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By the time Dr. Karen Edison saw the 41-year-old patient, several days had passed since his wife had first noticed a discolored spot on his back. Harvest season was underway, and the North Central Missouri farmer was reluctant to leave the fields and visit a physician.
Making matters more challenging, the family lived in a rural area nearly 3 hours away from a major medical center. The patient’s wife finally convinced her husband to visit a local hospital that had a telemedicine unit. Miles away at University of Missouri Health in Columbia, Dr. Edison viewed high-quality digital photos of the man’s back and spoke to the patient via video conferencing. Dr. Edison determined the blotch was a melanoma with a 1.1-mm Breslow measurement. The patient underwent a wide local excision along with a sentinel lymph node biopsy, which turned out to be negative.
“It makes me feel grateful for the technology and how it lets us reach patients earlier and gets them diagnosed correctly,” said Dr. Edison, Philip C. Anderson Professor and chair of the dermatology department at University of Missouri Health and medical director for the Missouri Telehealth Network. “This saves patients’ suffering and can save patients’ lives. It certainly did in this case,” he said.
Similar outcomes are playing out across the country as telemedicine use continues to grow, especially among dermatologists. Analysts predict the number of health providers offering telemedicine will rise from 22% in 2014 to 37% in 2015, according to research by Towers Watson, a professional services company. Another report, BCC Research, a market research company, shows the global telehospital/clinic and telehome market is expected to reach about $43 billion in 2019, up from $19 billion in 2014.
Dermatologists fit rather smoothly into the telemedicine space, said Dr. Edison, who has used telemedicine in some form for 20 years. “Dermatology is uniquely suited for use of the technology because we are a visual specialty,” she said in an interview. “The value of our expertise is in the training we [have] to diagnose.”
Best teledermatology uses
Teledermatology is one of the most active applications of telemedicine rendered in the United States, according to the American Telemedicine Association (ATA). Common uses include “store and forward,” a technique that uses asynchronous still digital image technology for communication, and “real-time interactive,” which uses videoconferencing technology. Dermatologist Raja Sivamani of the University of California Davis Health System is taking these approaches one step further by working to integrate mobile phone photography and cloud-based communications.
“Previously, the technology had to be separated between the photography and the communication,” Dr. Sivamani said in an interview. “However, now we are seeing that this can be combined on the same platform, making the communications less cumbersome.”
Dr. Sivamani and his colleagues are currently using the technology for research studies and to set up communication channels overseas between hospital dermatologists, remote villages, and health outposts in both Nepal and Sri Lanka, he said.
Consults with other specialists also top the list of beneficial uses of teledermatology. In a survey of 2,016 doctors by American Well, a telehealth services company, physicians ranked dermatology video consults as the most valuable video consult of all the specialties. To address this need, the American Academy of Dermatology and the University of Pennsylvania jointly developed AccessDerm, a national program that provides primary care providers who work in participating clinics with free access to the expertise of dermatologists, who are AAD members. The program allows primary care clinicians to submit consultations that dermatologists receive on their personal mobile devices or the Internet via HIPAA-secure means. AccessDerm is now being used in 16 states, but the AAD is seeking to increase participation by clinics in all 50 states.
“In addition to addressing physician shortages from a clinical standpoint, teledermatology programs are very important for vulnerable citizens in the United States and abroad,” Dr. William D. James, vice chair of the department of dermatology for Penn Medicine and a past AAD president said in a statement. “It is wonderful that the impact of these teledermatology consultations continues to expand.”
An essential key to teledermatology is image quality, noted Dr. Dennis H. Oh of the University of California, San Francisco. He is assistant chief of dermatology at the San Francisco VA Medical Center and a member of the ATA’s Teledermatology Special Interest Group. At the VA Medical Center in San Francisco, photography is done by dedicated imagers trained and certified through a standardized curriculum, Dr. Oh said in an interview. The quality of images is also regularly monitored, he added.
“Image quality is of course very important,” Dr. Oh said. “There are resources to help train imagers and maintain their competence, such as those provided by the [ATA].”
Telemedicine challenges abound
Despite the perks, dermatologists and other doctors who practice telemedicine face a host of challenges that come with the virtual territory. Barriers include reimbursement, licensing, malpractice, and regulation. Topping the barriers is a lack of uniform standards for practices. A key question: What constitutes the responsible use of telemedicine?
States have differing ideas. Some require a physical examination by a physician prior to telemedicine. Some allow an encounter to be conducted via telemedicine, while others mandate that the visit be in person. Alabama, Georgia, and Texas require an in-person follow-up visit after a telemedicine encounter, according to 2015 data from the ATA. Sixteen states and Washington, D.C., have informed consent requirements for telemedicine patients. Still other states have no defined rules for the practice of telemedicine.
To promote consistency and better usage, the Federation of State Medical Boards (FSMB) in 2014 issued a model policy to state medical boards about the recommended practice of telemedicine. The policy maintains that the same standard of care applied to face-to-face encounters be applied to telemedicine encounters, explained Lisa A. Robin, chief advocacy officer for the Federation of State Medical Boards. At least 29 state boards have telemedicine rules that are consistent with the model policy, Ms. Robin said in an interview.
“As telemedicine continues to evolve, we believe there must be a very strong focus on ensuring patient safety through sound policy-making and regulatory practices,” she said.
Medical specialty societies have weighed in on acceptable telehealth practices for doctors. AAD policy, amended in 2015, supports the use of telemedicine services as long as teledermatology care is of high quality, contributes to care coordination – rather than fragmentation, meets state licensure and other legal requirements, maintains patient choice and transparency, and protects patient privacy. Guidance issued by the American Medical Association makes it clear that physicians who practice telemedicine need to first establish a patient-physician relationship. The FSMB guidance also states that doctors should establish a relationship with patients before practicing telemedicine.
But how that relationship is created is up for debate. In Texas, disagreement over what creates a physician-patient relationship has led to litigation between the national telemedicine company Teladoc and the Texas Medical Board. The case centers on a medical board rule that requires physicians to have a face-to-face visit with patients before treating them through telemedicine. The relationship can be created through telemedicine at an established medical site, but it may not be established through an online questionnaire, an email, a text, a chat, or a telephonic evaluation or consultation. Teladoc sued the medical board in April claiming the rule violates federal antitrust laws. A judge temporarily halted the rule’s enforcement in May.
Such ongoing disputes show that telemedicine best practices still need alignment and standardization, according to teledermatology experts.
“Telemedicine is gaining support, but there are many rules that need to be worked out,” Dr. Sivamani said. “Some include how these services are being reimbursed. Another concern is how medical board licensing allows or disallows practice within a region or across state lines. These challenges will need to be worked out and may require coordination between states in their legislation.”
Regardless of how these rules are standardized, teledermatology will be a large part of the telemedicine landscape, Dr. Oh added.
“Teledermatology used to be perceived as a relative niche novelty, but it is clearly going to be an increasing part of current routine care, and indeed is already integral to some practices and health systems,” he said.
On Twitter @legal_med
By the time Dr. Karen Edison saw the 41-year-old patient, several days had passed since his wife had first noticed a discolored spot on his back. Harvest season was underway, and the North Central Missouri farmer was reluctant to leave the fields and visit a physician.
Making matters more challenging, the family lived in a rural area nearly 3 hours away from a major medical center. The patient’s wife finally convinced her husband to visit a local hospital that had a telemedicine unit. Miles away at University of Missouri Health in Columbia, Dr. Edison viewed high-quality digital photos of the man’s back and spoke to the patient via video conferencing. Dr. Edison determined the blotch was a melanoma with a 1.1-mm Breslow measurement. The patient underwent a wide local excision along with a sentinel lymph node biopsy, which turned out to be negative.
“It makes me feel grateful for the technology and how it lets us reach patients earlier and gets them diagnosed correctly,” said Dr. Edison, Philip C. Anderson Professor and chair of the dermatology department at University of Missouri Health and medical director for the Missouri Telehealth Network. “This saves patients’ suffering and can save patients’ lives. It certainly did in this case,” he said.
Similar outcomes are playing out across the country as telemedicine use continues to grow, especially among dermatologists. Analysts predict the number of health providers offering telemedicine will rise from 22% in 2014 to 37% in 2015, according to research by Towers Watson, a professional services company. Another report, BCC Research, a market research company, shows the global telehospital/clinic and telehome market is expected to reach about $43 billion in 2019, up from $19 billion in 2014.
Dermatologists fit rather smoothly into the telemedicine space, said Dr. Edison, who has used telemedicine in some form for 20 years. “Dermatology is uniquely suited for use of the technology because we are a visual specialty,” she said in an interview. “The value of our expertise is in the training we [have] to diagnose.”
Best teledermatology uses
Teledermatology is one of the most active applications of telemedicine rendered in the United States, according to the American Telemedicine Association (ATA). Common uses include “store and forward,” a technique that uses asynchronous still digital image technology for communication, and “real-time interactive,” which uses videoconferencing technology. Dermatologist Raja Sivamani of the University of California Davis Health System is taking these approaches one step further by working to integrate mobile phone photography and cloud-based communications.
“Previously, the technology had to be separated between the photography and the communication,” Dr. Sivamani said in an interview. “However, now we are seeing that this can be combined on the same platform, making the communications less cumbersome.”
Dr. Sivamani and his colleagues are currently using the technology for research studies and to set up communication channels overseas between hospital dermatologists, remote villages, and health outposts in both Nepal and Sri Lanka, he said.
Consults with other specialists also top the list of beneficial uses of teledermatology. In a survey of 2,016 doctors by American Well, a telehealth services company, physicians ranked dermatology video consults as the most valuable video consult of all the specialties. To address this need, the American Academy of Dermatology and the University of Pennsylvania jointly developed AccessDerm, a national program that provides primary care providers who work in participating clinics with free access to the expertise of dermatologists, who are AAD members. The program allows primary care clinicians to submit consultations that dermatologists receive on their personal mobile devices or the Internet via HIPAA-secure means. AccessDerm is now being used in 16 states, but the AAD is seeking to increase participation by clinics in all 50 states.
“In addition to addressing physician shortages from a clinical standpoint, teledermatology programs are very important for vulnerable citizens in the United States and abroad,” Dr. William D. James, vice chair of the department of dermatology for Penn Medicine and a past AAD president said in a statement. “It is wonderful that the impact of these teledermatology consultations continues to expand.”
An essential key to teledermatology is image quality, noted Dr. Dennis H. Oh of the University of California, San Francisco. He is assistant chief of dermatology at the San Francisco VA Medical Center and a member of the ATA’s Teledermatology Special Interest Group. At the VA Medical Center in San Francisco, photography is done by dedicated imagers trained and certified through a standardized curriculum, Dr. Oh said in an interview. The quality of images is also regularly monitored, he added.
“Image quality is of course very important,” Dr. Oh said. “There are resources to help train imagers and maintain their competence, such as those provided by the [ATA].”
Telemedicine challenges abound
Despite the perks, dermatologists and other doctors who practice telemedicine face a host of challenges that come with the virtual territory. Barriers include reimbursement, licensing, malpractice, and regulation. Topping the barriers is a lack of uniform standards for practices. A key question: What constitutes the responsible use of telemedicine?
States have differing ideas. Some require a physical examination by a physician prior to telemedicine. Some allow an encounter to be conducted via telemedicine, while others mandate that the visit be in person. Alabama, Georgia, and Texas require an in-person follow-up visit after a telemedicine encounter, according to 2015 data from the ATA. Sixteen states and Washington, D.C., have informed consent requirements for telemedicine patients. Still other states have no defined rules for the practice of telemedicine.
To promote consistency and better usage, the Federation of State Medical Boards (FSMB) in 2014 issued a model policy to state medical boards about the recommended practice of telemedicine. The policy maintains that the same standard of care applied to face-to-face encounters be applied to telemedicine encounters, explained Lisa A. Robin, chief advocacy officer for the Federation of State Medical Boards. At least 29 state boards have telemedicine rules that are consistent with the model policy, Ms. Robin said in an interview.
“As telemedicine continues to evolve, we believe there must be a very strong focus on ensuring patient safety through sound policy-making and regulatory practices,” she said.
Medical specialty societies have weighed in on acceptable telehealth practices for doctors. AAD policy, amended in 2015, supports the use of telemedicine services as long as teledermatology care is of high quality, contributes to care coordination – rather than fragmentation, meets state licensure and other legal requirements, maintains patient choice and transparency, and protects patient privacy. Guidance issued by the American Medical Association makes it clear that physicians who practice telemedicine need to first establish a patient-physician relationship. The FSMB guidance also states that doctors should establish a relationship with patients before practicing telemedicine.
But how that relationship is created is up for debate. In Texas, disagreement over what creates a physician-patient relationship has led to litigation between the national telemedicine company Teladoc and the Texas Medical Board. The case centers on a medical board rule that requires physicians to have a face-to-face visit with patients before treating them through telemedicine. The relationship can be created through telemedicine at an established medical site, but it may not be established through an online questionnaire, an email, a text, a chat, or a telephonic evaluation or consultation. Teladoc sued the medical board in April claiming the rule violates federal antitrust laws. A judge temporarily halted the rule’s enforcement in May.
Such ongoing disputes show that telemedicine best practices still need alignment and standardization, according to teledermatology experts.
“Telemedicine is gaining support, but there are many rules that need to be worked out,” Dr. Sivamani said. “Some include how these services are being reimbursed. Another concern is how medical board licensing allows or disallows practice within a region or across state lines. These challenges will need to be worked out and may require coordination between states in their legislation.”
Regardless of how these rules are standardized, teledermatology will be a large part of the telemedicine landscape, Dr. Oh added.
“Teledermatology used to be perceived as a relative niche novelty, but it is clearly going to be an increasing part of current routine care, and indeed is already integral to some practices and health systems,” he said.
On Twitter @legal_med
By the time Dr. Karen Edison saw the 41-year-old patient, several days had passed since his wife had first noticed a discolored spot on his back. Harvest season was underway, and the North Central Missouri farmer was reluctant to leave the fields and visit a physician.
Making matters more challenging, the family lived in a rural area nearly 3 hours away from a major medical center. The patient’s wife finally convinced her husband to visit a local hospital that had a telemedicine unit. Miles away at University of Missouri Health in Columbia, Dr. Edison viewed high-quality digital photos of the man’s back and spoke to the patient via video conferencing. Dr. Edison determined the blotch was a melanoma with a 1.1-mm Breslow measurement. The patient underwent a wide local excision along with a sentinel lymph node biopsy, which turned out to be negative.
“It makes me feel grateful for the technology and how it lets us reach patients earlier and gets them diagnosed correctly,” said Dr. Edison, Philip C. Anderson Professor and chair of the dermatology department at University of Missouri Health and medical director for the Missouri Telehealth Network. “This saves patients’ suffering and can save patients’ lives. It certainly did in this case,” he said.
Similar outcomes are playing out across the country as telemedicine use continues to grow, especially among dermatologists. Analysts predict the number of health providers offering telemedicine will rise from 22% in 2014 to 37% in 2015, according to research by Towers Watson, a professional services company. Another report, BCC Research, a market research company, shows the global telehospital/clinic and telehome market is expected to reach about $43 billion in 2019, up from $19 billion in 2014.
Dermatologists fit rather smoothly into the telemedicine space, said Dr. Edison, who has used telemedicine in some form for 20 years. “Dermatology is uniquely suited for use of the technology because we are a visual specialty,” she said in an interview. “The value of our expertise is in the training we [have] to diagnose.”
Best teledermatology uses
Teledermatology is one of the most active applications of telemedicine rendered in the United States, according to the American Telemedicine Association (ATA). Common uses include “store and forward,” a technique that uses asynchronous still digital image technology for communication, and “real-time interactive,” which uses videoconferencing technology. Dermatologist Raja Sivamani of the University of California Davis Health System is taking these approaches one step further by working to integrate mobile phone photography and cloud-based communications.
“Previously, the technology had to be separated between the photography and the communication,” Dr. Sivamani said in an interview. “However, now we are seeing that this can be combined on the same platform, making the communications less cumbersome.”
Dr. Sivamani and his colleagues are currently using the technology for research studies and to set up communication channels overseas between hospital dermatologists, remote villages, and health outposts in both Nepal and Sri Lanka, he said.
Consults with other specialists also top the list of beneficial uses of teledermatology. In a survey of 2,016 doctors by American Well, a telehealth services company, physicians ranked dermatology video consults as the most valuable video consult of all the specialties. To address this need, the American Academy of Dermatology and the University of Pennsylvania jointly developed AccessDerm, a national program that provides primary care providers who work in participating clinics with free access to the expertise of dermatologists, who are AAD members. The program allows primary care clinicians to submit consultations that dermatologists receive on their personal mobile devices or the Internet via HIPAA-secure means. AccessDerm is now being used in 16 states, but the AAD is seeking to increase participation by clinics in all 50 states.
“In addition to addressing physician shortages from a clinical standpoint, teledermatology programs are very important for vulnerable citizens in the United States and abroad,” Dr. William D. James, vice chair of the department of dermatology for Penn Medicine and a past AAD president said in a statement. “It is wonderful that the impact of these teledermatology consultations continues to expand.”
An essential key to teledermatology is image quality, noted Dr. Dennis H. Oh of the University of California, San Francisco. He is assistant chief of dermatology at the San Francisco VA Medical Center and a member of the ATA’s Teledermatology Special Interest Group. At the VA Medical Center in San Francisco, photography is done by dedicated imagers trained and certified through a standardized curriculum, Dr. Oh said in an interview. The quality of images is also regularly monitored, he added.
“Image quality is of course very important,” Dr. Oh said. “There are resources to help train imagers and maintain their competence, such as those provided by the [ATA].”
Telemedicine challenges abound
Despite the perks, dermatologists and other doctors who practice telemedicine face a host of challenges that come with the virtual territory. Barriers include reimbursement, licensing, malpractice, and regulation. Topping the barriers is a lack of uniform standards for practices. A key question: What constitutes the responsible use of telemedicine?
States have differing ideas. Some require a physical examination by a physician prior to telemedicine. Some allow an encounter to be conducted via telemedicine, while others mandate that the visit be in person. Alabama, Georgia, and Texas require an in-person follow-up visit after a telemedicine encounter, according to 2015 data from the ATA. Sixteen states and Washington, D.C., have informed consent requirements for telemedicine patients. Still other states have no defined rules for the practice of telemedicine.
To promote consistency and better usage, the Federation of State Medical Boards (FSMB) in 2014 issued a model policy to state medical boards about the recommended practice of telemedicine. The policy maintains that the same standard of care applied to face-to-face encounters be applied to telemedicine encounters, explained Lisa A. Robin, chief advocacy officer for the Federation of State Medical Boards. At least 29 state boards have telemedicine rules that are consistent with the model policy, Ms. Robin said in an interview.
“As telemedicine continues to evolve, we believe there must be a very strong focus on ensuring patient safety through sound policy-making and regulatory practices,” she said.
Medical specialty societies have weighed in on acceptable telehealth practices for doctors. AAD policy, amended in 2015, supports the use of telemedicine services as long as teledermatology care is of high quality, contributes to care coordination – rather than fragmentation, meets state licensure and other legal requirements, maintains patient choice and transparency, and protects patient privacy. Guidance issued by the American Medical Association makes it clear that physicians who practice telemedicine need to first establish a patient-physician relationship. The FSMB guidance also states that doctors should establish a relationship with patients before practicing telemedicine.
But how that relationship is created is up for debate. In Texas, disagreement over what creates a physician-patient relationship has led to litigation between the national telemedicine company Teladoc and the Texas Medical Board. The case centers on a medical board rule that requires physicians to have a face-to-face visit with patients before treating them through telemedicine. The relationship can be created through telemedicine at an established medical site, but it may not be established through an online questionnaire, an email, a text, a chat, or a telephonic evaluation or consultation. Teladoc sued the medical board in April claiming the rule violates federal antitrust laws. A judge temporarily halted the rule’s enforcement in May.
Such ongoing disputes show that telemedicine best practices still need alignment and standardization, according to teledermatology experts.
“Telemedicine is gaining support, but there are many rules that need to be worked out,” Dr. Sivamani said. “Some include how these services are being reimbursed. Another concern is how medical board licensing allows or disallows practice within a region or across state lines. These challenges will need to be worked out and may require coordination between states in their legislation.”
Regardless of how these rules are standardized, teledermatology will be a large part of the telemedicine landscape, Dr. Oh added.
“Teledermatology used to be perceived as a relative niche novelty, but it is clearly going to be an increasing part of current routine care, and indeed is already integral to some practices and health systems,” he said.
On Twitter @legal_med
