Global Lab for Innovation Innovation Profile Tele-Dermatology Tele-medicine technologies are used by a Primary Care Physician (PCP) to send case descriptors and photographs to a dermatologist with requests for diagnoses and treatment plans. Use of telemedicine to exchange this information reduces unnecessary in person dermatology visits, improves access for patients that require more immediate care from a dermatologist, and saves total cost of care. Application Profiled Here: Direct Dermatology (DD) What it is Tele-dermatology consultations are given to patients either direct-to-consumer or through primary care physicians (PCPs) who send medical information over a secure connection to a dermatologist who provides a diagnosis and treatment recommendation. Two types of technology are used to share digital images with dermatologists. In store-and-forward methods, case notes and digital images are sent via secure email to a tele-dermatologist who provides consultation services within one or two business days. Real time systems provide immediate information exchange through video telecommunication. In either case, patients who need procedures or care that the PCP cannot perform are referred to a dermatologist for an in-person visit. Category Summary Application Profiled: DirectDerm Focused Savings Level 2 Experience Engagement Outcomes Barriers Underestimates of Derm referrals Physician Resistance Licensure Limited Internet NR Investment $$ Training EMR Integration Potential for Spread Moderate Favorable General Implementation Insights Delivery Systems 38 Safety Net Target Population Yes Primary Care patients with dermatological conditions
Problems addressed Severe shortages of dermatologists, particularly for Medicaid patients; Multi-month waits for appointments with dermatologists; PCPs who are unable to secure appointments with dermatologists for their Medicaid patients may attempt to diagnose and treat dermatological cases that are beyond their experience and training. PCP diagnoses have been found to agree with dermatologist diagnoses in an estimated 50% of the cases. 1 How it works Using store-and-forward technology, a PCP or nurse takes a photo, completes an on-line questionnaire and transfers the information through a secure connection to a tele-dermatologist who returns a diagnosis and treatment recommendation within one to two business days. The patient returns to the PCP, who explains the tele-dermatologist s findings and treatment recommendations. The tele-dermatologist may provide the PCP with directions for performing the recommended dermatological procedures in the PCP office. The PCP or the dermatologist also may write a prescription for the patient as needed. If the dermatologist determines that an office visit with him or her is necessary for diagnosis or treatment, the patient has a follow-up appointment with a dermatologist. Savings are achieved by reducing unnecessary in-person dermatology visits and procedures by having a PCP supported by a tele-dermatologist. Contracted tele-dermatologists have been found to comply more consistently with prescribing formularies of client health plans than traditional face to face dermatologist consultants, thus reducing charges for pharmaceutical treatments. Longer-term savings may be achieved by the timely diagnosis and care of skin conditions, thereby avoiding more complex, difficult and expensive late-stage disease, such as metastatic melanoma. Innovators Direct Dermatology (DD), founded in 2010, provides online, tele-dermatology services for PCP practices covered by 10 Medicaid plans in California and Hawaii. DD is also used by some private pay systems, Medicare Advantage plans and several direct-to-consumer practices. DD uses its own proprietary store-and-forward tele-medicine software system and request templates. Several other private firms in the U.S. offer tele-dermatology consultations to health systems and consumers. These include: Skin of Mine (2010), offering tele-dermatology diagnosis and treatment in Massachusetts, California, Maine and other large states; Dermatologists-On-Call (2011) and YoDerm (2013), offering direct-to-consumer consultations. Some larger, private community-based practices in the U.S. also offer tele-dermatology consultations directly to patients who are unable to make an office visit or who prefer the convenience of a tele-dermatology consultation from home. Some programs, such as the University of Pittsburgh, offer consultations only within their home state, while others offer consultations in all 50 states. A few SUNY, Texas Tech, University of Pennsylvania offer consultations in Europe, Africa, Central America and other international locations. In Europe an early provider of tele-dermatology consultations was the Royal Hospital Trust of Belfast, Northern Ireland, which initiated its practice in the late 1990s. Global Lab Profile 2
Complexity (How complex are the organizational requirements) Focused. Tele-dermatology systems require secure connectivity between PCPs and dermatologists to transmit photographs (standard cameras can be used), questionnaires, and e-mail correspondence. PCPs and clinic staff are trained (in less than an hour) in the use of equipment and on-line forms that can be completed for a primary care practice. 2 Savings Yes. In a retrospective claims study, the Health Plan of San Joaquin (HPSJ), a California Medicaid program, found that their DD-treated patients averaged charges of about $132/case while their conventional dermatologytreated cases averaged roughly about $397/case. 3 This represents a reduction of roughly 65% in charges per case. While DD physician charges were similar to those of conventional dermatologists seeing patients in office visits, DD patients had dramatically lower pharmacy charges. 4 HPSJ also found that roughly 90% of cases treated with a DD consultation had no claims history of further dermatology in-person office visits. 5 Yes. In the San Juaquin Medicaid study, Patients obtained a diagnosis and treatment within two business days by a DD consultation through their PCP. Patients who went directly to a dermatologist for an office visit had an average wait of more than 90 days for an appointment. Tele-dermatology also works to increase overall access for a population by increasing the number of cases that a dermatologist can treat per work day. Direct Dermatology estimates that their service triples the number of cases that a dermatologist reviews per day over face-to-face care. 6 Patient experience Yes. In the same HPSJ study, patients reported greater satisfaction with treatment experience, and higher convenience derived from avoiding travel for a dermatology appointment. 7 Engagement Likely, but no information was available concerning impact on engagement. DD provides links to patient education websites focused on particular diagnoses, which patients can access through their PCP. 8 Outcomes Yes. More than 80% of skin conditions treated by DD were found to have improved at the patients follow-up visit. 9 No further reports were available for longer-term clinical or patient-reported outcomes. Global Lab Profile 3
Spread A 2012 report listed 38 U.S. medical centers, community clinics, Kaiser Facilities, VA Programs, regional telemedicine networks, and US Army/Air Force programs offering tele-dermatology consultations. 10 Tele-Dermatology providers are also found in Europe and Commonwealth countries, Asia, Eastern Europe, and some South American countries. Barriers and Drivers Barriers Under-utilization: Health plans underestimated need for more access to dermatalogic consultations because PCPs who are frustrated by multi-month waits stop making referrals. Cultural change: PCPs are reluctant to change their referral patterns or to assume responsibility for explaining the e-dermatologist s findings and recommendations to a patient. Licensing: A lack of reciprocal agreements between states or regional licensing bodies means that dermatologists must be licensed in all states to which they extend consultations. Tele-dermatology practices must accept the administrative burden and expense of maintaining multiple state medical licenses for their physicians. 11 Technology: Limited access to the Internet, especially among rural communities. Drivers Workfkow Shortage: Dermatologists are in short supply. Referral volume: PCP s refer patients for dermatology consultations more frequently than for any other specialty. One study found that 37% of primary care patients presented with at least one skin problem. 12 Demographic trends: Aging population has increasing need for skin cancer detection and treatment, which often presents in primary care. Similar innovations Tele-dermatology consultation services are also available from firms and medical centers using real-time video consultations, an alternative form of tele-dermatology. Real-time tele-dermatology tools use video telecommunication technology to share digital images immediately. These image-sharing systems have quality of care and patient follow-up advantages, but are more expensive to acquire and operate. 13 14 15 This profile addresses only the store-and-forward tele-dermatology consultation model. Another somewhat similar innovation is the e-referral and e-consult programs used to facilitate e-consultations between PCPs and dermatologists. Global Lab Profile 4
Innovation contact David Wong, MD, CEO, DirectDerm E-mail Address dwong@directderm.com Website www.directdermatology.com Endnotes 1 Lowell, B Dermatology Conditions in Primary Care, J. of Am. Acad. Of Dermatology, 2001. 2 Telephone Interview with D. Wong, Ceo, Direct Dermatology, February, 2014 3 Health Plan of San Joaquin, Innovative Solutions for Specialist Shortages, 2014. Direct Derm patients had case averages of $111 while conventional dermatologist treated cases averaged $973 in one case set and $1,058 in another. Cases were not randomized, some selection bias may have occurred. Direct Derm patients averaged $23/case in pharmacy charges while conventionally treated patients averaged $873 or $974/case. Ibid. The San Joaquin Medical Director attributes the pharmacy charge difference to more within formulary prescribing by Direct Derm dermatologists. Interview with David Eibling, Medical Director Health Plan of San Joaquin, February, 2014. 4 Ibid. 5 Health Plan of San Joaquin, op.cit. 6 Interview with D Wong, op. cit. A more conservative estimate is an increase from 36 to 50 cases per day per dermatologist. Armstrong, A, et. al. 7 Op cit. 8 Telephone Interview with D Wong, March, 2014. 9 Health Plan of San Joaquin, op.cit. 10 Armstrong, US Teledermatology Survey, 2012. American Society of Dermatologists, 2012. 11 Telephone interview with D. Wong, March, 2014. 12 Lowell, op. cit. 13 Store and Forward Teledematology Applications a report by the University of California at Davis, Department of Dermatology, (prepared for CHCF), 2009. 14 M.A. Loane et. al., A randomized controlled trial assessing the health economics of realtime teledermatology compared with conventional care: an urban versus rural perspective Telemed Telecare. 2001;7(2):108-18. 15 M.A. Loane, A randomized controlled trial to assess the clinical effectiveness of both realtime and store-and-forward teledermatology compared with conventional care. J Telemed Telecare. 2000;6 Suppl 1:S1-3. These studies also found that real-time consultations have higher costs. However, the quality of care for real-time consultations was found to be higher than store and forward and equal to face to face consultations. Global Lab Profile 5
Innovation summary legend... Neutral... Positive NR... Not Reported: Innovation candidate appears to have potential to meet criteria, but measures were not reported/found when profile was drafted Summary Application Profiled: DirectDerm Category Focused Savings Level 2 Experience Savings Level 1... Utilization-based savings equal to 20% or more for target patient group Level 2... Utilization based savings greater than 2% for target population Engagement Outcomes Barriers Underestimates of Derm referrals Physician Resistance Licensure Limited Internet NR Barrier(s) (barrier reported by innovator/users)... Significant barrier to adoption... Moderate barrier to adoption Investment Estimate of total costs to delivery system during first year to plan, acquire and implement innovation. These costs include reported evaluation fees, recruitment, hiring, training, capital equipment, IT development, and other expenses reported by innovators and early adopters. Some additional expenses may be incurred in individual situations. $... < $100,000 $$... $100,000 to $500,000 $$$... $500,000 to 2M $$$$... > $2M Investment $$ Training EMR Integration Potential for Spread Moderate Favorable General Implementation Insights Delivery Systems 38 Safety Net Target Population Yes Primary Care patients with dermatological conditions Potential for Spread Prospect that given implementation factors and mix of barriers and drivers that the innovation will have increased dissemination in near future.... Moderate Potential...Strong Potential Target population Patient or clinician group targeted by innovation and/or payor population in which innovation has been used Global Lab Profile 6