Telemedicine Project Connects Primary Care Docs, Patients With Dermatologists

In the past, when family physician Positron Kebebew M.D., M.P.H., needed to send patients from her federally qualified health center in Santa Monica, Calif., to a dermatologist, her only option was to refer them to the county hospital, where a patient with a potentially serious condition could face a wait of nine months or more for an appointment.

Today, Kebebew's Westside Family Health Center is one of 26 clinics in six states benefitting from a telemedicine pilot program that links primary care physicians and their patients with local dermatology specialists. The project, funded by the American Academy of Dermatology, or AAD, has resulted in 450 consults since its inception last fall.

"Most of our patients are uninsured and low income, so we have a lot of problems getting specialty care," Kebebew said. "This is one way we can do that in a timely manner. We get readings back in four business days."

Kebebew said that since she joined the pilot in February, her clinic has referred 40 cases to a county-affiliated dermatologist. Three of those cases required in-person visits for skin malignancy and complex skin disorders.

"Teledermatology has been beneficial for our clinic because we do not have any specialty care," she said. "The system is quick and easy to use: You take a picture of the skin lesion, answer prompted questions, and send."

Each participating clinic receives a cell phone loaded with telemedicine software. A primary care physician seeking a consultation is prompted by the application to answer a series of questions, and the patient's history is sent along with a photo of the patient's condition -- taken with the patient's permission -- to a local dermatologist via a specific Web portal.

The dermatologist responds with a diagnosis and a treatment plan at no cost. Kebebew said that if the dermatologist thinks the condition warrants further specialty care, the patient gets an appointment within 10 days.

The project started in September 2010 with a small pilot in Philadelphia before expanding to other states. The pilot will be expanding again in the near future, thanks to additional funding from the AAD. Primary care physicians interesting in participating can e-mail Scott Weinberg at the AAD.

Carrie Kovarik, M.D., assistant professor of dermatology and infectious diseases at the University of Pennsylvania, Philadelphia, and co-chair of the AAD's ad hoc task force on teledermatology for underserved communities, said participating dermatologists are partnering with local primary care clinics that treat uninsured and underinsured patients.

"Oakland's children's hospital, for example, is one of our sites, and they see predominantly Medicaid patients," said Kovarik. "Getting in to see a dermatologist with Medicaid is very difficult. We're trying to first help people with limited to no coverage. We can only scale up so quickly. People in rural areas, homebound patients and elderly patients would be our next goal."

Kovarik is one of 15 dermatologists who are volunteering their services for the project. Although live video telemedicine is widely reimbursed, Kovarik said the type of store-and-forward telemedicine being used in the pilot is reimbursed in only a few states.

"What we'd like to do is use evidence from this program to help convince CMS to reimburse for this type of service," she said. "In Pennsylvania, we can't get reimbursed for store-and-forward telemedicine whether it's done on a phone or a computer. Only live telemedicine has the potential of being reimbursed.

"We'd like to show this is a cost-saving approach to reaching not only patients who can't pay much, but people in rural areas and doing hospital consults in community hospitals where dermatologists aren't likely to go."

Family physician and pilot participant Adrienne Trustman, M.D., who practices in a community health center in San Francisco, recommended the program to other primary care physicians.

"Patients are getting input from a dermatologist a lot faster," said Trustman, who has referred 20 patients in three months since joining the project. "It normally would take about six months to get them into San Francisco General. For me, it's been a great service."

Trustman also said she has learned from the dermatologist's recommendations.

"It's changed my practice," she said. "It's changed my first-choice treatment for some things and given me a more firm follow-up for something I think is a benign skin lesion."

According to Kebebew, the program has been beneficial for midlevel providers in her practice, as well. "They don't have a lot of dermatology training," she said. "They're getting training as we go along, and it makes them better clinicians. It's kind of a learning process."

Kovarik said most of the consults fall into two categories. One is odd rashes family physicians aren't likely to see as often as dermatologists. "Some things are more easily recognizable for us because we see them a lot," she said, "and we can help with diagnoses or treatment options."

The other common scenario, said Kovarik, is that a primary care physician has made a diagnosis and offered a first-line treatment, but the patient didn't respond to therapy. "At that point, they want help because they're questioning whether their diagnosis is correct or they're struggling with what they should try next," she said. "A lot of family docs are good at diagnosing general conditions and treating them with general things, but when that doesn't work, that's when you might want another opinion."

Despite the success of the pilot, which Kovarik said works well for disorders such as eczema, psoriasis and other inflammatory conditions, she agreed with a recent study (abstract) in the Archives of Dermatology that concluded teledermatology is not an adequate substitute for total body examination when dealing with suspected malignancies.

"Telemedicine is much better for rashes rather than, 'Look at this mole,'" she said. "It's not a good way to do a skin cancer screening, where you really have to look at the patient from head to toe, looking at each of their lesions with your handheld microscope lens.

"When a primary care physician says, 'That mole looks funny. I'm going to take a picture of that,' they're self-selecting the one they think looks funny when it would be better for the patient to have all of them looked at. The pictures of single lesions are harder to interpret than rashes in general."