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Figure.
Patient-Provided Photograph 6 Days After Surgery
Patient-Provided Photograph 6 Days After Surgery

The patient called 6 days after surgery with concern about infection. The patient-provided photograph indicated a healthy, xenograft-facilitated granulating wound with a few millimeters of expected peripheral erythema and low concern for infection. Reassurance was provided. The patient was seen 2 weeks later for a previously scheduled postoperative visit and noted to have an appropriately healing wound.

Table.  
Patient Characteristics
Patient Characteristics
1.
Martin  I, Aphivantrakul  PP, Chen  KH, Chen  SC.  Adherence to teledermatology recommendations by primary health care professionals: strategies for improving follow-up on teledermatology recommendations.  JAMA Dermatol. 2015;151(10):1130-1132.PubMedGoogle ScholarCrossref
2.
Alam  M, Lee  A, Ibrahimi  OA,  et al; Cutaneous Surgery Consensus Group.  A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.  JAMA Dermatol. 2014;150(5):550-558.PubMedGoogle ScholarCrossref
3.
Ke  M, Moul  D, Camouse  M,  et al.  Where is it? the utility of biopsy-site photography.  Dermatol Surg. 2010;36(2):198-202.PubMedGoogle ScholarCrossref
4.
Nijhawan  RI, Lee  EH, Nehal  KS.  Biopsy site selfies—a quality improvement pilot study to assist with correct surgical site identification.  Dermatol Surg. 2015;41(4):499-504.PubMedGoogle ScholarCrossref
Research Letter
February 2017

Patient-Acquired Photographs for the Management of Postoperative Concerns

Author Affiliations
  • 1Department of Dermatology, The University of Texas Southwestern Medical Center, Dallas
JAMA Dermatol. 2017;153(2):226-228. doi:10.1001/jamadermatol.2016.4012

Telemedicine has improved accessibility and convenience for dermatologic care, especially for the management of medical concerns and for screening of skin cancers.1 The ubiquity of technology that is able to take photographs (eg, smartphones and digital cameras) has allowed for patient-directed use of teledermatology.1 Its applicability to dermatologic surgery is somewhat limited, although self-acquired patient photographs have been used for assistance with identification of biopsy sites.2-4 Our quality improvement study assessed the utility of patient-directed photography for triaging and managing concerns that occur after dermatologic surgery.

Methods

The University of Texas Southwestern Medical Center Institutional Review Board approved this study. As this was a retrospective internal quality improvement study, patient consent was waived. Patients who underwent a procedure performed by any of the Mohs surgeons at The University of Texas Southwestern Medical Center from November 17, 2015, to March 17, 2016, were included in this study. All patients who called with a postoperative concern (other than questions regarding wound care or pain control) were triaged by 1 of 2 Mohs surgeons (D.S. and R.I.N.) or 2 fellows (S.R.J. and M.S.M.), who followed a script to assess the patients’ concerns. Patients were offered the opportunity to email a photograph of the surgical site. All patient photographs are uploaded to the electronic medical record. Patients with photographic assessment of active bleeding or infection were requested to return for an in-office postoperative visit immediately. All patients who called were also offered a postoperative visit, but those who declined in-office assessment received a follow-up telephone call 1 to 3 days after the initial call to ensure that the patient was improving. Two of 3 dermatologic surgeons (S.R.J., M.S.M., and R.I.N.) blindly evaluated all photographs to assess interobserver concordance.

Results

Of the 877 patients who underwent procedures during the study period, 50 (5.7%) called with a postoperative concern. Most calls were regarding head and neck sites in patients who had undergone Mohs surgery (Table). Five calls (10.0%) involved concerns for active bleeding, hematoma, or infection, while the remaining 90.0% were of low urgency (Figure). Of the 50 patients who called, 43 (86.0%) provided photographs for evaluation, and 100% reported satisfaction (assessed at follow-up visit or via a telephone call) with assessment of the photograph, with a mean satisfaction score of 4.81 of 5 (where 5 indicates most satisfied). Seven patients (14.0%) did not send a photograph, citing the inability to do so or sensitivity of the involved site (eg, genitals). Convenience was the most cited reason for preference of evaluation of a photograph (42 of 43 [97.7%]).

All patients who sent a photograph reported alleviation of their concerns after receiving recommendations via the telephone. Twenty of the 43 patients (46.5%) evaluated by photograph were also seen in the clinic for suture removal or wound check, at which time there was also no change in assessment or management by the health care professional. Patients who were not followed up in the clinic were called, and all reported improvement of symptoms or concerns in the time since the surgery. Blinded review of patient photographs without clinical history demonstrated 95.3% concordance (41 of 43 photographs) in assessment among dermatologic surgeons. Reasons given for the 2 discordant cases are that one was a questionable infection for which clinical history was imperative (eg, worsening erythema and drainage) and the other was difficult to distinguish between hypergranulation vs hemorrhagic crust on a granulating mucosal lip.

Discussion

In this study, while all patients who called were offered a postoperative visit, most preferred to electronically transmit photographs for evaluation. All patients reported improvement of their symptoms following telephone triaging. Patients demonstrated a future preference for the use of photographs as opposed to a postoperative visit, citing convenience and rapid access to evaluation and care. Other benefits included a high level of patient satisfaction; limiting unnecessary and in-office evaluations, especially when only reassurance rather than treatment is required; and empowerment of patients with a role in the delivery of their health care. The high level of concordance in assessment by dermatologic surgeons demonstrated the reliability of these patient-acquired photographs. This approach also may be applicable for concerns after cosmetic procedures. In addition to the benefits, there are also limitations, such as patient transmission of photographs through unsecured networks, possible mismanagement owing to a discordant impression by the clinician, challenges for elderly patients in using the technology, patient reluctance to photograph anatomically sensitive locations (eg, genitals), and poor quality of the photographs. Advances in technology should allow for easier access to secure networks, such as through electronic medical record patient portals. New mobile applications have been developed with this capability, but their use requires patient awareness of the application. Overall, this pilot quality improvement study demonstrates the utility and convenience of teledermatology for triaging and managing most low-urgency postoperative concerns.

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Article Information

Accepted for Publication: August 27, 2016.

Corresponding Author: Rajiv I. Nijhawan, MD, Department of Dermatology, The University of Texas Southwestern Medical Center, 5939 Harry Hines Blvd, Ste 400, Dallas, TX 75390 (rajiv.nijhawan@utsw.edu).

Published Online: November 23, 2016. doi:10.1001/jamadermatol.2016.4012

Author Contributions: Drs Jeyamohan and Nijhawan had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Jeyamohan, Srivastava, Nijhawan.

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

Drafting of the manuscript: Jeyamohan, Nijhawan.

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

Statistical analysis: Jeyamohan, Srivastava, Nijhawan.

Administrative, technical, or material support: Jeyamohan, Moye, Nijhawan.

Study supervision: Jeyamohan, Srivastava, Nijhawan.

Conflict of Interest Disclosures: None reported.

References
1.
Martin  I, Aphivantrakul  PP, Chen  KH, Chen  SC.  Adherence to teledermatology recommendations by primary health care professionals: strategies for improving follow-up on teledermatology recommendations.  JAMA Dermatol. 2015;151(10):1130-1132.PubMedGoogle ScholarCrossref
2.
Alam  M, Lee  A, Ibrahimi  OA,  et al; Cutaneous Surgery Consensus Group.  A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.  JAMA Dermatol. 2014;150(5):550-558.PubMedGoogle ScholarCrossref
3.
Ke  M, Moul  D, Camouse  M,  et al.  Where is it? the utility of biopsy-site photography.  Dermatol Surg. 2010;36(2):198-202.PubMedGoogle ScholarCrossref
4.
Nijhawan  RI, Lee  EH, Nehal  KS.  Biopsy site selfies—a quality improvement pilot study to assist with correct surgical site identification.  Dermatol Surg. 2015;41(4):499-504.PubMedGoogle ScholarCrossref
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