Teledermatology Best Practices

Peter A. Lio, MD, shares what dermatologists need to know about telehealth and atopic dermatitis, including how to handle special situations and whether telemedicine is right for every patient with eczema.

Dr Lio is clinical assistant professor of dermatology and pediatrics at Feinberg School of Medicine at Northwestern University in Chicago, IL. He is a member of the Clinical Advisory Committee of the National Eczema Association.

Transcript
Dr Lio: There are a couple of different ways that we can do telemedicine, and the two major divisions—the division between the two—is synchronous, meaning at the same time. That's like a Zoom meeting, where you're talking live video. The other side is asynchronous, meaning not at the same time. That would be typically done as a store-and-forward type setup. The patient would take some photographs, maybe fill out some information, send that to you. Then, when you get the chance, you go through it all, write your response, and send it back to the patient.

There we pluses and minuses to each. My personal view is that the store-and-forward can be extremely efficient for small problems. If it's, for example, just mild atopic derm, because you could spend some time. You could have some templates ready, get a lot of information. You also get high-quality photos, ideally, which is great.

The negatives are sometimes you don't get good photos or good information, and you can't clarify. If they send you a bunch of blurry pictures really close up to somebody's face, and they don't tell a very good story, then you're like, "Well, I can't help you very much." Plus, there's no chance for follow-up. Maybe you think you're writing. As a clinician, I think I'm doing a good job, but the patient doesn't understand it or doesn't agree. Now, they can't interact very easily. Those are the pluses and minuses of asynchronous.

Of synchronous, the biggest plus is that it's just like a clinic visit. There's back and forth. You can say, "Hey, move up, move down. I can't see it. Show me from another angle." You have a back and forth when you do the plan and everything, which is great, too. The biggest negative is that there are minimal time savings. It's basically a visit, and sometimes, even harder. There are certain situations where I'm like, "Gosh, I wish you could just be here, because then I could hand you something," or, "I could see something better."

Or sometimes, if we have to do a procedure, if I need to do a biopsy, or I also would love sometimes to have one of my staff help me out. Maybe we want to go through their plan and not have to physically do every last part of the visit, which is good for me, because I feel like I learn a lot, and I hear every little piece.

On the other hand, it's probably not the most efficient use of everybody's time, because I could say, "I'm going to let my nurse or my assistant go through some of this, and I'll come back to answer questions." That's a little bit more efficient. These are the pluses and minuses of them both. I think that it is right for a lot of patients, and many patients do really enjoy it. I think you save so much time getting ready for your visit, traveling to your visit. I used to always think, when I was at the hospital, the main...Now, I'm in a smaller office. It's easier to access, but at the main hospital, it was such a pain in the butt. People drive in, sometimes 15, 20, 30, 40 minutes away or more, if they're coming from another state, 2 hours.

They get to the hospital, but they're nowhere near me yet. They have to go through the parking structure. That could add another 10 minutes, 15 minutes. Then when you're in the hospital, you're still not there. You've got to go across the bridge, up the floor, up the second elevator, and then the annex building. I kid you not, it could be another 20 minutes to get to the doctor's office, even once you're arrived.

There are a lot of things that are just simplified. The other thing that's really neat with tele is many times people don't remember their medicine names. They'll tell me, "I'm just using some white cream in a jar." I'm like, "That's everything I write. That's my whole. Which one?" They don't know. At home, I'll be like, "Go ahead, I'll wait." They can run over to the vanity, grab it, and show me. That is actually really powerful.

I think, for those things, it's great. You're right, for new patients, sometimes it is stressful, because you don't get to have the same rapport with somebody. It's much harder over video to connect. I think, for looking at the whole body, it can be more difficult, especially if the technology is not up to snuff. Bad lighting, bad camera.

I also think that, again, some disease are going to require a little bit closer inspection or procedures. Biopsies, injections, wraps, all of these kinds of things. I can't touch. I will say that I lose some of my senses, because I actually can sometimes smell staph infection in patients in real life. I obviously can't do it on video, so I lose some of my abilities. I think that it's probably best for more moderate, like mild or moderate issues in general. It's probably best for more therapeutic discussion, rather than primary diagnosis.

Diagnostic mysteries, I really don't want a video visit first. If it's somebody who has known atopic dermatitis, and they're looking for some new treatments, that's perfect. I think it's really good for follow-up visits in general. Once we establish that rapport, get the work done we need to get, it can be a very powerful tool for those follow-up visits, especially when things are going well. Everybody's so happy for a quick visit. People are like, "I'm great. I know it's only been five minutes, but I don't need you. I just wanted to check in." I'm like, "I love you. This is perfect." That's a great visit, and they didn't have to drive 2 hours and park to do that.