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A decade of telemedicine policy has advanced in just 2 weeks


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, Tex., or switch most patient consults to telemedicine, which he’d never used.

Dr. Seemal Desai is a dermatologist in private practice in Plano, Tex.

Dr. Seemal Desai

But as soon as he learned that telehealth regulations had been relaxed by the Centers for Medicare & Medicaid Services and that reimbursement had been broadened, Dr. Desai, a dermatologist in private practice and his staff began to mobilize.

“Kaboom! We made the decision to start doing it,” he said in an interview. “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 Dr. Desai, who is a member of the American Academy of Dermatology 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 Dr. 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.

Teledermatology innovators

“We’ve moved 10 years in telemedicine policy in 2 weeks,” said Karen Edison, MD, of the University of Missouri, Columbia. “The federal government has really loosened the reins.”

Dr. Karen Edison, dermatology department, University of Missouri, Columbia

Dr. Karen Edison

At least half of all dermatologists in the United States have adopted telehealth since the pandemic emerged, she estimated. And most, like Dr. 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 Dr. 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 said in an interview.

“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 Dr. 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 said in an interview. “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.


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