Confronting Issues and Challenges Beneath the Surface: Technology and Data Analytics
Telehealth and Eczema, featuring Peter Lio, MD, FAAD
Teledermatology Pros, Cons, and Best Practices
There are two general methods that we can use to complete a telemedicine visit. The first is synchronous, meaning at the same time or “live,” over a phone or video conference. The other is asynchronous, meaning not at the same time. Asynchronous typically uses a store-and-forward setup, in which the patient or their caregiver sends some photographs and information to the dermatologist who then can go through the notes, write a response, and send it back to the patient.
There are pluses and minuses to each method. My personal view is that store-and-forward telemedicine can be extremely efficient for less urgent problems, such as a mild flare of atopic dermatitis (AD). This method allows you to often get a higher quality image rather than video, and it also allows you to develop some response templates to have at the ready based on the patient’s care plan. However, the negative side is that sometimes the photographs or information from the patient are not clear. Because one cannot ask clarification or follow up questions at the moment, there can be a delay and a more protracted back and forth between patient and provider. There is also the potential for misunderstandings; we as clinicians may think our responses are easy to follow, but the patient may not understand our care plan instructions.
For synchronous telehealth, the biggest plus is that it is just like a clinic visit. There is real-time communication and we can tell the patient if they need to adjust their camera or show their AD lesion with more light on it. We can have that back-and-forth conversation and really understand how the disease is impacting their skin, well-being, and/or family. The biggest negative is minimal time savings, at least on the provider side. Since it is basically like a visit, it still requires scheduled time to be set aside specifically for the conversation. Additionally, there are times when the provider or the patient may find the virtual visit frustrating, because we cannot pass along product samples or take a biopsy if necessary.
Overall, though, I think that teledermatology is right for a lot of patients, and many patients do really enjoy it. Patients save the time spent getting ready for and traveling to a visit. While we may have only 15 minutes scheduled for an individual appointment, the patient may have 3 hours blocked off: 1 hour to drive to a hospital or clinic, 10 minutes to find parking, 10 minutes to get through the building security and elevator, 10 minutes to check into their appointment, their actual appointment, and then 1 hour drive home. Offering telehealth helps simplify this process for the patient, especially if their AD is well-controlled.
Another thing that is great about teledermatology is that many times our patients do not remember the names of their medications or products. I will have patients tell me, “I’m just using the white cream in a jar”—well, that is practically everything I write! If they are at home on a synchronous visit, I can ask them to run to their vanity and grab the product they are describing. That flexibility can be powerful for guiding our shared decision-making conversation.
An important thing to remember with telehealth is that it is not appropriate for every patient with AD. For new patients, it can be difficult to develop that rapport with them over video. Additionally, if someone seems to be having severe, widespread eczema, we would want to see that person in the office to evaluate their disease. We also do lose our ability to use other senses, such touch or smell. Patients who are great candidates for telemedicine are those with mild to moderate AD and those whose appointment is for an ongoing therapeutic discussion. Once we establish that rapport, telemedicine can be a very powerful tool for those follow-up visits, especially when things are going well. Everybody is so happy for an efficient visit.
Preparing Patients for a Virtual Visit
If you do have more of a diagnostic situation, there are a few tips you should share with your patients to help the virtual visit be more productive for both of you.
The first is that for many diseases in dermatology—and this may sound a little controversial, but it is really true—I do not need to see that much. Sometimes, patients will send me two dozen photographs. I almost never need all of those images, because so much of their burden depends on the overall impact on their life. That being said, for a new problem, especially one that does not yet have a firm diagnosis, patients should be encouraged to send a handful high-quality photographs before the telehealth visit.
Patients should also be encouraged to use a room that is quiet, well-lit, and ready with the proper equipment (eg, internet access, a laptop or phone). They should try to test that equipment beforehand to see if they have any issues that might need assistance.
I also ask patients to write down their questions and have them ready to go. I want them to feel good about the visit, too, so it is helpful if they can check off a list to make sure all their concerns about their skin are addressed.
If there are things we cannot get to in the virtual appointment, then the National Eczema Association (NEA) is an amazing resource to share with patients and families. There is the entire stack of information, from the most basic information all the way up to the experts sharing ideas and talking on the NEA website. Many sites on the Internet offer advice, but I want to connect my patients with the right resources in between their virtual and in-person visits. For many of my patients, they and their families have heard so many opinions and stories and have become disheartened, so having access to a reputable source and using telehealth for follow-up is key. We can use telehealth to continue our relationship, try new therapies, and take care of their skin needs in what I like to call the therapeutic alliance: working together to get better.
Technology and Data Analytics, featuring Raj Chovatiya, MD, PhD
Patient-Reported Outcomes to Support AD Care
AD is associated with heterogeneity across a number of different clinical domains. As dermatologists, our forte is describing skin findings. While that can be helpful, it does not capture the complete impact of AD. For instance, not everyone has a large body surface area or actively inflamed, oozing lesions – things that are easy to spot as a dermatologist. However, a patient might have severe disease measured by other metrics: number of comorbidities, symptomatic burden, or quality of life burden. Patients can have impairment in any of these areas, but none of these are immediately clear by just doing a physical exam. Unless we ask about these domains, we are not going to find out about them, despite being an integral part of the disease process.
Patient-reported outcome (PRO) measures are standardized tools that you can use to get patient-oriented health information in a systematic, formal way. It allows you to better characterize disease state and track changes and responses to therapy over time. I explain them to my patients or colleagues as another version of vital signs, except instead of blood pressure we are tracking symptoms and traits that are associated with the disease process. I am a big proponent of these tools; I think that they can actually save you time and allow you to direct your conversation to what is most important to the patient.
Implementation of PRO measures is another growing area of research. We are in the early stages of beginning to understand how to use these PROs in routine clinical care. Each clinic is unique and has differing ability to administer these measures, and I recommend to start small with simple, one-question measures at every visit. With AD patients, oftentimes with active disease, we see the patient every few months; if it is less active disease, we may see them every 6 months or once a year. All of those are reasonable intervals to use PROs.
One important question to ask is patient-reported global severity. Essentially, ask the patient and/or their caregiver “How severe do you think your disease is?” Studies have shown that this correlates well to what you see upon examination in clinic. Simple, one-question, numerical rating scale (NRS) questions designed to rate symptom severity also work well to track how the patient feels. If you can implement more specific measures that delve deeper into symptoms, that is even better, but even just using a few NRS questions can help guide discussion for the patient’s care plan.
Another important question to ask is the patient’s global impression of change. Do they think they have had a major improvement, a minor improvement, or no improvement, or are things getting worse? This information can be helpful when you want to assess treatment progress, and it takes only seconds. Depending on how much time you have, there are slightly longer questionnaires, including the Dermatology Life Quality Index, the Patient-Oriented Eczema Measure, or the Patient-Reported Outcomes Measurement Information System measures.
Something that gets lost is a more formalized approach to comorbidities. If there is not an in-depth review of systems, revealing details can be missed. For example, I ask patients about any difficulty swallowing. This could lead to diagnosis of eosinophilic esophagitis, which we know is increased in patients with AD. Additionally, I recommend questions to better understand the long-term course of AD, including how often the patient is flaring, what the disease course looks like over time, and periods of remission.
Lastly, I think we are making big headway with wearable health technology. This is an area we are going to explore more deeply in the future to understand how this continuous data coincides with PRO measures and how we can use both together. For example, there has been a lot of interesting work in trying to develop sensors related to sleep and scratching. It remains to be seen exactly how these will be implemented into routine care, but I think we are going to learn how these technologies play a part in AD care over the next decade.
Future of Data in Care
here are many outstanding questions that we have regarding care in AD, dermatology, and medicine in general. A few that come to mind include: how do we improve longitudinal care?; how do we limit unnecessary ambulatory visits?; and How do we target care for those who need to be seen more acutely and/or in person? Some of these questions came to light during the ongoing pandemic in terms of how we allocate resources control costs. This is where I think that PROs, clinician severity measures, and other analytics hold great promise.
If we can collect this kind of information in a routine fashion from our patients, the same way that we have been conditioned to think about pulse, blood pressure, and temperature, we are going to be able to track symptoms, disease course, and responses to therapy over the long-term.
These data can guide how we schedule our appointments - for instance when we know that a patient has severe flares only during one time of the year. It allows for differential focus of care, vs. somebody who is fairly clear throughout the year, vs. someone who is severe year-round. Data allows us to better dictate follow-ups, so our patients are not coming in any more or less than necessary. We could have automated prompts for care based on the data we add to the patient’s an electronic health record (EHR). The EHR could help ensure that no patient falls through the cracks and help us follow up with any patient who gets flagged because of their more acute disease.
Other specialties have embraced the use of PROs and shown that it is possible to design predictive models that allow patients to understand, based on their baseline factors, how a certain treatment or intervention may impact them in the long run. A great example is orthopedic surgery. They have adopted PROs like the PROMIS measures for joint replacement, and they have been able to track long-term outcomes and give patients better understanding of how their function or symptoms might be impacted by a particular procedure.
I think this is where the opportunity lies for us in dermatology, and this is why I am really excited about how we are going to incorporate PROs into our care. Given how many new AD treatments are on the horizon, with many more in the pipeline, we all think about how to match the right treatment with the right patient and provide the most accurate estimate of disease course, response, and side effects. Important elements of any AD treatment or care algorithm will include the clinical domains previously discussed: comorbidities, symptoms, burden, and so on. We can then use those patient-focused symptoms and clinician-focused examination/severity scores alongside basic demographic factors to give patients a better idea of where their care is headed.
One of the things that can be frustrating as a clinician is the lack of a streamlined measurement system for AD severity, particularly in the case of moderate-to-severe AD, when prescribing a new therapy. Some insurers might focus on failed therapies, whereas others focus on body surface area, and others still may focus on lesion severity as defined by the clinician. All miss a more holistic approach to understanding overall disease, meaning that there are AD patients not getting the adequate therapy that they need.
This is an opportunity for us to introduce standardized data, so we are all speaking the same language – an understanding what severity looks like in terms of itch, skin pain, clinical scores, comorbidities, and previous responses to treatment. We already have an EHR system where this could be built in, and no matter the direction we pursue, there should be a universal approach where we all look at the same thing and speak the same language, rather than doing something different for every single patient. We have many tools in place, but the challenge is now going to be how do we leverage those tools, get the electronic data we need, and streamline the process so it is less of a burden for clinicians, patient, and payers across the board.
