The Use of Non-Specialty Staff for Teledermatology in the

Veterans Health Administration

Brian C. Madden, Ph.D.

Craig C. Miller, M.D., Ph.D.

13 November 2006

Abstract• A chronic shortage exists in the personnel required to deliver

specialty care services in the Veterans Health Administration. The need is especially acute in dermatology. Telemedicine offers an opportunity to address this problem by allowing scarce services to be projected over the large, rural regions that characterize much of the VHA’s domain.

• A new system of care delivery is proposed – Distributed Specialty Care – that attempts to overcome organizational and statutory impediments through the improved incorporation of primary care physicians and midlevel personnel (nurse practitioners and physicians assistants).

• Implementation Issues: Training, Support, Image Quality, Organization, Statutes and Standards

Mission

• To provide dermatology care of the highest quality in a timely and efficient manner to the veterans of Upstate New York (VISN 2)

Goals

• To address the lack of specialty (dermatology) care at remote clinics in which specialists are not routinely available

• To provide for contingency care in clinics normally staffed by a specialist in which the specialist is temporarily physically unavailable

VISN 2 Dermatology: Current Status

• Limited number of service sites– long trips for patients

• inconvenience• cancellations

– increased costs

• Long wait times– “Care delayed is care denied”– does not meet VA standards for the “30/30/20” rule

VISN 2 Dermatology AssetsClinic 1/2 day clinics/wk pts/wk wait

Buffalo BCD* 5 100 9 wksNP 5 50 4 wks

Bath BCD 2 25 5 wks

Rochester BCD* 1 40 7 wks

Canandaigua BCD 1 15 5 wks

Syracuse** NSMD 5 50 4 wksNP 1-2 15 7 wks

Albany BCD 4 50 6 wks

BCD=board certified dermatologist; NP=nurse practitioner; NSMD=non-specialist MD*: resident clinic**: Skin Evaluation Clinic

The Model:

>> Distributed Specialty Care <<

for Dermatology

Primary Care | Skin Evaluation Clinic | Dermatologist

DSC: components• Non-specialist providers

– Nurse practitioners– Physician assistants– Non-specialist physicians (includes dermatology residents)

• Training– Basic dermatology therapeutics / procedures– Image acquisition– Feedback

• Technology– Camera– Image data manipulation / storage

• Support– Reference materials– Technical assistance

DSC: the process

Non-specialist / Midlevel staffSkin Evaluation Clinic

Teledermatology consultant

Dermatology Service AgreementConsult request (Decision Tree)

Encounter note: H+P, initial Dx and Tx Imaging (Rules of Engagement)

Primary care (referring) provider

Teledermatology consultant response(secondary diagnostics / Tx options)

Dermatology consult response(acceptance of care, discharge)

Dermatology Service Agreement

• Establishes conditions that are appropriate for dermatology consultation

• Suggests initial interventions for known dermatological diagnoses

• Determines urgency of consultation

Skin Evaluation Clinic Service Protocol for Scheduling Consults

Will accept referrals to the teledermatology service for some know 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).

Part A:(A) Will accept referrals for the following known conditions only after initial therapy has failed:

Treatment required prior to consultation (note: conditions marked with an asterisk should be addressed only after the provider has obtained the necessary training and equipment to properly diagnose and treat):

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: calcipotriene scalp solution qam, betamethsone valerate foam qhs for 8 weeks.

Seborrheic dermatitis Scalp: ketoconazole shampoo 2-3 times a week; betamethsone 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, tetracycline 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 topical 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.

Pruritis Amminium lactate moisturizer 12% lotion, qd, and antihistamine prn; if condition persists more than 6-8 wks refer to SEC; always consider causes such as cholestasis, renal failure, thyroid disorder.

Acute (< 6 wks) urticaria (“hives”)

Oral antihistamines; consider prednisone taper (starting with 40-60 mg qam and tapering over 2 wks); identify and mitigate underlying etiology, always consider infection neoplasia, connective tissue disease, food, drugs;

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.

Part B:

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

Details: Teledermatology

appointment priority:

Acute Rash Blistering | purpuric < 10% BSA and non-systemic

w/i 24-48 hours

Blistering | purpuric > 10% BSA or systemic

send to ED promptly

Other w/i 1 week

Chronic Rash Any w/i 4 weeks

Pigmented Lesion +ABCD | ulcerated w/i 1 week

Other w/i 4 weeks

Non-Pigmented Lesion Ulcerated | multinodular | rapid growth(< month)

w/i 2 weeks

Other w/i 4 weeks

No visible signs Pruritus / Dysesthesia w/i 4 weeks

Deep dermal or sub-cutaneous nodules with no overlying change

w/i 4 weeks

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

w/i 4 weeks

Part C:

(C) Will not accept referrals for: Suggestions: Consider referral to:

Removal of skin tags Limited liquid nitrogen (try “freeze clamp” technique - dip needle holder in liquid nitrogen and then pinch skin tags until frozen 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.

PODIATRY

Removal of benign melanocytic nevi (“moles”)

No treatment is necessary unless 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

 Non-malignant condition of the skin that is stable or improved and can be followed by primary care for follow-up. Patients with documented cutaneous malignancy or who are at risk for malignancy (h/o multiple dysplastic nevi, strong family h/o melanoma, multiple actinic keratoses (especially if immunocompromised)) will be retained in Skin Evaluation Clinic for regular evaluative follow-up examinations at appropriate intervals (at 3 to 12 mo).

Discharge from Clinic Criteria

Dermatology Consult Template

• Mechanism on CPRS for entering a dermatology consult request

• Represents a dermatology decision tree that mirrors the service agreement

N Y

N Y

N Y

N Y

N Y

Patient with Skin ProblemPresents to PCP

Q1: Is it emergent?

Decision Tree for Dermatologic Diseases

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)

Skin Evaluation Clinic Visit• Skin-focused H+P

• Diagnostic procedures and therapeutics– can be initiated during initial visit prior to

Teledermatology consultant response

• Encounter note – standard SOAP format– documented in CPRS– identify Teledermatology consultant as co-signer

• Imaging– according to the Rules of Engagement

Imaging

• Determine need for imaging (imaging criteria)

• Obtain witnessed consent (iMed)

• Obtain series of digital images- Patient ID image- Contextual image (anatomic context)- Morphological image (close-up photo

provide diagnostic features)

• Attach images to the CPRS note through VistA Image Capture client

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

Rules of Engagement

Teledermatology imaging criteria:

• 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

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

• Any patient that requires a biopsy

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

• Patch test evaluation

Image acquisition/capture

• Image acquisition – the camera platform– configured to minimize artifacts due to color shifts

and motion/focus blur

– exceeds resolution standards set by the American Academy of Dermatology

• Image capture – attaching to CPRS– capture software/card reader

– image size management• compression (contextual)• cropping (morphological)

Teledermatology consultant response

• Timing– Store and forward (vs. real time)

• maximizes efficient use of the specialist (the limiting factor) and the teledermatology non-specialist provider

– 48 hour turnaround for consult response

• CPRS documentation– addendum to the note

• identify teledermatology provider as an additional signer

– recommendations• Confirm / alter / expand differential diagnosis• offer additional diagnostic / treatment options

Issues• Credentialing

– Teledermatology non-specialist providers must have privileges stating their proficiency in dermatology procedures (shave and punch biopsy, cryotherapy, electrodessication and curettage)

– Teledermatology consultant must be credentialed at the site of the patient encounter

• Standardization– Teledermatology imaging and display falls under no uniform set of standards

• image quality / white balance / color management• formatting / compression• displays

• Validation– Diagnostic accuracy– Business plan

• cost effective• healthcare product of sufficient quality

– patient satisfaction– morbidity / mortality statistics

VISN2 Teledermatology Initiative

Stage I: online by Jan 2007

Stage II: proposed