Q&A: Telemedicine approach as effective as in-person doctor’s visits for psoriasis management

April Armstrong
April W. Armstrong

Almost three-quarters of health care providers have adopted some form of telemedicine solutions or services as of 2017, according to data from HIMSS Analytics, with the adoption of services increasing 9% since 2016.

In an effort to provide more accurate care to patients in rural areas, as well as combat looming physician shortages, more providers are increasingly turning to telemedicine.

April W. Armstrong, MD, MPH, associate professor of clinical dermatology and associate dean for clinical research at the Keck School of Medicine of USC, and colleagues recently presented data at the American Academy of Dermatology Annual Meeting that assessed how telemedicine fared in aiding patients with psoriasis.

Armstrong spoke with Healio Internal Medicine about the research, how the online model works, and how the model could be scalable to other chronic skin conditions. – by Ryan McDonald

Question: What was the motivation behind conducting the study?

Answer: As many dermatologists know, the access to providers is pretty poor in a lot of areas in the country. We were interested in how to potentially increase access to dermatologists, but also provide a way to allow patients to still get quality care regardless of where they live. Additionally, I think we wanted to look at ‘technology-enabled ways’ in which we could increase access and maintain the quality of care. What that means is, how can we take advantage of the current technology that is available for telehealth and use that toward increasing access to patients with chronic skin diseases?

Psoriasis is one of the key chronic inflammatory skin diseases that needs regular care by dermatologists as well as involving primary care doctors. What we had proposed was this online model in which patients with psoriasis could access dermatologists directly, as well as access their PCPs directly online so that they could get expert care, both expeditiously and with high quality.

Q: How did you conduct the study?

A: We recruited 300 patients with psoriasis and then randomized them into an online group or an in-person group. The results I presented at the American Academy of Dermatology Annual Meeting included the primary outcome which looked at if the patients who received online care had equivalent improvements in psoriasis disease severity compared with the in-person group.

A patient could see their provider online and, in most instances, the patient saw a dermatologist. Or, the patient could see their providers in person. The frequencies of those visits were determined by their disease severity. Every 3 months we sent them some assessments that they would have to complete. Those assessments included things such as, how their psoriasis was doing, what their quality of life was and what their level of access to care was.

For this study our results looked at improvements in their psoriasis and we compared the two groups directly to each other.

Q: What did the study demonstrate?

What we found was that the patients in the online group had an equivalent improvement in their psoriasis disease severity as those who were randomized to the in-person group.

The study was 1 year long, and we conducted assessments every 3 months for the groups. At each assessment we looked at the improvement in disease severity, as measured by PASI – which is a validated disease severity instrument used for psoriasis – or BSA scores. The one thing that didn’t turn out to be equivalent was the change in the patients’ global self-assessment of their severity. We found that the patients in the online group thought their overall improvement in their own global assessment of their severity was slightly higher than that of the in-person group.

Overall, the instrument is showing a consistent trend that people who were randomized to the online group had an equivalent outcome to those who were seen in person. The degree of adverse events was also similar between the two groups.

Q: How does the online model used in the study work?

A: In an online encounter, the patient is taught to take standardized photos of their psoriasis. They take what are called global photos, which assess the overall body surface involvement of the psoriasis, and they take close-up photos of their psoriasis parts. The patients would take those photos and then upload those images onto a secured, telehealth platform and as they upload the images, they complete an online visit. Through structured fields, a patient is asked what their current symptoms are, how they’re doing, what medications they’re taking and their review of symptoms. It essentially takes their clinical history as well as their photos and they send that information to the dermatologist and that dermatologist can then look at those images and decide how the patient is doing and then provide education through the online portal. This is all asynchronous, so this is happening at different times. When a patient is taking and submitting the photos, the doctor is reviewing them at a different time. Additionally, physicians could prescribe certain medications through the online portal.

We did interviews with the patients and overall, they were very pleased with the online model and thought that it really saved them a lot of time in terms of transportation, as well as going into an office and waiting.

Q: Was there anything surprising about the results of the study?

A: What’s surprising is what we see these days, and how much we can actually diagnose and manage online. People always thought that perhaps seeing patients in person would be superior to seeing them online, but our study shows otherwise. I think the main conclusion of the study is probably surprising to a lot of people who don’t usually practice telehealth. This is something that I think a lot of providers are grappling with and trying to figure out how they can incorporate that into their clinical practices. And I think a lot of it depends on the quality of the images and the quality of information that they get.

Q: Are there any concerns with using telemedicine in practice?

A: I think the key thing is to ensure high quality and making sure that for this type of model that there is a licensed physician at the other end. Also, safeguards need to be in place such as, making sure there’s enough images of sufficient quality to assess what’s going on and that the history that the patients submit is complete so that the dermatologist will be making an assessment or recommendation based on accurate, current and complete information.

The other area of main concern, which this study did not address, is reimbursement. I think a lot of providers are worried about how their online effort is going to be captured when they are already so busy in the clinic. It’s important for example, for this telehealth platform to make a distinction between what constitutes an online visit and what is considered just a follow-up question. This is something I hear a lot of from providers, "I already do telehealth, I answer patients’ messages and so forth." And certainly, that’s one form of online communication. In terms of getting reimbursement, states have different rules and regulations in regard to what they can and cannot reimburse. For the states that do reimburse, typically we need to ensure that there is complete information.

Q: What do these results mean moving forward in practice?

A: I think these results can be very helpful for people thinking about implementing telehealth, especially in the provision of care for psoriasis patients in clinical practice. I think that they can be reasonably assured that if patients are willing to participate in this and are properly trained about how to use the telehealth platform, that in general they should be able to provide accurate information such that the quality of care that is rendered online will be equivalent to that of an in-person visit.

I think that a lot of other things need to happen to make this scalable, such as reimbursement. Also, I think we are always looking for technological innovations, advancements or upgrades to the different systems to make it even more user-friendly to both the patients as well as the providers.

For me, the next step would be to look at other disease populations. Because, for example, psoriasis is an important and prevalent chronic skin disease. It happens more often in adults. For other diseases, that is not always the case. Things like atopic dermatitis, we don’t have data on telehealth and how that could potentially benefit that patient population. And that is a large patient population that involves both children and adults. I think that will be important with regards to understanding how the telehealth model could be scalable to other disease populations.

Q: How could primary care physicians use this model to aid in their patients’ psoriasis management?

A: PCPs can use the online model to provide care to their patients in the form of formal ‘online visits’ as long as they feel comfortable that the history can be collected in an accurate fashion and that the physical exam can be done without an in-person visit. That is, they need to ensure that the information that is typically done via physical exam can be gathered through the images.

The information gathered via the online model can certainly be used for triage purposes for a PCP. Much of the success will depend on the type of clinical information and depth of clinical information.

Disclosure: Armstrong reports no relevant financial disclosures related to this study. The study was funded by Patient-Centered Outcomes Research Institute. Other disclosures Armstrong reports include advisory and investigator roles with AbbVie, Eli Lilly, Janssen, Novartis and Ortho Dermatologics.

April Armstrong
April W. Armstrong

Almost three-quarters of health care providers have adopted some form of telemedicine solutions or services as of 2017, according to data from HIMSS Analytics, with the adoption of services increasing 9% since 2016.

In an effort to provide more accurate care to patients in rural areas, as well as combat looming physician shortages, more providers are increasingly turning to telemedicine.

April W. Armstrong, MD, MPH, associate professor of clinical dermatology and associate dean for clinical research at the Keck School of Medicine of USC, and colleagues recently presented data at the American Academy of Dermatology Annual Meeting that assessed how telemedicine fared in aiding patients with psoriasis.

Armstrong spoke with Healio Internal Medicine about the research, how the online model works, and how the model could be scalable to other chronic skin conditions. – by Ryan McDonald

Question: What was the motivation behind conducting the study?

Answer: As many dermatologists know, the access to providers is pretty poor in a lot of areas in the country. We were interested in how to potentially increase access to dermatologists, but also provide a way to allow patients to still get quality care regardless of where they live. Additionally, I think we wanted to look at ‘technology-enabled ways’ in which we could increase access and maintain the quality of care. What that means is, how can we take advantage of the current technology that is available for telehealth and use that toward increasing access to patients with chronic skin diseases?

Psoriasis is one of the key chronic inflammatory skin diseases that needs regular care by dermatologists as well as involving primary care doctors. What we had proposed was this online model in which patients with psoriasis could access dermatologists directly, as well as access their PCPs directly online so that they could get expert care, both expeditiously and with high quality.

Q: How did you conduct the study?

A: We recruited 300 patients with psoriasis and then randomized them into an online group or an in-person group. The results I presented at the American Academy of Dermatology Annual Meeting included the primary outcome which looked at if the patients who received online care had equivalent improvements in psoriasis disease severity compared with the in-person group.

A patient could see their provider online and, in most instances, the patient saw a dermatologist. Or, the patient could see their providers in person. The frequencies of those visits were determined by their disease severity. Every 3 months we sent them some assessments that they would have to complete. Those assessments included things such as, how their psoriasis was doing, what their quality of life was and what their level of access to care was.

For this study our results looked at improvements in their psoriasis and we compared the two groups directly to each other.

PAGE BREAK

Q: What did the study demonstrate?

What we found was that the patients in the online group had an equivalent improvement in their psoriasis disease severity as those who were randomized to the in-person group.

The study was 1 year long, and we conducted assessments every 3 months for the groups. At each assessment we looked at the improvement in disease severity, as measured by PASI – which is a validated disease severity instrument used for psoriasis – or BSA scores. The one thing that didn’t turn out to be equivalent was the change in the patients’ global self-assessment of their severity. We found that the patients in the online group thought their overall improvement in their own global assessment of their severity was slightly higher than that of the in-person group.

Overall, the instrument is showing a consistent trend that people who were randomized to the online group had an equivalent outcome to those who were seen in person. The degree of adverse events was also similar between the two groups.

Q: How does the online model used in the study work?

A: In an online encounter, the patient is taught to take standardized photos of their psoriasis. They take what are called global photos, which assess the overall body surface involvement of the psoriasis, and they take close-up photos of their psoriasis parts. The patients would take those photos and then upload those images onto a secured, telehealth platform and as they upload the images, they complete an online visit. Through structured fields, a patient is asked what their current symptoms are, how they’re doing, what medications they’re taking and their review of symptoms. It essentially takes their clinical history as well as their photos and they send that information to the dermatologist and that dermatologist can then look at those images and decide how the patient is doing and then provide education through the online portal. This is all asynchronous, so this is happening at different times. When a patient is taking and submitting the photos, the doctor is reviewing them at a different time. Additionally, physicians could prescribe certain medications through the online portal.

We did interviews with the patients and overall, they were very pleased with the online model and thought that it really saved them a lot of time in terms of transportation, as well as going into an office and waiting.

PAGE BREAK

Q: Was there anything surprising about the results of the study?

A: What’s surprising is what we see these days, and how much we can actually diagnose and manage online. People always thought that perhaps seeing patients in person would be superior to seeing them online, but our study shows otherwise. I think the main conclusion of the study is probably surprising to a lot of people who don’t usually practice telehealth. This is something that I think a lot of providers are grappling with and trying to figure out how they can incorporate that into their clinical practices. And I think a lot of it depends on the quality of the images and the quality of information that they get.

Q: Are there any concerns with using telemedicine in practice?

A: I think the key thing is to ensure high quality and making sure that for this type of model that there is a licensed physician at the other end. Also, safeguards need to be in place such as, making sure there’s enough images of sufficient quality to assess what’s going on and that the history that the patients submit is complete so that the dermatologist will be making an assessment or recommendation based on accurate, current and complete information.

The other area of main concern, which this study did not address, is reimbursement. I think a lot of providers are worried about how their online effort is going to be captured when they are already so busy in the clinic. It’s important for example, for this telehealth platform to make a distinction between what constitutes an online visit and what is considered just a follow-up question. This is something I hear a lot of from providers, "I already do telehealth, I answer patients’ messages and so forth." And certainly, that’s one form of online communication. In terms of getting reimbursement, states have different rules and regulations in regard to what they can and cannot reimburse. For the states that do reimburse, typically we need to ensure that there is complete information.

Q: What do these results mean moving forward in practice?

A: I think these results can be very helpful for people thinking about implementing telehealth, especially in the provision of care for psoriasis patients in clinical practice. I think that they can be reasonably assured that if patients are willing to participate in this and are properly trained about how to use the telehealth platform, that in general they should be able to provide accurate information such that the quality of care that is rendered online will be equivalent to that of an in-person visit.

I think that a lot of other things need to happen to make this scalable, such as reimbursement. Also, I think we are always looking for technological innovations, advancements or upgrades to the different systems to make it even more user-friendly to both the patients as well as the providers.

For me, the next step would be to look at other disease populations. Because, for example, psoriasis is an important and prevalent chronic skin disease. It happens more often in adults. For other diseases, that is not always the case. Things like atopic dermatitis, we don’t have data on telehealth and how that could potentially benefit that patient population. And that is a large patient population that involves both children and adults. I think that will be important with regards to understanding how the telehealth model could be scalable to other disease populations.

Q: How could primary care physicians use this model to aid in their patients’ psoriasis management?

A: PCPs can use the online model to provide care to their patients in the form of formal ‘online visits’ as long as they feel comfortable that the history can be collected in an accurate fashion and that the physical exam can be done without an in-person visit. That is, they need to ensure that the information that is typically done via physical exam can be gathered through the images.

The information gathered via the online model can certainly be used for triage purposes for a PCP. Much of the success will depend on the type of clinical information and depth of clinical information.

Disclosure: Armstrong reports no relevant financial disclosures related to this study. The study was funded by Patient-Centered Outcomes Research Institute. Other disclosures Armstrong reports include advisory and investigator roles with AbbVie, Eli Lilly, Janssen, Novartis and Ortho Dermatologics.