Over 140 years ago, The Lancet published an article that discussed conducting doctor’s appointments over a telephone call to reduce the number of unnecessary office visits.1 The idea of remote care was novel given the newness of telephone system in the mid-1800s, but the concept really took off with the technological advances made in the 20th century.
In 2002, the American Academy of Dermatology issued a position statement on teledermatology.2 This statement, most recently amended in March 2016, classifies teledermatology into two specific delivery platforms: live interactive and store-and-forward. Each category is relatively self-explanatory; live interactive teledermatology involves a real-time video conference whereas store-and-forward collects a dermatologic history and set of images for later review. Both methods are growing in popularity at multiple levels, including direct-to-consumer and provider-to-provider models.3
Direct-to-consumer services such as Curology and Apostrophe are trying to revolutionize, and in ways completely replace, the need for in-person visits to the dermatologist. With these subscription-based services, patients submit various photos through a web-based platform for evaluation by a board-certified dermatologist, who then prescribes a personalized treatment to target concerns such as acne, scarring, and wrinkles.4,5 These services claim to help reduce costs, travel, and patient anxiety—so does teledermatology have a role with patients with chronic and more severe skin diseases?
“I think the climate has finally arrived where everybody is comfortable with the technology and the value proposition of telemedicine,” said Jonathan Cotliar, MD, chief medical officer at Science 37 in Los Angeles, CA. His company aims to make virtual clinical research, and ultimately patient care, more accessible through telemedicine.
A partnership between Science 37 and the Keck School of Medicine of the University of Southern California (USC) in Los Angeles seeks to determine how telemedicine can deliver care equivalent to in-person visits for patients with atopic dermatitis (AD). This particular study received a $3.4 million grant from the National Institutes of Health (NIH), making it the largest teledermatology study ever funded by the NIH.6 According to the press release, the study will evaluate telemedicine as a method of delivery care for more than 300 patients with AD.6 It builds upon years of previous research that finds teledermatology can be used to provide accurate diagnoses in various practice settings,7-10 and optimism is high that the future results will indicate a special role for teledermatology in the management of chronic skin diseases.
Partnering Over Quality of Care
“Dermatology is a fitting field for telemedicine. With a qualified provider such as board-certified dermatologists, teledermatology has the potential to provide high-quality care and supplement in-person care. This particular study builds upon a prior pilot study,11” said April Armstrong, MD, MPH, associate dean for clinical research and professor of dermatology at the Keck School of Medicine and the study’s principal investigator. Dr Armstrong also sees patients as a dermatologist with Keck Medicine of USC. “This new study looks at a larger number of patients, but we’re also using validated outcomes, so we have confidence in the data with regards to whether the patients are going to be equivalent in terms of their disease outcome and quality of life.”
She emphasized the research firm’s capabilities as a large draw for the partnership. “Science 37 is very innovative in their approach to research. When I was looking at the different telehealth platforms, I found that Science 37’s philosophy of ‘clinical trials that can be done anywhere’ aligned really well with our motivation for the study,” she said.
“Dr Armstrong has been very progressive and one of the loudest voices within the academic dermatology community about empowering patients,” said Dr Cotliar. “She has previously completed work looking at psoriasis outcomes in patients who have had either online support or telemedicine as the basis of their care.7 This particular study was a natural extension of that work that’s she’s done.” Dr Cotliar continued to explain that Dr Armstrong’s previous work made the collaboration with Science 37 a natural fit as the organization attempts to democratize clinical participation in research.
Dr Armstrong expressed similar sentiments. “When we think of patient-centered care, we really put our action where our words are. Many patients with chronic skin diseases are constrained geographically or by poor transportation, restricting their access to quality medical care. We want to ensure that patients, regardless of their geography and access to transportation, receive the same exceptional care as someone who has access to a highly-specialized academic medical center.”
The overall study design, noted Dr Armstrong, has a few different components as part of its validated outcomes. The study will analyze disease severity of AD in addition to effect on patient quality of life. Cost will be considered as well. “Ultimately,” said Dr Armstrong, “the motivation for the study design came from really thinking about patient-centered care. Specifically, for children and adults with eczema, how we can minimize their need to take time away from school and work to obtain specialist care? Telemedicine allows patients to spend less time inside health care facilities while enabling them to receive the same quality of care. In addition, for dermatologists, teledermatology provides them the flexibility to render their expertise from anywhere and at any time. The study also looks like costs associated with telemedicine versus in-person care. This is an important aspect of the study because we need to understand the economic sustainability of such an online model.”
Dr Cotliar further elaborated on overall care for patients with AD. In recent years, clinicians have learned that the care and management of eczema is best provided by a multidisciplinary team. Besides the dermatologist, eczema should be managed concomitantly with primary care physicians, sleep specialists, psychologists or psychiatrists, and other specialties. “We’re learning about quality of sleep in adults with eczema, cardiovascular outcomes, and risk of infection—all the things we used to not necessarily consider holistically when we were treating eczema patients are now, based on what we know in the literature, so important to address,” said Dr Cotliar.
Technology in Action
This latest research study on teledermatology for the management of AD uses a proprietary platform that completely enables virtual research in the patient’s home. The Network Oriented Research Assistant (NORA) is a comprehensive tool that operationalizes a virtual study by streamlining data collection.
“NORA has a variety of modules that allow for the execution of clinical research in patients’ homes, with everything from a consent module to a video module that allows us to engage with patients in their homes, in times such as when a mobile nurse or a mobile phlebotomist is visiting, so we can oversee all the activities that are going on during a particular study visit,” said Dr Cotliar. He also explained that NORA can integrate a variety of different biowearbles and sensors into its platform as well as house all of the source documents vital to any clinical research study.
