Distributed Specialty Care

a telemedicine model for delivery of dermatology specialty care in VISN 2

Craig C. Miller, MD, PhD

Brian C. Madden, PhD

13 November 2006

Overview Why?

Imbalance between supply of dermatology specialists and demand for treatment of skin diseases in VISN 2

How? Distributed Specialty Care model

• Three-tiered system for delivery of skin care• Primary care provider• Skin Evaluation Clinic• Teledermatology consultant

Shortage of dermatology assets in VISN 2

Dermatology demand Over 12,000 patient visits per year Requirement to provide veterans with “specialty care” Time constraints: 30-30-20 rule

Dermatology supply Limited VA staff dermatologists

• Disconnect between VA and civilian sectors• Non-priority

Lack of acceptable non-VA care• Limited availability--unacceptable delays• Expensive

VISN2 Dermatology Assets

DSC model: goals

Allows for more efficient utilization of dermatology specialty assets

Maintains high quality of care for skin related disease

• Timely• Efficacious

DSC model: key features

Store-forward technology

Skin Evaluation Clinic Trained non-specialist skin care providers Intermediaries between primary care and the

specialist

Performance measures Dynamic adaptive system Continuous enhancement

Telemedicine methodology Real-time

Video with synchronous (“face-to-face”) patient-consultant encounters

• Low resolution, high bandwidth• Inefficient utilization of consultant

Store-forward Still images with asynchronous patient-consultant encounters

• High resolution, low bandwidth• Efficient utilization of consultant• Dependent upon skills of non-specialist

• Obtain proper history• Decide on what is “image worthy”• Self-initiate therapeutics and/or diagnostic procedures

DSC: Three-tier delivery system

Primary Care Provider

Skin Evaluation Clinic

TeledermatologyConsultant

Service Agreement

Rules of Engagement

Tier 1: Primary care provider Identify patient with skin complaint

Utilize Skin Evaluation consult menu to direct patient care

Initiate consultation with Skin Evaluation Clinic (when appropriate)

Skin Evaluation consult menu Decision Tree for managing patients with skin dz

Determines appropriateness of consultation Directs patient flow

Service Agreement Directs initial therapeutic approach for established skin diseases Prioritizes unknown skin conditions Suggests alternative approaches for skin disorders that are not

referable to SEC

Skin Evaluation consult request form Asks for reason for consult and whether patient has been seen

previously in SEC

Dermatology Decision Tree: an algorithm for skin dz patient flow

N Y

N Y

N Y

N Y

N Y

Patient with Skin Problem Presents to PCP

Q1: Is it emergent?

Disease Decision Tree for Dermatology

Q2: Is it a known Dx? Send to ED

Q3: Is it appropriate for dermatology?

Q4: Is it treatable?

Q5: Is it responsive?

Send to Skin Evaluation

Send to Skin Evaluation

Send to Skin Evaluation

Send to Other Service / Off Service

Discharge or maintenance (patient remains with PCP)

Components of Service Agreement

Part A Known conditions and treatments

Part B Priorities of unknowns and areas of concern

Part C Uncovered items (limited resources)

APPENDIX 1: PCP/SEC Service Agreement Ğ Protocol for Scheduling Consults

Will accept referrals to the teledermatology service for some known conditions of the skin that have failed treatment attempts (see part A) and conditions of the skin with uncertain diagnoses (see part B) but will not accept referrals for some other skin conditions (see part C). (A) Will accept referrals for the fol lowing known conditions only after initial therapy has failed:

Treatment needed prior to consultation:

Psoriasis Trunk/extremities: fluocinonide ointment qhs and calcipotriene ointment qam for 8 weeks. Body folds: calcipotriene ointment and desonide ointment +/- ketoconazole cream bid for 8 weeks. Scalp: calcipot riene scalp solution qam, betamethsone valerate foam qhs for 8 weeks.

Seborrheic dermatitis Scalp: ketoconazole shampoo 2-3 times a week; bet amethsone valerate foam qhs prn itching for 6-8 weeks. Face/ears/chest : ketoconazole and desonide creams bid for 6-8 weeks.

Rosacea Initially try metronidazole cream bid to face for 6-8 weeks; if no improvement, try clindamycin 1% solution or sulfacetamide/sulfur lotion bid or, for more severe cases, tetracycl ine 500 mg PO bid for 8 weeks.

Stasis dermatitis Leg elevation, compression stockings (20 mm Hg/below the knee--make sure there is no lower extremity arterial disease), and triamcinolone 0.1% ointment qhs for 6-8 weeks; if ulcers are present, try silvadene cream; if no improvement, refer to Vascular/Wound Care Clinic.

Hand eczema Clobetasol ointment bid for 4 weeks. Tell patient to avoid irritants (e.g. frequent hand washing/chemicals/detergents).

Dermatophyte infection (tinea cruris, tinea pedis, tinea corporis, tinea manum)

Loprox bid for 6-8 weeks.

Acne For mild acne, use a t opical antibiotic such as clindamycin solution qam and a topical retinoid such as tretinoin 0.025% cream qhs for 6-8 weeks. For more severe inflammatory acne, use the above topicals in addition to an 8 week course of an oral antibiotic such as tetracycline 500 mg PO bid, doxycycline 100 mg PO bid, or minocycline 100 mg PO bid.

Acute (< 6 wks) urticaria (ÒhivesÓ)

Oral antihistamines; consider prednisone taper (starting with 40-60 mg qam and tapering over 2 wks); identify and mitigate underlying etiology (e.g., drugs, infection, foods)

Warts (non-genital) Initially treat with topical salicylic acid plaster for 8 weeks and/or liquid nitrogen for 3 treatments, 4 weeks apart.

Genital warts (male) Podophyllin solution M-W-F for 4 wks, cryotherapy (liquid nitrogen) or imiquimod cream M-W-F for 4 wks.

(B) Will accept referrals for unknown conditions with the following signs or symptoms:

Details:

SEC appointment priority:

Blistering | purpuric < 10% BSA and non-systemic

w/i 24-48 hours

Blistering | purpuric > 10% BSA or systemic

send to ED promptly

Acute Rash

Other w/i 1 week Chronic Rash Any w/i 4 weeks

+ABCD | ulcerated w/i 1 week Pigmented Lesion Other w/i 4 weeks Ulcerated | multinodular | rapid growth (< month)

w/i 2 weeks Non-Pigmented Les ion

Other w/i 4 weeks Pruritus / Dysesthesia w/i 4 weeks Deep dermal or sub-cutaneous nodules with no overlying change

w/i 4 weeks No visible signs

Masking of signs by dark skin tones (Types V-VI)

w/i 4 weeks

(C) Will not accept referrals for:

Suggestions:

Consider referral to:

Removal of skin tags Limited liquid nitrogen (try Òfreeze clampÓ technique - dip needle holder in liquid nitrogen and then pinch skin tags until f rozen down to the base).

SURGERY/ENT/OPHTHO

Toenail onychomycosis (fungal nail)

Consider no treatment given the cost, potential side effects of oral therapy, and high rate of recurrence.

PODIAT RY

Removal of benign melanocytic nevi (ÒmolesÓ)

No treatment is necessary un less clinically indicated.

SURGERY or ENT

Removal of seborrheic keratoses (we will treat an irritated/inflamed lesion that is causing the patient discomfort; please do not refer patients for purely cosmetic reasons)

Liquid nitrogen (requires less than what a wart requires).

SURGERY or ENT

Treatment of genital warts (female)

Try podophyllin solution, liquid nitrogen, or imiquimod cream.

OB-GYN

Topical medication renewal Refer to Dermatology Note for any restrictions on use

N/A

Tier 2: Skin Evaluation Clinic Evaluate patient

Initiate treatment or perform diagnostic tests

Acquire images according to the “rules of engagement”

Enter teledermatology consult(when appropriate)

Skin evaluation clinic providers Various backgrounds

Nurse practitioners/Physician assistants Dermatology residents Primary care physicians

Training Training in dermatology clinic

• Approach to the dermatology patient• Rudimentary dermatology differential diagnosis• Introduction to dermatology therapeutics

Hands-on training in techniques• Biopsy--shave, punch• Cryotherapy• Electrodessication and curettage

Hands-on training in image acquisition Access to dermatology educational resources Feedback

Rules of Engagement

Initial consult that specifically refers to evaluation of a lesion for suspected malignancy

Any patient in which there is a question as to the diagnosis that may affect treatment approach such that the consequence of proceeding along one of alternative lines of therapy could result in a delay in appropriate and prognostically significant care

Any patient that requires a biopsy

Any patient that will be started on systemic medications that require monitoring

Patch test evaluation

The Camera

8 MP SLR camera Macro lens Macro flash Back-up available Technical support

The Canon EOS Digital Rebel with the Canon EF 100mm f/2.8 USM Macro Lens and Canon Macro Twin Lite

Image acquisition/capture

Image acquisition Patient ID Contextual (anatomic context) Morphological (diagnostic

close-up)

Image capture Client software/access Card reader

Image quality Literature

supports the validity of teledermatology in diagnosis of skin lesions

Standards for image resolution/color DSC standards >> American Academy of Dermatology and the

American Telemedicine Association Future DICOM standard

Techniques to ensure image quality Standard and simple image acquisition process Calibration for “true” colors Training Feedback Validation

Tier 3: Teledermatology consultant Review SEC note

Emphasis on history

View images VistA Image Display

Document Link to Teledermatology consultation Template

Code

DSC: Three-tier delivery system

Primary Care Provider

Skin Evaluation Clinic

TeledermatologyConsultant

Service Agreement

Rules of Engagement

Performance Training

Basic dermatology therapeutics/procedures Image acquisition Resources

• Reference materials• Continuing education

Validation Diagnostic accuracy

• JCAHO requirement Business plan

• Cost effective• Healthcare product of sufficient quality

• Patient satisfaction• Morbidity/mortality statistics

DSC: Strategy for success Personnel

Primary care provider (PCP) Skin evaluation clinic non-specialist provider Teledermatology consultant VISN2 Telemedicine consultant

Process Patient management via CPRS Image acquisition Store-forward teledermatology Coding

Performance Training Resources Validation

Performance

Personnel Process

VISN2 Teledermatology Initiative