermatologist visits within days (for conditions such as cutaneous T-cell lymphoma and infectious rashes) or within 1 to 2 weeks (for conditions such as scabies, melanoma, invasive squamous cell carcinoma, and lupus); these wait times were substantially shorter than the 16-week average wait time without teledermatology.
Patient Impact Vignette
A 56-year-old man came to primary care with a skin concern that was originally thought to be eczema but turned out to be T-cell lymphoma. The patient was offered a dermatology appointment within 24 hours after his primary care visit and was able to see a dermatologist four days later. Without this program, the patient might have waited for months to see a dermatologist and could have experienced life-threatening health complications.
Two hundred consults (24%) were triaged as showing medium-priority conditions (such as basal cell carcinomas, squamous cell carcinomas, and atypical moles), with the patients receiving expedited visits within 2 to 4 weeks. One hundred and seventeen consults (14%) were determined to show low-priority conditions (such as acne, eczema, contact dermatitis, and seborrheic keratoses); in these cases, the patients did not receive expedited visits and were scheduled for the next available dermatology appointment.
For 63 consults (7%), the remote dermatologist indicated that the image was unreadable due to user error or that more information was needed to triage. These patients still received dermatologist visits within 2 to 4 weeks.
For half of the teledermatology consults (426 of 850; 50%), an in-person dermatology appointment was not deemed necessary. Without the teledermatology service, these patients would have had to visit a dermatologist for the initial consult. Eliminating these in-person specialist visits created an estimated savings of $74,976 in dermatology-related spending, primarily as a result of lower reimbursement rates for remote consults compared with in-person visits as well as reduced time spent by CHC staff making referrals. The patients in this group realized an additional financial benefit in that they not incur costs due to transportation, missed time at work, and co-pays for dermatologist visits.
Triage rates from the first 19 months of the program indicate that 50% of patients presenting to primary care with skin concerns do not need a specialist referral. With this triage rate, if the teledermatology consult process were scaled up and used for all patients who typically would be referred to a dermatologist (assuming that all insurance plans covered the service), these seven CHCs could reduce dermatology spending for their patients by approximately $400,000 each year. In a fee-for-service system, these savings would be largely realized by payers. However, in a value-based contract system that incentivizes cost reduction, the savings could be shared among all stakeholders, including the payers, CHCs, and dermatologists, depending on contract structure.
In addition to the 426 patients who did not need a dermatology appointment, there was a subset of the 117 patients with low-priority conditions for whom the remote dermatologist provided treatment suggestions that enabled the PCP to manage the patient’s ongoing dermatologic care. For this subset of patients, there were additional avoided specialty visits and cost savings that are not included in the figures above.
Furthermore, over time, teledermatology will likely create significantly more savings resulting from the early detection of serious skin conditions and the prevention of long-term complications and associated medical care.
Limited Insurance Reimbursement
Limited insurance reimbursement for teledermatology was the biggest challenge for this initiative; as a result, the CHCs and 3Derm Systems devoted significant effort to determining reimbursement options for remote dermatologists.
Because Massachusetts does not yet have teledermatology reimbursement standards or regulations, the CHCs had to advocate for reimbursement and negotiate rates individually with each payer. The CHCs reached agreements with four payers on a reimbursement rate and billing code, but patients who were insured under other health plans did not have coverage for the teledermatology service. Some of the payers that agreed to cover the remote dermatology readings administered Medicaid plans; however, not all Medicaid recipients had coverage for teledermatology. Furthermore, not all of the remote dermatology providers contracted with all four of the payers for this service, creating additional complexity around insurance reimbursement.
At the end of the pilot project, the CHC collaborative obtained a grant from Partners HealthCare to cover teledermatology readings for Medicaid recipients, and the group is engaged in ongoing conversations and advocacy with the state Medicaid program and other payers about increasing coverage for teledermatology. The collaborative is hopeful that insurance coverage will expand in the near future, which will enable the teledermatology program to be sustained without grant funding.
The incomplete insurance coverage also created workflow challenges because CHC staff had to verify insurance coverage before placing teledermatology orders. This requirement created barriers to provider buy-in and limited provider adoption of the technology at some sites. CHCs implemented several workarounds to facilitate insurance verification and increase provider adoption, such as modifying the EHR to highlight eligible insurance plans and creating mandatory workflows in which medical assistants check insurance and providers are expected to triage qualifying patients with teledermatology before scheduling in-person appointments.
EHR Integration and Internet Bandwidth
EHR integration was another challenge. CHCs implemented EHR modifications to integrate some tools, such as creating teledermatology order sets. However, the CHCs did not have the resources to allow for additional EHR integration that would have created more efficiencies. For example, a fully integrated system would automatically send insurance information to the remote reading site and would automatically add dermatologist consult reports to the EHR, saving staff time. Finally, Internet bandwidth was a barrier for one CHC, necessitating upgrades to enable data upload and transmission.
Where to Start
Through the work of the CHC collaborative, the teledermatology implementation process has been refined and streamlined such that a new CHC can be up and running in about 5 weeks. Initial steps include assembling an implementation team, identifying remote dermatologists to perform consults and local dermatology offices to ensure availability for urgent cases, upgrading Wi-Fi as needed to enable image transmission, and making EHR modifications.
Additional implementation activities include training sessions, mock encounter run-throughs and demonstrations, and promotional campaigns to facilitate workflow adoption. Training sessions for medical assistants and providers typically take less than 10 minutes, and those for referral, information technology, and medical records staff typically take about 30 minutes.
Start-up costs include those associated with equipment purchases, Wi-Fi upgrades, EHR modifications, and staff time for planning and oversight. Ongoing costs include the 3Derm subscription fee and equipment maintenance. Detailed implementation and cost information can be provided by the authors upon request.
Funding: The collaborative was funded by a grant through the Partnership for Community Health Excellence & Innovation grant program, an initiative of Neighborhood Health Plan and Partners HealthCare. Partners HealthCare also provided additional grant funding to cover teledermatology readings for Medicaid recipients.
Acknowledgments: Barbara Kohler, MBA, Chief Operating Office, 3Derm Systems, Inc.; Eileen Dryden, PhD, Research Health Scientist, ENRM VA Medical Center; Elizabeth Browne, MBA, Executive Director, Charles River Community Health; Frances Anthes, MSW, President and Chief Executive Officer, Family Health Center of Worcester; Chuck Jones, MBA, President and Chief Executive Officer, Harbor Health Services; Kiame Mahaniah, MD, Chief Executive Officer, Lynn Community Health Center; Cynthia H. Sierra, MA, Chief Executive Officer, Manet Community Health Center; and William J. Halpin, Jr., Chief Executive Officer, South Boston Community Health Center.