The Use of Non-Specialty Staff for Teledermatology in the Veterans Health Administration

1. 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

2. 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

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

4. 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

5. 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

6. VISN 2 Dermatology Assets Clinic1/2 day clinics/wkpts/wkwait Buffalo BCD* 5 100 9 wks NP 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 wks NP 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

7. The Model: >> Distributed Specialty Care << for Dermatology Primary Care | Skin Evaluation Clinic | Dermatologist

8. 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

9. DSC: the process Primary care (referring) provider Dermatology Service Agreement Consult request (Decision Tree) Dermatology consult response (acceptance of care, discharge) Non-specialist / Midlevel staff Skin Evaluation Clinic Encounter note: H+P, initial Dx and Tx Imaging (Rules of Engagement) Teledermatology consultant response (secondary diagnostics / Tx options) Teledermatology consultant

10. Dermatology Service Agreement • Establishes conditions that are appropriate for dermatology consultation • Suggests initial interventions for known dermatological diagnoses • Determines urgency of consultation

11. 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).

12. Part A:

13. Part B:

14. Part C:

15. Discharge from Clinic Criteria 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).

16. Dermatology Consult Template • Mechanism on CPRS for entering a dermatology consult request • Represents a dermatology decision tree that mirrors the service agreement

17. Decision Tree for Dermatologic Diseases Patient with Skin Problem Presents to PCP Q1: Is it emergent? Y N Send to ED Q2: Is it a known Dx? Y N Q3: Is it appropriate for dermatology? Send to Skin Evaluation N Y Send to Other Service / Off Service Q4: Is it treatable? Y N Send to Skin Evaluation Q5: Is it responsive? Y N Discharge or maintenance (patient remains with PCP) Send to Skin Evaluation

18. 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

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

20. 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

21. 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)

22. 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

23. 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

24. Stage I: online by Jan 2007 VISN2 Teledermatology Initiative Stage II: proposed