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The rapid spread of COVID-19 forced Seemal Desai, MD, to make an excruciating choice; he could either shutter his busy dermatology practice in Plano, Texas, or switch most patient consults to telemedicine, which he'd never used.
But as soon as he learned that telehealth regulations had been relaxed by the Centers for Medicare & Medicaid Services (CMS) and that reimbursement had been broadened, Desai and his staff began to mobilize.
"Kaboom! We made the decision to start doing it," he told Medscape Medical News. "We drafted a consent form, uploaded it to our website, called patients, changed our voice greeting, and got clarity on insurance coverage. We've been flying by the seat of our pants."
"I'm doing it because I don't have a choice at this point," said Desai, who is a member of the American Academy of Dermatology (AAD) board of directors and its coronavirus task force. "I'm very worried about continuing to be able to meet our payroll expenses for staff and overhead to keep the office open."
"Flying by the Seat of Our Pants" to See Patients Virtually
Dermatologists have long been considered pioneers in telemedicine. They have, since the 1990s, capitalized on the visual nature of the specialty to diagnose and treat skin diseases by incorporating photos, videos, and virtual-patient visits. But the pandemic has forced the hands of even holdouts like Desai, who clung to in-person consults because of confusion related to HIPAA compliance issues and the sense that teledermatology "really dehumanizes patient interaction" for him.
In fact, as of 2017, only 15% of the nation's 11,000 or so dermatologists had implemented telehealth into their practices, according to an AAD practice survey. In the wake of COVID-19, however, that percentage has likely more than tripled, experts estimate.
Now, dermatologists are assuming the mantle of educators for other specialists who never considered telehealth before in-person visits became fraught with concerns about the spread of the virus. And some are publishing guidelines for colleagues on how to prioritize teledermatology to stem transmission and conserve personal protective equipment (PPE) and hospital beds.
User-friendly technology and the relaxed telehealth restrictions have made it fairly simple for patients and physicians to connect. Facetime and other once-prohibited platforms are all currently permissible, although physicians are encouraged to notify patients about potential privacy risks, according to an AAD teledermatology tool kit.
"We've moved 10 years in telemedicine policy in 2 weeks," said Karen Edison, MD, from the University of Missouri, in Columbia. "The federal government has really loosened the reins."
At least half of all dermatologists in the United States have adopted telehealth since the pandemic emerged, she estimated. And most, like Desai, have done so in just the last several weeks.
"You can do about 90% of what you need to do as a dermatologist using the technology," said Edison, who launched the first dermatology Extension for Community Healthcare Outcomes, or ECHO, program in the Midwest. That telehealth model was originally developed to connect rural general practitioners with specialists at academic medical centers or large health systems.
"People are used to taking pictures with their phones. In some ways, this crisis may change the face of our specialty," she told Medscape Medical News.
"As we're all practicing social distancing, I think physicians and patients are rethinking how we can access healthcare without pursuing traditional face-to-face interactions," said Ivy Lee, MD, from the University of California, San Francisco, who is past chair of the AAD telemedicine task force and current chair of the teledermatology committee at the American Telemedicine Association. "Virtual health and telemedicine fit perfectly with that."
Even before the pandemic, the innovative ways dermatologists were using telehealth were garnering increasing acclaim. All four clinical groups short-listed for dermatology team of the year at the BMJ Awards 2020 employed telehealth to improve patient services in the United Kingdom.
In the United States, dermatologists are joining forces to boost understanding of how telehealth can protect patients and clinicians from some of the ravages of the virus.
The Society of Dermatology Hospitalists has developed an algorithm — built on experiences its members have had caring for hospitalized patients with acute dermatologic conditions — to provide a "logical way" to triage telemedicine consults in multiple hospital settings during the coronavirus crisis, said President-Elect Daniela Kroshinsky, MD, from Massachusetts General Hospital in Boston.
Telemedicine consultation is prioritized and patients at high risk for COVID-19 exposure are identified so that exposure time and resource use are limited and patient and staff safety are maximized.
"We want to empower our colleagues in community hospitals to play a role in safely providing care for patients in need but to be mindful about preserving resources," said Kroshinsky, who reported that the algorithm will be published imminently.
"If you don't have to see a patient in person and can offer recommendations through telederm, you don't need to put on a gown, gloves, mask, or goggles," she told Medscape Medical News. "If you're unable to assess photos, then of course you'll use the appropriate protective wear, but it will be better if you can obtain the same result" without having to do so.
After the first week of tracking data to gauge the effectiveness of the algorithm at Massachusetts General, Kroshinsky says she is buoyed.
Of the 35 patients assessed electronically — all of whom would previously have been seen in person — only four ended up needing a subsequent in-person consult, she reported.
"It's worked out great," said Kroshinsky, who noted that the pandemic is a "nice opportunity" to test different telehealth platforms and improve quality down the line. "We never had to use any excessive PPE, beyond what was routine, and the majority of patients were able to be staffed remotely. All patients had successful outcomes."
With telehealth more firmly established in dermatology than in most other specialties, dermatologists are now helping clinicians in other fields who are rapidly ramping up their own telemedicine offerings.
These might include obstetrics and gynecology or "any medical specialty where they need to do checkups with their patients and don't want them coming in for nonemergent visits," said Carrie Kovarik, MD, from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia.
In addition to fielding many recent calls and emails from physicians seeking guidance on telehealth, Kovarik, Lee, and their colleagues have published the steps required to integrate the technology into outpatient practices.
"Now that there's a time for broad implementation, our colleagues are looking to us for help and troubleshooting advice," said Kovarik, who is a member of the AAD COVID-19 response task force.
Various specialties "lend themselves to telehealth, depending on how image- or data-dependent they are," Lee told Medscape Medical News. "But all specialists thinking of limiting or shutting down their practices are thinking about how they can provide continuity of care without exposing patients or staff to the risk of contracting the coronavirus."
In his first week of virtual patient consults, Desai said he saw about 75 patients, which is still far fewer than the 160 to 180 he sees in person in a normal week.
"The problem is that patients don't really want to do telehealth. You'd think it would be a good option," he said, "but patients hesitate because they don't really know how to use their device." Some have instead rescheduled in-person appointments for months down the line.
Although telehealth has enabled Desai to readily assess patients with acne, hair loss, psoriasis, rashes, warts, and eczema, he's concerned that necessary procedures, such as biopsies and dermoscopies, could be dangerously delayed. It's also hard to assess the texture and thickness of certain skin lesions in photos or videos, he said.
"I'm trying to stay optimistic that this will get better and we're able to move back to taking care of patients the way we need to," he said.
Like Desai, other dermatologists who've implemented telemedicine during the pandemic have largely been swayed by the relaxed CMS regulations. "It's made all the difference," Kovarik said. "It has brought down the anxiety level and decreased questions about platforms and concentrated them on how to code the visits."
And although it's difficult to envision post-COVID medical practice in the thick of the pandemic, dermatologists expect the current strides in telemedicine will stick.
"I'm hoping that telehealth use isn't dialed back all the way to baseline" after the pandemic eases, Kovarik told Medscape Medical News. "The cat's out of the bag, and now that it is, hopefully it won't be put back in."
"If there's a silver lining to this," Kroshinsky said, "I hope it's that we'll be able to innovate around healthcare in a fashion we wouldn't have seen otherwise."
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