Transcript Distributed Specialty Care - The Skin Appearance Laboratory Brian

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 Assets
Clinic
1/2 day clinics/wk
pts/wk
wait
Buffalo
BCD*
NP
5
5
100
50
9 wks
4 wks
Bath
BCD
2
25
5 wks
Rochester
BCD*
1
40
7 wks
Canandaigua
BCD
1
15
5 wks
Syracuse**
NSMD
NP
5
1-2
50
15
4 wks
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
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
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:
Psoriasis
Seborrheic dermatitis
Rosacea
Stasis dermatitis
Hand eczema
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):
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.
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 68 weeks.
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.
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.
Clobetasol ointment bid for 4 weeks. Tell patient to avoid
irritants (e.g. frequent hand washing/chemicals/detergents).
Loprox bid for 6-8 weeks.
Dermatophyte infection
(tinea cruris, tinea pedis,
tinea corporis, tinea manum)
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
Oral antihistamines; consider prednisone taper (starting with 40(“hives”)
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
Ulcerated | multinodular | rapid growth
(< month)
w/i 2 weeks
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
Masking of signs by dark skin tones
(Types V-VI)
w/i 4 weeks
Non-Pigmented Lesion
No visible signs
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”)
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)
No treatment is necessary unless
clinically indicated.
Liquid nitrogen (requires less than what
a wart requires).
SURGERY or ENT
Treatment of genital warts
(female)
Topical medication renewal
Try podophyllin solution, liquid nitrogen,
or imiquimod cream.
Refer to Dermatology Note for any
restrictions on use
OB-GYN
SURGERY or ENT
N/A
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).
Dermatology Consult Template
• Mechanism on CPRS for entering a dermatology
consult request
• Represents a dermatology decision tree that
mirrors the service agreement
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?
N
Send to Skin Evaluation
Y
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