Teledermatology – Was your Remote Eczema Skin Consultation helpful?

This is the final post of the 5-part series and today, I will try to apply all that we have learnt in the past 4 posts to eczema skin consultations. I have presented it in survey format for each step of teledermatology and look forward to hearing your experience!

Teledermatology Checklist - Did you Remote Eczema Consultation go well?

Teledermatology Checklist – Did you Remote Eczema Consultation go well?

Before the Teledermatology Process

Q1 Were you given a leaflet to explain teledermatology and what form of teledermatology is available to you?

Q2 Were you aware that you do not have to consent to teledermatology?

Q3 Were you told that if an in-person consultation is deemed required during the process, you will have access to the dermatologist?

Q4 Were you told if it is going to be stored and forward or live videoconferencing?

Q5 Were you told that your eczema is suitable or not suitable for teledermatology? For instance, full body eczema, or rashes in scalp, private parts or pigmented rash are difficult to capture fully in images. Or that your eczema is localised and can be clearly identified in image.

Q6 Were you told that teledermatology may not be as accurately diagnosed than face-to-face consultation?

Starting the Teledermatology Process

Q7 Were you told who is the dermatologist and his/her licensure and board certification?

Q8 Were you told what images of your eczema will be taken and how these will be stored and protected?

Q9 Were you given the instructions on how you can access your own patient record?

Q10 Did you feel that the referring physician is comprehensive in recording your medical history?

Q11 Were you asked these questions on your eczema?

  • Previous treatment for eczema and response to medication
  • Personal and family history of skin disease and atopy
  • Known allergies
  • Active problem list
  • Body map is recommended to show the site of lesions and the extent of inflammation at each site

Q12 Did you feel you were treated with dignity during the photography session?

Q13 Were you told that you can have a companion during the consultation with the referring physician?

Skin Management Plan

Q14 Were you provided with a skin management plan? e.g. what medication, for how long/ which part of skin/ frequency/ how much to use

Q15 Was it made clear to you who is responsible for your care? e.g. to communicate with you and ensure that treatment is clearly communicated

Q16 Was there nursing staff to help you with skin care? e.g. guidance on how to moisture and wet wrap

Q17 Could your referring physician explain clearly which type of eczema you have, and the steps to reduce flare-ups e.g. allergy avoidance, active steps to reduce staph bacteria

Follow-up with Face-to-Face Skin Specialist Consultation

Q18 Did you have to wait longer than traditional referral to see the dermatologist who has provided the skin management plan?

Q19 Did you have to provide the same information again at the skin specialist clinic?

If you were referred for videoconferencing with the dermatologist,

Q20 Did the dermatologist have your information and referral form?

Q21 Was the videoconferencing set up in advance and smooth?

Q22 Were you told beforehand where you would need to uncover for the skin to be imaged?

Q23 Were all the persons in the room identified?

In instances where the set up or preparation for teledermatology is inadequate, the dermatologist may only confirm a diagnosis/ provide a treatment plan in-person. As such, it may end up being more time consuming to engage in teledermatolgy. What’s your experience? How many of the 23 questions were ‘checked’ for you?

For all other posts in this 5-part series, see

Teledermatology – Advantages of Remote Skin Consultation

Last 3 weeks we have covered 3 posts in this 5-part series on Teledermatology:

Teledermatology takes away the need to travel and meet in person with the skin specialist. This brings about numerous advantages such as:

Many advantages of teledermatology but the set-up at both doctors' clinics have to support it

Many advantages of teledermatology but the set-up at both doctors’ clinics have to support it

Shorter wait time – Compared to traditional referrals, a referring physician that a patient sees (nearer and more accessible) can help to capture, store and transmit the patient information and skin images to a dermatologist. The access to a dermatologist is therefore faster.

Accessibility for patients who live in areas without dermatology care – Singapore is small but in many other countries, specialist dermatology department may only be available in certain areas and teledermatology is a way for patients living in more remote areas to have access to specialist care.

Familiarity – For skin issues that both the referring clinician and the dermatologist feel that it is appropriate for the dermatologist to prescribe a skin management plan and the referring clinician to administer and be responsible for the patient interaction and care, the patient will then be seeing the same doctor (referring clinician) who he/she has already established a relationship with.

Convenience – Potentially faster, cheaper and less stressful than to travel and visit another doctor.

More detailed record – As the process of teledermatology is reliant on the transmission of patient information, images and then the relay of the diagnosis and treatment plan, followed with the outcome of previous treatment, there is a well documented record of the patient information and the skin condition. This record may be more detailed in in-person consultation.

Reduction of waiting lists at dermatology clinics – As certain skin conditions do not warrant establishing a relationship with dermatologist but rather straightforward in the diagnosis and treatment, the waiting lists at dermatology clinics can be shortened.

However, it is NOT ALWAYS that these advantages can materialize and both the referring physician and dermatologist can take actions and have systems in place to ensure success in teledermatology:

At the Referring Physician

  1. Proper record of patient information, medical history and the history of the skin lesions
  2. Staff to take skin images that meet the guidelines of images in teledermatology – dermatology nurse trained to take high quality skin images
  3. Integrated system at the referring physician to incorporate teledermatology
  4. Proper planning of the consultation process at the referring physician to take the images required after the consultation
  5. Selection of patient – Patients who are resistance to teledermatology, for instance, elderly, shy or young patients, or with rash at private parts should not be pressured to consent to teledermatology
  6. Educational materials on the diagnosed skin condition to be available for the patient and the care team

At the Dermatologist

  1. Dermatologists who signed up for teledermatology should have the resources to promptly feedback on the information provided by the referring clinician
  2. Dermatologists should have resources for the referring clinician and his/her clinic on various skin conditions
  3. Close communication and record of patient care with a system to obtain feedback and address weakness in the process
  4. Patients should not have to furnish information all over again if referred for an in-person consultation at the skin specialist clinic, i.e. teledermatology should be integrated with the specialist clinic system
  5. Patients should have a shorter waiting time for in-person specialist skin consultation compared to traditional referral
  6. Patients should have easy access to dermatologist for face-to-face session
  7. Patients should be given clear skin management plan

If traveling to the dermatologist is not an issue to begin with and the mode of teledermatology is video conferencing, there may not be much cost/time-savings involved. On the other hand, it benefits certain situations such as elderly living in a home who may not have access to specialist care if not for teledermatology.

If you want to understand more of the quality standards in teledermatology, do read British Association of Dermatologists’ standards. Share in the comments if you have benefited from teledermatology and what advice you have for patients to get the most out of it, your sharing will help another!

Teledermatology – Shortfalls in Teleconsultation

Last week we covered a critical part of the teledermatology process – getting quality patient information and skin images (for Store and Forward). This week we break down the various steps in teledermatology and explore why each step may not work as well as in-person consultation.

Face to face consultation remain the gold standard as there are many areas where teledermatology may fall short. The referring provider and the dermatologist must be familiar and trained to conduct teleconsultation to mitigate these shortfalls.

Understand these potential shortfalls in teledermatology and see if your doctor is mitigating them when treating your skin

Understand these potential shortfalls in teledermatology and see if your doctor is mitigating them when treating your skin

Step 1 – Understanding the Patient

In face to face consultation, non-verbal cues can be noted including signs of stress that may be important in measuring the quality of life and severity of skin condition e.g. eczema. In triage teledermatology, it is often limited to paper documentation or standard referral letter.

Mitigating factors – There should be a system in place at the referring physician clinic to understand the patient. For instance, comprehensive questionnaires, trained doctors and nurses to capture patient information and images and sufficient time to do so.

Step 2 – Skin Evaluation

In face to face consultation, the physician can use sense of touch and able to see ALL the skin areas. In teledermatology, it is limited to the skin area where the photograph has taken. There are certain skin areas where it is recommended to have an in-person consultation, such as:

  1. The whole body has skin problems, for instance, generalized eczema rather than localized. Physicians have to note to treat the patient as a whole, even when the information is centered on the lesions (a potential pitfall of teledermatolgoy is focusing only on the skin lesion).
  2. The skin conditions are on areas of skin with hair that cover up the skin rash, for instance, the scalp.
  3. The skin lesions if pigmented are harder to view as an image.
  4. Mucosal lesions and orifices, e.g. genital, present difficulty to take accurate image.

Mitigating factors – Skin images have to be taken from various angles, with mid close-up and macro close-up distance and skin lesions clearly marked. Therefore, the referring physician who takes the image or review the suitability of the image has to be trained. Special lighting or dermatoscopes may be required.

Step 3 – Administering the Treatment

It is more likely for the treatment to be carried out as prescribed if there is in-person interaction. Patients have an opportunity to ask their questions directly to the dermatologist and such interaction provide opportunity to optimize patient care.

Mitigating factors – If the treatment is to be handled by the referring physician, educational materials may need to be provided for both the referring physician and the patient. There ought to be close communication between the referring physician and the dermatologist so that the treatment and skin management plan for the patient is agreed and both physicians feel confident with the plan.

Step 4 – Responsibility for the Patient Care

It should be clear within the care team and clearly communicated who is responsible for the patient. In particular, in the quality standards by BAD, it is stated under ‘Patients with long-term skin conditions (eg eczema or psoriasis)’ that

Patients with chronic inflammatory skin disease should be managed through teledermatology only if the referring clinician has the facilities and clinical experience to provide on-going patient support and review based on the skin care management plan provided by the reporting skin specialist.

The rationale is that these skin conditions fluctuate significantly in severity and may require complex treatment plans for safe and effective long-term management. Patients (and parents/carer) should have access to suitable nursing expertise for treatment, counseling, education and advice. Another rationale is that these skin conditions may come with significant physical, social and psychological impairment and therefore the ability to provide on-going patient support is critical to patient care.

There is a reported loss of rapport with the patient through the teledermatology. As such for certain skin conditions that are chronic, fluctuating and require long-term care, teledermatology may not be suitable.

Next week, we will explore what are the advantages of teledermatology. Have you tried teledermatology? Did you feel at any time that your health and skin conditions are not fully understood? Was your referring physician convinced with the skin management plan and were you confident in following through with it?

Share in the comments, especially important as teledermatology is gaining in popularity and we want to do our little part to steer it in the right direction for skin/eczema patients!

Teledermatology – Skin Images and Patient Information

Last week, the basics of teledermatology was introduced – What Teledermatology is, its different forms and patient points when getting started on it. Today, we continue with the 2nd part of this 5-part series, focusing on a central part of the teledermatology process – Skin Images and Patient Information. Much of the guidelines are obtained from the British Association of Dermatologists’ Quality Standards for Teledermatology.

Information for Skin Patients

Before getting started on (and providing consent to) teledermatology, there are good practices on what Information You (as the skin patient) Ought To Be Provided With

  1. What the tele dermatology process involves and why it is helpful in your case
  2. Why there may be a difference in diagnostic accuracy from in-person consultation
  3. Process in place to have an in-person consultation should the need arise
  4. Who takes the images and what images are needed
  5. What information will be sent with the images
  6. How the images are transferred
  7. Information about the specialist to whom the images are sent to and what the specialist will do with the information
  8. What happens in response to the teledermtaology consultation
  9. How you can access your own information
  10. Where your skin images are stored, for how long and who have access
  11. The fact that you do not have to consent for teledermatology

Information from Skin Patients

Once you have consented to teledermatology, a critical part of the process is compiling complete and accurate Information on You and Your Skin Condition. Information that are expected to be collected, stored and transmitted (Store-and-Forward) are:

Personal Information on Patient 

  • Date of birth
  • Gender
  • Ethnic group
  • Address, contact number

Information on Patient’s Skin Condition

  • Date of onset and duration of skin lesions
  • Whether single or multiple skin lesions
  • Locations of the skin lesions
  • Changes in size, shape and colour
  • Any bleeding and/or ulceration
  • Symptoms that accompany the skin lesions

Information on Patient’s Medical History 

  • Any personal and/or family history of skin cancers
  • Other risk factors, e.g. excessive sun exposure, fair skin, large number of birth marks, currently on immunosuppressant medication
  • Other medical conditions
  • Repeat and recent medications

In particular, for those with inflammatory skin condition, e.g eczema, information from you that is required are:

  • Previous treatment for eczema and response to medication
  • Personal and family history of skin disease and atopy
  • Known allergies
  • Active problem list
  • Body map is recommended to show the site of lesions and the extent of inflammation at each site

A note on Skin Images

Importance of Quality Skin Images and Patient Information for Teledermatology

Importance of Quality Skin Images and Patient Information for Teledermatology

  1. If the skin images are to be taken at the clinic of your referring physician, a few points that they ought to bear in mind are:
  2. Protecting your modesty – You have the right to have a chaperone or bring a companion
  3. Images should be a minimum of 2000×1500 pixels or 3 megapixels
  4. Images should be taken at least at two different angles, to compensate for loss of details from reflection
  5. Images should be mid-close up to identify where the lesion is and macro (close-up)
  6. The focusing distance should be at least 20cm for macro close-up.
  7. Image filenames should be clearly identified
  8. Skin lesions can be identified using sticky labels, surgical tape or washable markers.

In Store and Forward Teledermatology, capturing quality images, recording accurate and complete information is a critical success factor. If the dermatologist is comfortable with the quality of imaging and information, it is less likely that you will be called in for an in-person consultation.

What is your experience? Were you provided with adequate information BEFORE you consent to teledermatology and did you feel that your referring physician recorded all the requisite information? Share in the comments so we can benefit from your experience!

Teledermatology – Different Forms of Skin Consultations

With many people having access to cameras and internet, teledermatology is gaining popularity with the potential of getting a dermatologist’s consultation in a shorter time (compared to a long referral wait). This 5-part series explore the numerous aspects of teledermatology, much of the information is from dermatology associations like the American Telemedicine Association, American Academy of Dermatology, British Association of Dermatologists (BAD) and numerous published research/review papers.

What is Teledermatology?

Teledermatology is a skin consultation carried out remotely using telecommunications, it can take different forms such as:

Store and Forward – This refers to images being stored, sent to the dermatologist with patient information who will then revert with the consultation. Thus, it is not ‘real time’.

Real-time Interactive – This uses videoconferencing.

Direct-to-patient – Images are sent to the dermatologist and there is a live interaction.

Triage consultation – This involves two physicians, where one physician (referring physician) will send the patient information and images to the dermatologist and interact with the dermatologist. The patient interacts with the referring physician.

Store and Forward – When is it Used?

Store and forward is increasingly used, in various forms of skin consultations.

In direct-to-patient teldermatology, store and forward is between:

  • Patient and Dermatologist
  • Patient sends his medical history and images directly to dermatologist
  • Dermatologist provides care directly to patient

Store and forward can also be used in teletriage, whereby:

  • Referring physician interacts with patients, to obtain medical history and skin images
  • Referring provider sends the patient information to dermatologist
  • Dermatologist decides on next step – in-person consultation, tele consultation or no specialist consultation required
  • If it is to be via tele consultation, the dermatologist provides a consultative report back to the referring provider with a skin management plan
  • Referring physician is responsible to carry out the treatment recommendations

Some ‘Get Started’ Pointers for Patients:

Teledermatology Get Started Pointers for Skin Patients

Pointers for Patients considering Teledermatology

#1 Be clear about what you sign up for

As there are various forms teledermatology can take, make sure you find out which one your referring provider has in mind – will he remain as your primary care doctor or it is expected to eventually lead to a referral to see a dermatologist directly

#2 Licensure and board certification of dermatologists

In certain countries/states, there are regulations that mandate patients have a choice of dermatologist, access to where the dermatologist is licensed and what are his/her board certifications. Sometimes dermatologists can provide teledermatology only in states where he/she is licensed. Other states regulate that prescription can only be provided when there is a live interaction. Being licensed in a particular state may also mean being familiar with the health care infrastructure and the resources you (as the patient) have access to.

#3 Access to in-person followup

It would be ideal for you to have the option to access to the dermatologist in-person even if the teledermatology is currently not direct-to-patient form. Where the teledermatology is direct-to-patient, dermatologists are expected to have met you in person or to do so via a live video conferencing before prescribing medication.

#4 Expect your medical history to be stored and transmitted

As opposed to in-person consultation where images of your skin may not be taken, teledermatology relies on the storage of such images to be transmitted to a dermatologist. There are guidelines on collection of patient data and on privacy. Some data that are required to be collected are:

Medical history – for instance, history of eczema or atopic conditions in family

Medical records – past treatment given and current treatment will be documented electronically for all physicians in your care team to have access to. The patient’s existing primary care physician and dermatologist (if any) should be identified.

#5 Right doctor at right time and place

No matter what form of  teledermatology, it should be no less effective and efficient than a in-person referred consultation. The main advantage of teledermatology is the potential to receive a specialist consultation sooner and to have access to the right doctor. The teledermatology process should not end up being convoluted and time-consuming.

Have you tried teledermatology? Has it benefited you? Share in the comments so that the rest of us can benefit!

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