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Table.  
Primary Health Care Professional–Documented Recommendation Follow-up
Primary Health Care Professional–Documented Recommendation Follow-up
1.
Pak  H, Triplett  CA, Lindquist  JH, Grambow  SC, Whited  JD.  Store-and-forward teledermatology results in similar clinical outcomes to conventional clinic-based care. J Telemed Telecare. 2007;13(1):26-30.
PubMedArticle
2.
Krupinski  E, Burdick  A, Pak  H,  et al.  American Telemedicine Association’s practice guidelines for teledermatology. Telemed J E Health. 2008;14(3):289-302.
PubMedArticle
3.
Armstrong  AW, Kwong  MW, Chase  EP, Ledo  L, Nesbitt  TS, Shewry  SL.  Teledermatology operational considerations, challenges, and benefits: the referring providers’ perspective. Telemed J E Health. 2012;18(8):580-584.
PubMedArticle
4.
Eastman  KL, Lutton  MC, Raugi  GJ,  et al.  A teledermatology care management protocol for tracking completion of teledermatology recommendations. J Telemed Telecare. 2012;18(7):374-378.
PubMedArticle
5.
Warshaw  E, Greer  N, Hillman  Y,  et al. Teledermatology for Diagnosis and Management of Skin Conditions: A Systematic Review of the Evidence. Washington, DC: Dept of Veterans Affairs; 2010.
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Research Letter
October 2015

Adherence to Teledermatology Recommendations by Primary Health Care ProfessionalsStrategies for Improving Follow-up on Teledermatology Recommendations

Author Affiliations
  • 1Department of Dermatology, Emory University, Atlanta, Georgia
  • 2Division of Dermatology, Department of Dermatology, Atlanta Veterans Affairs Medical Center, Emory University School of Medicine, Atlanta, Georgia
JAMA Dermatol. 2015;151(10):1130-1132. doi:10.1001/jamadermatol.2015.1884

Dermatology is well suited to telemedicine because diagnosis and management greatly depend on the visual presentation of a disease. Studies have shown little difference between teledermatology and conventional face-to-face (FTF) care in clinical outcomes.1 By using communication technologies, dermatologists can improve access to specialty care in a cost-effective manner.2 Not only can teledermatology play an important role in reducing wait times and accommodating persons without local dermatologists but it can also act as a means of educating primary health care professionals (PHCPs) regarding the management of common skin conditions.3

The Dermatology Division in the Atlanta Veterans Affairs Medical Center started its teledermatology service on July 5, 2012, and receives referrals from 10 community-based outpatient centers. Before the launch of teledermatology, a dermatology training course (DTC) was conducted, funded as a “miniresidency” by the Office of Specialty Care Transformation, for PHCPs in community-based outpatient centers. To prepare PHCPs to care for common dermatologic conditions, the DTC provided 2 days of hands-on training and lectures regarding melanoma and nonmelanoma skin cancer, acne, dermatitis, and psoriasis, all with corresponding case reports. We were interested in determining the effectiveness of teledermatology in terms of how often referring PHCPs followed teledermatology recommendations, exploring the effect of the DTC on adherence to the recommendations, and assessing the efficiency of teledermatology in terms of the number of visits saved and the average turnaround time.

Methods

The Emory University Institutional Review Board approved the study. We conducted a retrospective medical record review of the Veterans Affairs computerized patient record system of all veterans who had received and completed teledermatology services from September 1, 2012, through April 30, 2013. Notes written by PHCPs and nurses were reviewed, as well as pharmacy lists, to determine whether recommendations given by the teledermatologist were implemented. Three possible recommendations included prescribing medications, reassuring patients, and conducting FTF appointments (including biopsies). Turnaround times were also recorded.

Results

Of 1001 teledermatology referrals, 997 had recommendations, of which 241 (24.5%) came from PHCPs who participated in the DTC (Table). Medication was recommended most commonly (467 [46.8%]) and reassurance least commonly (174 [17.5%]). Primary health care professionals followed 80% of all recommendations; FTF appointments were the recommendations that were most commonly followed (98% of the time). A total of 40.8% of recommendations for reassuring patients and 24.6% of recommendations for prescribing medications were not implemented.

We found that participants in the DTC were not more likely to follow recommendations. However, the average turnaround time for the 1001 teledermatology consultations was 1 business day and 668 (66.8%) patients did not need a FTF appointment.

Discussion

The experience of the teledermatology service in the Atlanta Veterans Affairs Medical Center has been paradigm-changing for the veterans, with fast turnaround times and decreased need for FTF appointments. However, our study demonstrates that the success of a teledermatology program relies heavily on the effective participation of PHCPs. While the recommendations for an FTF appointment were followed most often, this was owing to the direct scheduling of follow-up appointments at the Atlanta Veterans Affairs Medical Center instead of waiting for the PHCP to review the recommendations in the consultation notes. Thus, the 98% adherence was not in compliance at all. More telling was the lack of adherence to medication and reassurance recommendations. Training did not increase the adherence rate because there was no increased likelihood that PHCPs who participated in the DTC would follow the recommendations. More likely, other factors, such as the attitude of the PHCP and lack of resources, were involved. Our results reinforce previous studies’ conclusions that emphasized the importance of an infrastructure for teledermatology, including communication and tracking protocols, support staff, and well-defined roles for team members.4,5 Our group is exploring protocol changes in which the dermatology department prescribes the medication, a nurse explains difficult-to-use medications and assesses the outcomes, and a standardized letter enables PHCPs to more effectively communicate with patients. We hope that such maneuvers will further enable teledermatology to be an efficient health care model.

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Article Information

Accepted for Publication: May 13, 2015.

Corresponding Author: Suephy C. Chen, MD, MS, Division of Dermatology, Department of Dermatology, Atlanta Veterans Affairs Medical Center, Emory University School of Medicine, 1525 Clifton Rd, First Floor, Atlanta, GA 30322 (schen2@emory.edu).

Published Online: July 8, 2015. doi:10.1001/jamadermatol.2015.1884.

Author Contributions: Dr S. C. Chen had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Aphivantrakul, K.-H. Chen, S. C. Chen.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Martin.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: K.-H. Chen.

Administrative, technical, or material support: S. C. Chen.

Study supervision: S. C. Chen.

Conflict of Interest Disclosures: Dr S. C. Chen reports serving as a consultant to Astellas Pharma US, Inc; receiving grants from Hoffman-Laroche Inc and Galderma; and receiving royalties from RosaQoLTM, licensed by Galderma, and ItchyQoLTM, licensed by Biogen and Kyowa Hakko Kirin Co, Ltd. No other disclosures were reported.

References
1.
Pak  H, Triplett  CA, Lindquist  JH, Grambow  SC, Whited  JD.  Store-and-forward teledermatology results in similar clinical outcomes to conventional clinic-based care. J Telemed Telecare. 2007;13(1):26-30.
PubMedArticle
2.
Krupinski  E, Burdick  A, Pak  H,  et al.  American Telemedicine Association’s practice guidelines for teledermatology. Telemed J E Health. 2008;14(3):289-302.
PubMedArticle
3.
Armstrong  AW, Kwong  MW, Chase  EP, Ledo  L, Nesbitt  TS, Shewry  SL.  Teledermatology operational considerations, challenges, and benefits: the referring providers’ perspective. Telemed J E Health. 2012;18(8):580-584.
PubMedArticle
4.
Eastman  KL, Lutton  MC, Raugi  GJ,  et al.  A teledermatology care management protocol for tracking completion of teledermatology recommendations. J Telemed Telecare. 2012;18(7):374-378.
PubMedArticle
5.
Warshaw  E, Greer  N, Hillman  Y,  et al. Teledermatology for Diagnosis and Management of Skin Conditions: A Systematic Review of the Evidence. Washington, DC: Dept of Veterans Affairs; 2010.
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