The coronavirus pandemic forced the dermatology community to utilize telehealth platforms to provide care during the early stages of this health crisis. At the time, there was little guidance and a lack of essential protective gear to permit safe, in-person visits. Using FaceTime, WhatsApp, and specialized platforms such as Klara, we were able to communicate with our patients and preserve some aspects of a face-to-face visit. Despite sending video visit instructions and receiving time-intensive coaching from our staff, the pictures we received from our patients combined with the often times grainy video resolution during virtual visits made it very difficult to adequately visualize the areas in question. A complete skin examination is virtually impossible with our current cellular phones and computers. However, these visits permitted us to provide a rudimentary level of care that was essential for our patients.
The rapid availability of plastic partitions, protective gear, protocols for screening, temperature monitoring, enhanced air filtering, testing, universal in-practice masking, and education permitted my practice to resume a near-normal case load. My staff and I feel comfortable that we are providing the best and safest care under these circumstances. However, some patients prefer the convenience of a telehealth visit. Unfortunately, my experience with the available platforms put front and center the inadequacy of this type of visit. The most glaring problem is the poor visualization with these virtual visits. I work on most of my patients with loops, magnifiers, and dermatoscopes, performing a complete skin examination on all that are open to it at all new visits and most routine follow-up sessions. We simply cannot adequately visualize the skin in a practical manner with the telehealth tools at hand.
A complete skin examination is an essential part of our visit. It is nearly impossible to perform this type of evaluation over a cellular phone or with most computer cameras. How many basal cell carcinomas, squamous cell carcinomas, or melanomas will we miss with virtual visits? It is routine that all of us find these lesions often without our patients realizing that they have an issue! How many times during an in-person visit do we look at a specific lesion repeatedly or at different angles and perspectives to come to a determination and disposition on a specific growth? Is it right to pass on this type of visit for the convenience of a televisit?
This is not to say that there is absolutely no utility in dermatology for telehealth. Follow-up visits for our patients on isotretinoin have been helpful, particularly given the ability to utilize at-home pregnancy tests for our female patients during the pandemic and this patient population’s relative facility with technology. My nurse has also found success utilizing virtual visits for cosmetic and laser consultations. For potential cosmetic patients who live far from our clinic, this has proved helpful as it lowers the cost for initiating a visit to learn if particular treatments might be right for their concerns. However, even routine follow-up visits for our patients with psoriasis or atopic dermatitis are not as easy.
Our practice cares for a large number of individuals who are on biologics or immunosuppressive treatments for psoriasis, atopic dermatitis, or other significant dermatologic conditions. How does one accurately evaluate these individuals or generate a Psoriasis Area and Severity Index or Eczema Area and Severity Index score? Given that these scores are often required by many insurers for drug coverage and for certain dermatology-specific quality measures in Merit-based Incentive Payment System, we are jeopardizing both our patients’ ability to receive the medications they need and our ability to meet these quality measures for the Quality Payment Program. How well can we differentiate an eczematous dermatitis from psoriaform dermatitis with the images that we often obtain from a telehealth visit? How does one evaluate a person with a possible drug eruption without visualizing the entire patient or questioning while looking at different parts of the body?
Finally, how do we do biopsies, remove skin cancers, perform device treatments, do photodynamic therapy, freeze actinic keratosis, or even do clinical research without an in-person visit? A large percentage of my telehealth visits ultimately require an office visit to do these procedures, which could all have been done at one visit instead of two! We simply are at our best with an in-person office examination from a quality and efficiency perspective. Telehealth visits with the current technology available to most dermatology practices cannot measure up to our high standards for quality.
Dr Tanghetti is the medical director of Center for Dermatology and Laser Surgery in Sacramento, CA.
Disclosure: The author reports no relevant financial relationships.
