Teledermatology and Quality: Friend or Foe?
By Joseph C. Kvedar, MD, Vice President, Connected Health, Partners HealthCare, Professor of Dermatology, Harvard Medical School
Digital health technologies can help bridge the gap between the growing number of patients and the shrinking number of healthcare providers. Yet, for teledermatology, there are a number of challenges and opportunities in the adoption of tools like direct-to-consumer (DTC) websites and mobile apps for treating skin disease.
Smartphones, sensors, health trackers and other digital health devices monitor everything from daily step count to blood pressure and sleep patterns. We call this the ‘consumerization of healthcare,’ as individuals have come to expect the same ‘always on, always available’ convenience and service from their healthcare providers as they do for online banking, travel planning and shopping.
For dermatologists, these digital health tools can capture images that allow for the accurate diagnosis of skin disorders from the convenience of an individual’s home and can help to improve clinical outcomes and patient satisfaction. DTC teledermatology could conceivably reduce costs and achieve equal or better quality of care for patients, without them having to leave their home. However, there are still questions around the diagnostic accuracy of teledermatology, especially in the context of a newly formed doctor-patient relationship.
Let’s explore this further:
Most health care requires authentic relationships.
It seems safe to conclude that the possibility of fraud in an online relationship is much higher than in person. Most clinicians feel that forming a relationship with their patients is a core part of providing quality healthcare. Until this authentication challenge is solved, it’s hard to imagine many healthcare interactions with new patients being conducted in an online environment. Videoconferencing certainly adds a great deal of value beyond text-based interactions, but video technology does not offer sufficient resolution for most dermatologic diagnoses, necessitating an added layer of complexity (still images). For this reason, most teledermatology systems do not include video interactions.
How do we define quality care in this new environment?
The idea of allowing patients to upload images of body moles or facial acne for evaluation by providers they have never met gives many of my colleagues great consternation. My colleagues fret that a patient will send them an image of a mole that is benign but ignores a mole that is an incipient melanoma. To me, this seems less onerous than the authentication issue, as patients are capable of managing their own risks when these risks are spelled out.
"DTC teledermatology could conceivably reduce costs and achieve equal or better quality of care for patients, without them having to leave their home. However, there are still questions around the diagnostic accuracy of teledermatology"
A closely related fear or objection is one of physician liability. In this context, the doctor is not only afraid they will provide substandard care by not doing a complete physical exam but that they may be held liable for that omission.
Once again, spelling out that a patient is taking accountability for those aspects of his care not addressed in an online interaction seems reasonable to me. I think the liability concerns are overstated.
Is the technology up to the task at hand?
In the late 1990s, we (and many others) did painstaking clinical studies to empirically test whether a set of digital images is of sufficient quality to be a diagnostic tool in lieu of an in-person exam. There now exists a body of literature that demonstrates this equivalency, with the possible exception of some pigmented lesions. We also carefully examined the feasibility that patients could take their own, clinically accurate, facial images of acne. Are there other examples? Mental health providers routinely care for new patients and conduct follow up visits using video conferencing technology. There are probably a few other examples as well.
To provide a quality care experience online without having met the patient in person, I contend that the following criteria would need to be met:
1. Limit the interactions to problems that have a diagnostic data set that can be easily and reliably acquired by a consumer/patient.
2. Assure that the patient is capable of understanding that the online interaction is problem specific and may carry risks, particularly for the omission of care involving other health problems.
3. Assure that the treatment decisions for the specific condition at hand are algorithmic and do not require an authentic relationship (i.e., the problem is transactional or of low emotional value to both provider and patient).
There are some things to work out, but there is good to be had by encouraging the thoughtful growth of teledermatology. For example, we need more patient-focused regulation and further study. We should also determine which symptoms are properly suited to online diagnosis versus the need for in-person care. The American Telemedicine Association (ATA) offers an accreditation process for DTC telemedicine. This is an important start, but probably not enough.