Creation of an Internal Teledermatology Store-and-Forward System in an Existing Electronic Health Record

Abstract

IMPORTANCE External store-and-forward (SAF) teledermatology systems operate separately from the primary health record and have many limitations, including care fragmentation, inadequate communication among clinicians, and privacy and security concerns, among others. Development of internal SAF workflows within existing electronic health records (EHRs) should be the standard for large health care organizations for delivering high-quality dermatologic care, improving access, and capturing other telemedicine benchmark data. Epic EHR software (Epic Systems Corporation) is currently one of the most widely used EHR system in the United States, and development of a successful SAF workflow within it is needed.OBJECTIVES To develop an SAF teledermatology workflow within the Epic system, the existing EHR system of Parkland Health and Hospital System (Dallas, Texas), assess its effectiveness in improving access to care, and validate its reliability; and to evaluate the system's ability to capture meaningful outcomes. DESIGN, SETTING, AND PARTICIPANTS Electronic consults were independently evaluated by 2 board-certified dermatologists, who provided diagnoses and treatment plans to primary care physicians (PCPs). Results were compared with in-person referrals from May to December 2013 from the same clinic (a community outpatient clinic in a safety-net public hospital system). Patients were those 18 years or older with dermatologic complaints who would have otherwise been referred to dermatology clinic. MAIN OUTCOMES AND MEASURESMedian time to evaluation; percentage of patients evaluated by a dermatologist through either teledermatology or in-person compared with the previous year.RESULTS Seventy-nine teledermatology consults were placed by 6 PCPs from an outpatient clinic between May and December 2014; 57 (74%) were female and their mean (SD) age was 47.0 (12.4) years. Teledermatology reduced median time to evaluation from 70.0 days (interquartile range [IQR], 33.25-83.0 days) to 0.5 days (IQR, 0.172-0.94 days) and median time to treatment from 73.5 to 3.0 days compared with in-person dermatology visits. Overall, a greater percentage of patients (120 of 144 [83.3%]) were evaluated by a dermatologist through either teledermatology or in-person during the 2014 study period compared with the previous year (111 of 173 [64.2%]). Primary care physicians followed management recommendations 93% of the time.CONCLUSIONS AND RELEVANCE Epic-based SAF teledermatology can improve access to dermatologic care in a public safety-net hospital setting. We hope that the system will serve as a model for other health care organizations wanting to create SAF teledermatology workflows within the Epic EHR system.

Utilization of Asynchronous and Synchronous Teledermatology in a Large Health Care System During the COVID-19 Pandemic

“…5 Asynchronous visits use store-and-forward technologies such as secure text, e-mail, or direct-to-physician electronic medical records. [6][7][8] Synchronous visits are performed using live, real-time, and collaborative telecommunications technology (audio and/or video) between the provider and the patient. 7,8 Hybridization is the use of asynchronous and synchronous modalities simultaneously.…”

“…7 Yet, both systems also have disadvantages such as privacy concerns, technological difficulties, and a lack of communication for asynchronous visits. 2,6 Limited data exist comparing the technologies and, as such, a consensus on patient and provider preference has not yet been reached. [9][10][11] In general, telehealth utilization by patients in a large commercially insured population in the United States averaged *6.6 telehealth visits per 1,000 patient-visits per year.…”

Implementation of Teledermatology: Theory and Practice

“…Concerns regarding privacy and security exist regarding how histories and images are sent, and if programs obtain patient consent [79,84,85]. These concerns are particularly relevant with the increased use of mobile phones [86] and direct-to-patient care [87].…”

A review of literature supporting the development of practice guidelines for teledermatology in Australia

“…Mobile phone applications are increasingly being used for SAF teledermatology . Secure email and integrated electronic medical records to share images between the referrer and provider are alternative methods of implementing SAF teledermatology. To facilitate SAF, the Guidelines describe minimum technical standards for clinical photography and dermoscopy.…”