COVID-19 forces telemedicine into prime time in dermatology
As COVID-19 prevented millions of patients from seeing their doctors, the demand for telemedicine in dermatology increased.
As a response to this development, in June 2020, the National Psoriasis Foundation’s COVID-19 Task Force updated its list of recommendations for patients and practitioners to cover topics pertaining to telehealth.
“Telemedicine should be offered to manage patients wherever possible when local restrictions or pandemic conditions limit the ability for in-person visits,” the authors wrote.
Clinically stable patients on treatment are candidates for telehealth, as are those requiring follow-up care or prescription refills and those with COVID-19 who are experiencing flares, according to the authors. They added that, for new patients, only those with significant hurdles to in-person care should be seen via telemedicine. In-person visits should also be considered if patients evolve or experience disease progression.
With these recommendations, dermatology may finally be stepping into a new paradigm of care that is likely to last long after the pandemic ends, according to Melvin Chiu, MD, a dermatologist with Keck Medicine at the University of Southern California and clinical professor of dermatology at the Keck School of Medicine at the University of Southern California.
“Before the pandemic, telemedicine was used pretty minimally in dermatology,” Chiu told Healio, suggesting that dermatologists would take advantage of technology in two main ways.
First, some would use it as it is being used now, with live interactive visits. However, prior to COVID-19, those visits were generally reserved for patients in remote rural areas with no access to any dermatology services. Second, others would use it for asynchronous visits — either from doctor to doctor to discuss a particularly challenging patient or from doctor to patient — that involve the exchange of photos and other information via text, email or other web-based platforms.
“But there were not many dermatologists using either of these strategies,” Chiu said, noting that this was largely due to its overall lack of acceptance by physicians and patients “It was a fringe technology.”
In addition, structural barriers were in place and reimbursement was low, according to Chiu.
“There were a lot of regulations by CMS and other regulatory bodies about how much could be done in a telemedicine visit,” he said. “There just was not a lot of incentive to do it.”
This situation changed almost on a dime with the advent of the pandemic. “A lot of the CMS restrictions were lifted in an attempt to make it easier for patients to be seen by their dermatologist via telemedicine,” Chiu said. “Reimbursement structures became clearer and more fair.”
With those simple changes, telemedicine became “a much more useful tool,” according to Chiu.
What dermatology discovered that many other specialties had already learned is that telemedicine allows for the ability to provide care to patients in the comfort of their homes. Barriers to care, ranging from the frustrations of traffic to the costs of tolls or public transportation, have been removed, according to Chiu.
Like many others in the dermatology community, Chiu can see clear benefits of this development. “Patients are more likely to keep their appointments,” he said. “They can stay in closer contact with their physician.”
All of this, of course, translates into two key parameters: better adherence to treatments and improved clinical outcomes. Some data are beginning to bear this out.
In a study published in JAMA Network Open, Armstrong and colleagues aimed to assess the utility of asynchronous online visits for 148 patients with psoriasis and their primary care physicians. The also assessed an equal number of patients for in-office visits. Results showed that the adjusted difference between the online and in-person groups in the mean change in the self-administered Psoriasis Area and Severity Index score during the 12-month study period was –0.27 (95% CI, –0.85 to 0.31) and the difference in the mean change in body surface area affected by psoriasis was –0.05% (95% CI, –1.58 to 1.48), the researchers reported. Also, the difference in the mean change in patient global assessment score was –0.11 (95% CI, –0.32 to 0.1). In short, patients in the online arm demonstrated improved outcomes.
As the pandemic progresses, more such data are likely to emerge. In the meantime, however, it may be necessary for the dermatology community to take a hard look at some of the drawbacks of telemedicine if it is to become a permanent part of care.
Although telemedicine removes some barriers to care, it also has the potential to create new ones, according to Chiu. For instance, the setting during a telemedicine visit can prove challenging.
“One key issue is that, depending on where the patient is taking the call, of course, they may not have full privacy,” Chiu said. “Even in their home, with their spouse, children or other family there, this may interfere with the comfort they feel and limit the amount of information they might share.”
Another important consideration is the significance of conducting a thorough physical exam, according to Chiu. “In dermatology, this is of paramount importance.”
Chiu believes that the “healing power of touch” is not to be underestimated, even in the hyperspecialized world of screening technologies and targeted therapies. “That is the part of medicine I miss most when I am doing telemedicine visits.”
As for other concerns, technological limitations also pose problems. “The video resolution of video calls on the patient end can often be poor,” Chiu said. “The lighting is often insufficient.”
Specifically, some parts of the body, such as the scalp and fingernails, are difficult to see over video, even with good resolution and a tech-savvy patient, according to Chiu.
In addition, some patients may have better internet service than others. Dropped calls can disrupt the flow of a visit and force the next patient to wait. For patients with low digital literacy, using a platform more complicated than FaceTime may require extensive explanation. Conversely, using a platform that is widely available on any phone or tablet may be subject to malware or other online predators.
The good news is that some data are showing improvements in the technological components of teledermatology.
In a poster at the European Academy of Dermatology and Venereology Congress, Ali and colleagues used Facebook advertisements to recruit 33 patients with psoriasis vulgaris. Their disease underwent assessment from two physicians using the PASI and the Physician Global Assessment. Each patient later took smartphone photos of the same lesions that were then evaluated by five blinded dermatologists for erythema, induration/thickness and scaling. Results showed perfect agreement of PGA in 53.1% of patients between live and remote assessment. The correlation was 57.6% for first and second in-person assessment.
“This study showed good agreement between psoriasis severity assessed in person and from remote, suggesting that psoriasis severity can, with very low inter-rater variation, be reliably assessed using patient-obtained smartphone photos combined with patient-reported psoriasis extent,” the authors wrote.
A new normal
This combination of photos, videos and patient-reported data is likely to form the backbone of telehealth in the dermatology space moving forward. However, dermatologists have yet to optimize use of smartphones and devices like the Fitbit, while dermatology-specific apps, unlike general telemedicine visits, have not become widely used in the specialty as yet.
Like many dermatologists, Chiu would be happy to employ such devices in his practice, but only if those devices are safe, effective and easy to use for most of his patient population. “Just like with symptom diaries, some data can be better than others,” he added.
All things considered, Chiu has embraced telemedicine as the new reality of his practice. With that in mind, he offered some thoughts for clinicians doing the same. “My advice for clinicians seeing patients via telemedicine would be to try to get photos prior to the visit,” he said. “I have found that to be most useful.”
Patience, flexibility and understanding are also of paramount importance. “There are always going to be barriers, many of which are going to be out of your control,” Chiu said.
If, as he mentioned, the visuals and the technological hurdles are just too insurmountable to conduct a useful visit, Chiu does not hesitate to conduct a visit over a phone call or ask a patient to come to the office for a closer look.
“But telemedicine, despite its imperfections, is likely to be a useful tool for dermatology into the future,” Chiu said. “We just have to make sure to remember that, until we iron out some of these issues, everyone is trying their best in a difficult situation.”
Ali Z, et al. Psoriasis severity may be reliably assessed using photographs taken by the patient at home. Presented at: European Academy of Dermatology and Venereology Congress; Oct 29-31, 2020 (virtual meeting).
Armstrong AW, et al. JAMA Netw Open. 2018;doi:10.1001/jamanetworkopen.2018.3062.
NPF Task Force statement:
National Psoriasis Foundation. COVID-19 Task Force Guidance Statements Available at: https://www.psoriasis.org/covid-19-task-force-guidance-statements/. Accessed June 2, 2021.
For more information:
Melvin Chiu, MD, can be reached at 1500 San Pablo St., Los Angeles, CA 90033; email: Cynthia.Smith@med.usc.edu.