The impact of store-and-forward teledermatology on skin cancer diagnosis and treatment

Background

Although the diagnostic accuracy of teledermatology has been extensively studied, the clinical outcomes associated with teledermatology are still unclear.

Objective

We examined the time intervals in which skin cancer patients referred conventionally or by store-and-forward teledermatology were evaluated, diagnosed, and treated.

Methods

A chart review was performed of all patients who had been treated for skin cancer in a Veterans Affairs medical center's dermatologic surgery clinics as a result of a conventional dermatology or teledermatology referral from 3 remote primary care clinics over a 4.5 year period.

Results

One hundred sixty-nine patient cases met the study criteria (45.6% conventional referrals, 54.4% teledermatology referrals). For conventional and teledermatology referrals, respectively, the overall mean time intervals for initial consult completion were 48 and 4 days (p < .0001), for biopsy were 57 and 38 days (p = .034), and for surgery were 125 and 104 days (p = .006). Teledermatology consults were also associated with fewer dermatology clinic visits before surgery (p = .02).

Limitations

This was a retrospective study conducted on a Veterans Affairs healthcare system and a specific skin cancer patient population, which may not be directly comparable to other organizations.

Conclusion

Clinical outcomes in skin cancer management via teledermatology, as measured by times to diagnosis and to surgical treatment, can be comparable to, if not better than, management by conventional referrals for remotely located patients.

Introduction

Access to dermatologic care is often limited and delayed, in part because of a scarcity of dermatologists in many geographic areas.¹ Teledermatology offers one approach to serve remotely located patients who do not have convenient direct access to a dermatologist.² With store-and-forward (S/F) teledermatology, a primary care provider (PCP) transmits still digital images of a patient's skin lesions with an accompanying consult request to a dermatologist at another location who asynchronously evaluates the information and then communicates recommendations on management to the PCP.

The diagnostic reliability and accuracy of S/F teledermatology have generally compared favorably to conventional clinic-based visits.3, 4 Other clinical end points have also been examined, including patient satisfaction,5, 6, 7, 8, 9, 10, 11 concordance in recommendations for management including biopsy,11, 12, 13, 14 and time to initial intervention.11, 15, 16, 17 Beyond these surrogate or intermediate end points, however, few studies have addressed whether S/F teledermatology in actual practice affects the ultimate clinical outcomes or resolution of a dermatologic problem, in part because of logistical problems in patient follow-up.¹⁸ A recent randomized prospective study reported that S/F teledermatology and conventional clinic consultation resulted in comparable clinical outcomes, although the reported results were not stratified for specific diagnoses or diagnostic categories, and outcomes were measured predominantly by a single rater subjectively evaluating the appearance of digital images of patients.¹⁹ Most recently, S/F teledermatology has been reported to be a preoperative planning tool that can shorten the waiting intervals to surgical treatment and avoid unnecessary dermatology clinic visits.²⁰ These studies are early steps in addressing a relative lack of research assessing definitive clinical outcomes.3, 4

Skin cancers are an important public health issue. Unlike measures for many skin disease outcomes that can be more complex, the time interval from consultation to surgery for a skin cancer is an objective and readily measured end point for measuring outcomes of skin cancer management. The time interval to surgery is also highly relevant since earlier treatment of skin cancers can potentially minimize morbidity from these malignancies.²¹ Although medical therapy for certain cutaneous malignancies is an option in some cases, surgical excision or destruction remains the most definitive and reliable therapy for all skin cancers. However, in actual clinical practice, the process of identifying and treating patients with skin cancer is complex, since it requires communication and coordinated encounters among patients, PCPs, evaluating dermatologists, and surgeons. The impact of teledermatology on this process is unclear.

The Veterans Affairs (VA) Medical Center at San Francisco is a referral site for VA community-based outpatient clinics in coastal Northern California, including Santa Rosa, Ukiah, and Eureka, located 60, 120, and 300 miles away, respectively. Although the bulk of dermatology providers practice at the medical center in San Francisco, a dermatology nurse practitioner at the Santa Rosa clinic serves many of the Santa Rosa and Ukiah patients 1.5 days each week. PCPs in Eureka as well as the dermatology nurse practitioner in Santa Rosa are capable of doing skin biopsies. In a conventional referral, a PCP completes a text-based electronic consult request and the clinic staff at either San Francisco or Santa Rosa schedules the patient for a dermatology clinic visit based on the stated urgency of the request (Fig 1).

San Francisco VA Medical Center began to offer S/F teledermatology consultations in 2003 as an alternative to conventional consultations for patients at the Eureka, Ukiah, and Santa Rosa clinics. The universal adoption of an electronic medical record system in the VA permits archiving and exchange of text and images among health providers at every VA facility. In addition to the electronic text-based consult request form, the PCP also submits digital images of the referred lesion(s). Upon receipt of the consult request, the teledermatology consultant reviews the images and any submitted clinical history and responds with a consult note that includes a diagnostic assessment and management recommendations. Recommendations may specify that the patient be entirely managed by the PCP, including performance of a biopsy, or that the patient be scheduled for a dermatology clinic visit for further evaluation and/or biopsy. Regardless of the type of consultation process, patients with skin cancers are scheduled at San Francisco VA Medical Center for surgical treatment or occasionally for excisional biopsy.

We retrospectively analyzed remotely located patients treated in the VA dermatologic surgery clinics to determine whether differences existed between patients referred via teledermatology and via conventional consultation. We observed that S/F teledermatology referrals were overall associated with both earlier diagnosis and surgical treatment of skin cancers in comparison with conventional clinic-based referrals for remotely located patients.