Telehealth paves path for dermatologists during COVID-19
Dermatology practices required evolution and adaptation as the COVID-19 pandemic struck the United States. One of the ways the specialty has been able to continue serving patients was via implementation of comprehensive telemedicine programs.
Orit Markowitz, MD, associate professor of dermatology at the Icahn School of Medicine at Mount Sinai and director of pigmented lesions and skin cancer in the department of dermatology Faculty Practice at Mount Sinai, converted her practice to teledermatology as soon as New York went into confinement. While she still sees some urgent cases in the office, the vast majority have been remote visits.
Many patients are at too high a risk to go into a medical office, and there is a high rate of fear among patients in contracting COVID-19, she told Healio.
“We cannot have high-risk patients – and many skin cancer patients are high-risk – coming in without at least having a virtual screening,” she said. “We have to see what we can accomplish virtually before bringing them in ... so they don’t have to sit in the waiting area.”
Melanoma diagnosis, as well as the diagnosis of other skin cancers and skin afflictions, is achieved remotely with the help of home dermoscopy tools that can be attached to cell phones, full-body imaging taken by the patients themselves and a pigmented lesion assay.
There are challenges to providing excellent care in a virtual setting, including an increase in time spent with each patient.
Markowitz has experienced great success with at-home dermoscopy and imaging, but it includes a much longer process than a regular in-office dermatology visit.
“My procedure is a lengthy one. There’s a lot of handholding in terms of how to visualize things, using the proper lighting and patient preparation,” she said. “In the office, it is much more straight-forward, but if done correctly, it’s only a matter of additional time for the clinician and a lot of additional safety and advocacy for the patient.”
Each teledermatology appointment is preceded with a phone call in which the patient is instructed on how to take proper images and are given instructions and videos guiding them through the process. Those images are then transmitted via a HIPAA-compliant program for analysis by the provider. Only after these steps have been taken is there a virtual visit and then a plan for follow-up images or a pigmented lesion assay test, if needed.
“I need them to utilize the same kind of lighting that I use in my office, which is daylight,” Markowitz said. “This enables us to get a more accurate understanding between dermoscopy at home, very close-up detailed exams and then additionally this pigmented lesion assay test so I can really home in on which lesions need to be managed.”
Additionally, only about half of dermatologists use dermoscopy, so patients must ensure their provider is adept at the technology.
While there are some artificial intelligence programs and phone applications designed to detect skin cancer, Markowitz does not recommend patients use them, because they are not proven to be effective.
“In terms of dermatology, if people are thinking that AI is going to help in making a diagnosis, that would be a very large leap of faith,” she said. “You need a board-certified dermatologist who has the time and support and is specialized in the specific area where you need help.”
Management of some cases will require in-person visits for procedures and further testing. Patients diagnosed with melanoma, especially, will need to be brought into the office for surgery or other management, while other skin cancers may need confirmatory scans or laser treatments.
Using teledermatology allows clinicians to limit those visits to only the most urgent.
“You don’t want to have any missed melanoma, but you also don’t want to have any false positives and send patients in unnecessarily. [Teledermatology] enabled people to get the care they need at home and then come in for the very specific visit without a wait and with staff completely prepared, knowing exactly what they’re coming in for,” Markowtiz said.
Getting patients to accept telemehealth appointments can also be a challenge. While many are afraid of in-office visits, many others fear telehealth. And those fears lead to delays in treatment, which can ultimately lead to more severe problems and melanoma fatalities.
“I hope we empower people that they don’t have to be afraid,” Markowtiz said. “Do not be afraid. It’s ok to reach out, start with telehealth and see what the professional can and cannot do for you. At least you won’t be sitting home scared and pushing things off. This is how we’re going to save lives.”
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