Fewer doctors, more cameras to spur teledermatology

By Jonah Comstock
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Medical peripherals can combine with a smartphone to create the function of an ultrasound machine, an EKG reader, or an otoscope, to name just a few diagnostic devices. But without buying anything extra, nearly every consumer mobile device has a camera of some sort built-in. That means that when it comes to dermatology, most patients have, right in their pockets, the tools to gather much of the data their doctor needs to treat them.

Teledermatology was a major topic at the American Telemedicine Association conference in Austin, Texas, in particular the "store and forward" kind, which is teledermatology where patients take pictures and send them to their dermatologist, who sends a treatment plan back -- rather than conducting the examination in realtime. Just as the country is experiencing a dermatologist shortage, sufficiently high quality cameras are becoming widespread enough to support remote skin care.

At ATA, a number of direct-to-consumer teledermatology providers spoke about their different approaches to teledermatology. Mark Seraly represented DermatologistOnCall, an online platform that connects patients to dermatologists, David J. Wong spoke on behalf of Direct Dermatology, an online dermatology practice, and Ryan Hambley talked about startup YoDerm which hones in on diagnosis, treatment and prescription for acne specifically. Jeff Benobio, a Kaiser Permanente dermatologist, rounded out the panel, but as an integrated healthcare system Kaiser Permanente's stood out as the only one who wasn't thinking in terms of D2C.

"Dermatology is all about what it looks like," said Seraly, noting that most of a dermatologist's early training is making diagnoses from photographs. "Every dermatologist, I am confident, when they leave their training they are already naturally trained teledermatologists."

The presenters agreed that patients' cameras are good diagnostic tools.

"We've been surprised, we've been amazed that patients send good, high-quality photos. Patients know that if it looks bad to them, it's not going to look any better to me, as a dermatologist," said Wong. He added that there are limits to teledermatology, and that they will send patients to in-person specialists for certain procedures like a full body skin check, but that's a minority of cases.

With a shortage of dermatologists nationwide that's projected to worsen, teledermatology allows existing doctors to see more patients.

"Access is a huge problem," said Wong. "Delayed diagnosis in melanoma is something we see all the time, because they can't get in to see us. We have a great opportunity to really define the ways and best practices to provide this care."

Services like Wong's Direct Dermatology give patients detailed instructions to photograph their skin complaints. The doctor can study the securely forwarded photograph before visiting with the patient remotely. Depending on what state they're based in, teledermatologists can prescribe most medications (Hambley said the only acne medications his dermatologists don't prescribe are isotretinoin and birth control). Visits actually last longer than many in-person dermatology check-ups, and they produce a record future complaints can be compared against -- something that doesn't always happen in the clinic.

One problem with online dermatology is that it represents a change to how people think of consuming healthcare. Seraly, Wong, and Hambleys' services are entirely online, and they rely on patients thinking to look online for their dermatology care in the first place.

"One of the big issues for us is educating the market," Hambley said. "There arent very many people out there searching the internet for these telemedicine services. For services like YoDerm, that's definitely a big barrier." YoDerm charges patients $59 per visit and doesn't accept any insurance. Accepting insurance can be a tricky proposition for teledermatologists -- according to Dr. Marc Goldyne, a UCSF Medical Center dermatologist who also spoke at the conference, store and forward is only explicitly covered by insurance in seven states.

Anna Orlowski, a lawyer who spoke on another panel at ATA, said that so far there have been no reported cases of a malpractice lawsuit related to teledermatology specifically, and the liability for a teledermatologist is likely low, since the law considers dermatology to be a low-risk specialty. Nonetheless, YoDerm provides malpractice insurance as part of its compensation of independently contracted dermatologists.

Benabio of Kaiser Permanente represents an alternate model for teledermatology, one tied to a more comprehensive health system. Benabio shared how "store and forward" telemedicine works in context at Kaiser Permanente.

"So [a primary care doctor] has a patient who comes into his office with rashes," he said. "He tries all the regular stuff, he's getting nowhere. So he takes a picture, sends it to me, I can look at it, say 'Duh, it's pityriasis rosea,' you knew that. The value proposition is: I just took a regular primary care doctor and made him into a 'Super Doc'."

But Benabio thinks startups like Direct Dermatology, DermatologistOnCall, and YoDerm have a big role to play in keeping patients with easily treatable skin conditions out of the larger healthcare system in the first place, and reducing the burden on dermatologists in the system.

"One of the biggest challenges is for healthcare to get the hell out of the way and let these entrepreneurs solve this," he said.

Each of the startups on the panel used technology and photographs as an intermediary for trained dermatologists. But a number of app startups like Skin Scan and Mole Detective, arguably take remote diagnosis of skin conditions one step further, by using an algorithm to give users feedback on whether a skin lesion might necessitate a visit to the doctor or not. These controversial consumer apps were the subject of some debate at the recent congressional hearings on mobile health regulation.

Until those apps have been clinically proven and FDA cleared, teledermatology remains a much safer proposition.