Transcript Slide 1
Distributed Specialty Care
a telemedicine model for delivery of
dermatology specialty care in VISN 2
Craig C. Miller, MD, PhD
Brian C. Madden, PhD
13 November 2006
Overview
Why?
Imbalance between supply of dermatology
specialists and demand for treatment of skin
diseases in VISN 2
How?
Distributed Specialty Care model
• Three-tiered system for delivery of skin care
• Primary care provider
• Skin Evaluation Clinic
• Teledermatology consultant
Shortage of dermatology
assets in VISN 2
Dermatology demand
Over 12,000 patient visits per year
Requirement to provide veterans with “specialty care”
Time constraints: 30-30-20 rule
Dermatology supply
Limited VA staff dermatologists
• Disconnect between VA and civilian sectors
• Non-priority
Lack of acceptable non-VA care
• Limited availability--unacceptable delays
• Expensive
VISN2 Dermatology Assets
DSC model: goals
Allows for more efficient utilization of
dermatology specialty assets
Maintains high quality of care for skin
related disease
• Timely
• Efficacious
DSC model: key features
Store-forward technology
Skin Evaluation Clinic
Trained non-specialist skin care providers
Intermediaries between primary care and the
specialist
Performance measures
Dynamic adaptive system
Continuous enhancement
Telemedicine methodology
Real-time
Video with synchronous (“face-to-face”) patientconsultant encounters
• Low resolution, high bandwidth
• Inefficient utilization of consultant
Store-forward
Still images with asynchronous patient-consultant
encounters
• High resolution, low bandwidth
• Efficient utilization of consultant
• Dependent upon skills of non-specialist
• Obtain proper history
• Decide on what is “image worthy”
• Self-initiate therapeutics and/or diagnostic procedures
DSC: Three-tier delivery system
Primary Care Provider
Service Agreement
Skin Evaluation Clinic
Rules of Engagement
Teledermatology
Consultant
Tier 1: Primary care provider
Identify patient with skin complaint
Utilize Skin Evaluation consult
menu to direct patient care
Initiate consultation with Skin
Evaluation Clinic (when
appropriate)
Skin Evaluation consult menu
Decision Tree for managing patients with skin dz
Service Agreement
Determines appropriateness of consultation
Directs patient flow
Directs initial therapeutic approach for established skin
diseases
Prioritizes unknown skin conditions
Suggests alternative approaches for skin disorders that are not
referable to SEC
Skin Evaluation consult request form
Asks for reason for consult and whether patient has been seen
previously in SEC
Dermatology Decision Tree: an algorithm for skin dz patient flow
Disease Decision Tree for Dermatology
P atient with Skin Problem
P resents t o P CP
Q1: Is it emergent?
N
Y
Send t o ED
Q2: Is it a known Dx?
Y
N
Q3: Is it appropriat e
for dermatology?
Send t o Skin Evaluation
N
Y
Send t o Other
Service / Off Service
Q4: Is it treatable?
Y
N
Send t o Skin Evaluation
Q5: Is it responsive?
N
Send t o Skin Evaluation
Y
Discharge or maintenance
(patient remains with P CP )
Components of Service
Agreement
Part A
Part B
Known conditions and treatments
Priorities of unknowns and areas of concern
Part C
Uncovered items (limited resources)
APPEND IX 1:
PCP/SEC Se rvice Agre e me nt Ğ Protocol for Sche dulingConsults
Will accept referrals to the teledermatology service for some known conditions of the skin that
have failed treatment attempts (see part A) and conditions of the skin with uncertain diagnoses
(see part B) but w ill not accept referral s for som e otherskin conditions (see part C).
(A) Will accept referrals for
the following known conditions Treatment needed prior to consultation:
only after initialtherapy has
fai led:
Psoriasis
Trunk/extremi ties: fluocinonide ointment qhs and calcipotriene
ointment qam for 8 weeks.
Body fol ds: cal cipotriene oi ntment and desonide ointment +/ketoconazole cream bid for 8 weeks.
Seborrheic dermatitis
Scalp: cal cipotriene scalp solution qam, betamethsone valerate
foam qhs for 8 weeks.
Scalp: ketoconazole shampoo 2-3 times a week; beta methsone
valerate foam qhs prn itching for 6-8 weeks.
Face/ears/chest: ketoconazole and desonide creams bid for 6-8
weeks.
Rosacea
Stasi s dermatitis
Hand eczema
Dermatophyte infection (tinea
cruris, tinea pedis, tinea
corpori s, tinea manum)
Acne
Acute (< 6 wks) urticaria
(Òhi
vesÓ)
Ini tiall y trymetronidazole cream bidto 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 bidfor
8 weeks.
Leg elevation, compressi on stockings (20 mm Hg/below the knee-make sure there is no lower extremi ty 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.
For mild acne, use a topical anti
bioticsuch as clindamycin solution
qam and a topic al retinoid such as tretinoin 0.025% cream qhs for
6-8 weeks.
For more severe inflam matory acne, use the above topicals in
addition to an 8 week course of an oral anti bioti c such as
tetracycline 500 m g PO bid,doxycycline 100 m g PO bid, or
minocycline 100 m g PO bid.
Oral antihistamines; consider prednisone taper (starting with 40-60
mg qam and tapering over 2 wks); identifyand mit igate underly ing
eti ology (e.g., drugs, infection, foods)
Warts (non-genital)
Genital warts (m ale)
(B) Will accept referrals for
unknown conditions with the
fol lowing signs or symptom s:
Ini tiall y tr
eat with topic al sali cylic acid plaster for 8 weeks and/or
liquid nitrogen for 3 treatments, 4 weeks apart.
Podophyllin solution M-W-F for 4 wks, cryotherapy (li quid nitrogen)
or imiquimod cream M-W-F for 4 wks.
Details:
SEC appointment priority:
Blistering | purpuric < 10% BSA and
non-syst em i c
Blistering | purpuric > 10% BSA or
system i c
Other
Any
+ABCD | ulcerated
Other
Ulcerated | m ultinodular | rapid
growth (< month)
Other
Pruritus / Dysesthesia
Deep derm al orsub-cutaneous
nodules with no overlying change
Maski ng of signs by dark skin tones
(Types V-VI)
w/i 24-48 hours
(C) Will not accept referrals
for:
Suggesti ons:
Consider referral to:
Rem oval of skin tags
Lim i ted liquid nitrogen (try Òfr
eeze
clampÓtechnique - dip needle holder
in liquid nitrogen and then pinch skin
tags until rozen
f
down to the base).
Consider no treatment given the cost,
potenti alside effects of oral therapy,
and high rate of recurrence.
No treatment is necessary unless
clinically indicated.
Liquid nitrogen (requires less than
what a wart requires).
SURGERY/ENT /OPHT HO
Acute Rash
Chronic Rash
Pigmented Lesion
Non-Pigmented Lesion
No visible signs
Toenail onych om ycosis
(fungal nail )
Rem oval of benign
melanocyticnevi (ÒmolesÓ)
Rem oval of seborrheic
keratoses (we will treat an
irri tated/i nfl amed lesion that is
causing the patient discomfort;
please do not refer patients for
purely cosm eti c reasons)
Treatment of genital warts
T ry podophyllin soluti on,liquid
(fem ale)
nitrogen, or imiquimod cream .
Topical medication renewal
Refer to Derm atology Note for any
restrictions on use
send to ED prom ptly
w/i
w/i
w/i
w/i
w/i
1 week
4 weeks
1 week
4 weeks
2 weeks
w/i 4 weeks
w/i 4 weeks
w/i 4 weeks
w/i 4 weeks
PODIATRY
SURGERY or ENT
SURGERY or ENT
OB-GYN
N/A
Tier 2: Skin Evaluation Clinic
Evaluate patient
Initiate treatment or perform diagnostic tests
Acquire images according to
the “rules of engagement”
Enter teledermatology consult
(when appropriate)
Skin evaluation clinic providers
Various backgrounds
Nurse practitioners/Physician assistants
Dermatology residents
Primary care physicians
Training
Training in dermatology clinic
• Approach to the dermatology patient
• Rudimentary dermatology differential diagnosis
• Introduction to dermatology therapeutics
Hands-on training in techniques
• Biopsy--shave, punch
• Cryotherapy
• Electrodessication and curettage
Hands-on training in image acquisition
Access to dermatology educational resources
Feedback
Rules of Engagement
Initial consult that specifically refers to evaluation of a lesion for suspected
malignancy
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
Any patient that requires a biopsy
Any patient that will be started on systemic
medications that require monitoring
Patch test evaluation
The Camera
8 MP SLR camera
Macro lens
Macro flash
Back-up available
Technical support
The Canon EOS Digital Rebel with the Canon EF 100mm
f/2.8 USM Macro Lens and Canon Macro Twin Lite
Image acquisition/capture
Image acquisition
Patient ID
Contextual (anatomic context)
Morphological (diagnostic
close-up)
Image capture
Client software/access
Card reader
Image quality
Literature
Standards for image resolution/color
supports the validity of teledermatology in diagnosis of skin
lesions
DSC standards >> American Academy of Dermatology and the
American Telemedicine Association
Future DICOM standard
Techniques to ensure image quality
Standard and simple image acquisition process
Calibration for “true” colors
Training
Feedback
Validation
Tier 3: Teledermatology consultant
Review SEC note
View images
VistA Image Display
Document
Emphasis on history
Link to Teledermatology consultation
Template
Code
DSC: Three-tier delivery system
Primary Care Provider
Service Agreement
Skin Evaluation Clinic
Rules of Engagement
Teledermatology
Consultant
Performance
Training
Basic dermatology therapeutics/procedures
Image acquisition
Resources
• Reference materials
• Continuing education
Validation
Diagnostic accuracy
• JCAHO requirement
Business plan
• Cost effective
• Healthcare product of sufficient quality
• Patient satisfaction
• Morbidity/mortality statistics
DSC: Strategy for success
Personnel
Performance
Process
Primary care provider (PCP)
Skin evaluation clinic non-specialist provider
Teledermatology consultant
VISN2 Telemedicine consultant
Patient management via CPRS
Image acquisition
Store-forward teledermatology
Coding
Performance
Training
Resources
Validation
Personnel
Process
VISN2 Teledermatology Initiative