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Research Highlight

Evaluating Mobile Teledermatology to Enhance Veterans' Access to Skin Care

Expert skin care from board-certified dermatologists is a limited resource in VA. Veterans can experience long waits for a new or follow-up appointment in a VA dermatology clinic for which they may travel long distances, particularly if they reside in rural areas. To improve access to dermatologic care, VA has developed a national store-and-forward telehealth (SFT) teledermatology program, overseen by the Office of Connected Care (OCC). SFT teledermatology is usually consultative, allowing a primary care provider (PCP) to order a teledermatology imaging consult that is processed by a trained imager at the primary care clinic; the imager manually transfers history from the PCP along with captured digital skin images to a new teledermatology reading consult request for review by a remotely located dermatologist, all via VA’s electronic health record (EHR). In the EHR, the dermatologist provides a diagnostic impression and management recommendations to the PCP, who is then responsible for implementing them.

VA’s teledermatology program has proven successful in those facilities that have adopted it. ¹ However, for all of teledermatology’s growth and clear benefits for increasing access to expert dermatologic care in VA, adoption of consultative SFT teledermatology in VA has been uneven. One barrier to adoption may be that teledermatology workflow depends on primary care clinics where the process can disrupt workflow and increase workload for primary care staff, thus discouraging adoption.

Mobile Teledermatology App Solutions

To address this barrier and thus broaden teledermatology usage in VA, OCC has developed two mobile apps. The first, VA Telederm, is designed to replicate and interchangeably interact with the existing consultative teledermatology workflow in the current EHR so that PCPs and imagers can use either the app or the EHR to initiate and process teledermatology consults. Importantly, VA Telederm streamlines the existing process. Rather than requiring an imager to manually transfer the PCP’s clinical history to the imager’s consult request to the dermatology reader, VA Telederm does so automatically. The app also enables imagers to capture images with the mobile device’s camera, and directly upload them to the EHR, thus eliminating the current requirements of uploading images at VA workstations and then deleting images from the camera afterward. As a result, this app both enhances patient privacy and the fidelity of clinical history transfer, and reduces the primary care staff’s work in submitting teledermatology consults.

The second app, My VA Images, is a patient-facing app which allows established dermatology clinic patients to follow-up with their dermatologists remotely using their own mobile devices. OCC has designed My VA Images to interact with Patient Viewer, an app available for VA clinicians to manage patient care. By reducing the need for some patients to follow-up in person, this direct-to-patient teledermatology pathway minimizes the travel time and distance required for Veterans to obtain skin care, and may further improve timeliness and reliability of their follow-ups. Secondary benefits may include increased access to in-person dermatology clinics as appointment slots formerly used for these types of patients are freed.

Testing the Promise of Mobile Teledermatology

Although the emergence of mobile teledermatology capability in VA is an exciting development, it is important to validate its promise and to identify areas for improvement. With the recent signing of the 2018 MISSION Act into law, the need to collect metrics demonstrating reach and effectiveness of  telehealth has gained further visibility. The Act broadly attempts to address the issue of Veterans’ access to care in multiple areas. Importantly for the operation of VA telehealth and telemedicine, the Act affirms VA’s ability to deliver care by telehealth across state lines. The Act also requires VA to report on the effectiveness of telemedicine, including Veterans’ and VA providers’ satisfaction with telemedicine, as well as telemedicine’s impact on access to health care, productivity, wait times, usage, in-person clinics, and cost savings. The law’s reporting requirements signal both a new level of recognition of telehealth as well as a future where telehealth will be held accountable to demonstrate concrete outcomes for its stakeholders.

The Health Services Research and Development (HSR&D) study, “Teledermatology mobile apps: implementation and impact on Veterans’ access to dermatology,” is one attempt to measure both process and outcomes rigorously for one particular telehealth initiative. The intent is to validate VA’s mobile teledermatology apps’ effectiveness in improving access to care. This study may also yield valuable lessons to optimize implementation of other mobile telehealth initiatives. The work has been a partnership between OCC and a research team comprised of VA investigators at San Francisco and Providence, and HSR&D’s Durham and Boston Centers of Innovation.

To assess implementation, the research team planned a formative evaluation across three pilot sites, including both interview-based data gathering and online questionnaires to assess Organizational Readiness for Change,² the implementation process, and sustainability. Research on interventions dependent on leading-edge technology can be challenged by technical difficulties; this has proven true in this study. VA Telederm was the first app to enter field testing, but the app was not functional at two of three pilot sites for technical reasons, which limited the formative evaluation. Ultimately, technical issues outside the control of the research team and operational partner have postponed the study of this app. The apps used for the patient-facing process are emerging from development only recently after delays and are anticipated to commence field testing and formative evaluation soon.

To rigorously assess the impact of these teledermatology apps on various measures of access such as consult completion times and distance traveled, the research team is planning a randomized national study of the apps. Several operational considerations affected the research design. First, because use of mobile devices is not yet common in VA health care and because the patient-facing pathway is novel to VA, concern existed that simultaneous release of these apps to all intervention sites might prove challenging for OCC and for many facilities to implement. Second, as noted above, considerable heterogeneity exists since some VA facilities are extremely active adopters of teledermatology, while others are not.

Consequently, the research team has designed a stepped-wedge cluster-randomized trial to permit sequential release of the apps to groups of 7 facilities every 3 months, with sites awaiting intervention serving as controls.³ OCC will introduce VA Telederm to facilities where teledermatology constitutes between 0 to 9 percent of total dermatology encounters, whereas My VA Images will be introduced to facilities where teledermatology is ≥9 percent of all dermatology encounters. The research will evaluate multiple measures of access to achieve a comprehensive and accurate evaluation of each app’s impact. These measures include consult and appointment completion times, the number of teledermatology encounters, the percentage of dermatology encounters using each app, and the nominal travel distance avoided. Unique to the My VA Images app, outcome measures will also include the proportion of new patient visits in a dermatology clinic, the timeliness of patient follow-up, and the no-show rate.

At present there is a dearth of systematic studies, particularly randomized clinical trials that measure and validate the worth of digital telehealth technology. The VA Teledermatology Mobile App study, due to its size and rigor, has the potential to make an important early contribution to the teledermatology and telehealth literature, and may serve as a model for future studies assessing outcomes and implementation of mobile telehealth.

References

1. Landow SM, Oh DH, Weinstock MA. “Teledermatology within the Veterans Health Administration, 2002-2014.” Telemedicine Journal and E-Health 2015 Oct; 21(10):769-3.
2. Weiner BJ. “A Theory of Organizational Readiness for Change,” Implementation Science 2009 Oct 19; 4:67.
3. Done N, et al. “VA Telederm Study: Protocol for a Stepped-Wedge Cluster Randomised Trial to Compare Access to Care for a Mobile App Versus a Workstation-based Store-and-Forward Teledermatology Process,” BMJ Open 2018 Dec 14;8(12).