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Where is telemedicine headed?

The medication that Alanna Mills, 48, of Swartz Creek, Michigan, takes to treat her psoriasis modulates her immune system. Mills had two follow-up care visits with her dermatologist scheduled when the COVID-19 pandemic was in full swing. She and her doctor agreed it would be better to “meet” by cellphone rather than face to face. Mills admits she was skeptical about using teledermatology for her appointments. However, after doing the virtual video visits, Mills thought they were far better than having to go to her doctor’s office and potentially risking exposure to the coronavirus.

Like Mills, Sandie Herron, 61, of Sarasota, Florida, who has had psoriasis for 17 years, didn’t want to visit her doctor’s office in the spring for her six-month follow-up visit because of the pandemic. So, she scheduled a telemedicine visit. Before her video chat with her doctor, Herron took photos of her skin with her smartphone and emailed them to her. Her doctor had the photos in front of her when they connected with Google Duo.

Telemedicine encompasses a wide range of technology enabled services that allow a person to “visit” his or her health care provider without physically entering the building. It can include simpler things, like emailing photos to the health care provider or conducting a visit via phone conversation, or slightly more involved technology, like live video chatting.

Dermatologists have been researching the use of telemedicine in their field for some time, says April W. Armstrong, M.D., MPH, professor of dermatology and associate dean for clinical research at the Keck School of Medicine of the University of Southern California, and chair of the National Psoriasis Foundation (NPF) medical board. “We have looked at how we can use synchronous (realtime) and asynchronous (not at the same time) technology to help serve patients in areas that don’t have access to specialty care,” she says. Armstrong recently published a year-long study which found that psoriasis patients’ disease severity and quality of life outcomes were the same whether they were seen in person or had a visit with their provider via photographs.

Since the novel coronavirus was first reported, more doctors and patients have turned to telemedicine to help reduce the virus’ spread and keep their patients safe. “In our practice, we saw 10 times as many patients in the month of March alone via telemedicine than we did all of last year [via telemedicine],” says George Han, M.D., Ph.D., system medical director for dermatology at Mount Sinai Health System in New York City. Han is also chief of teledermatology for the Department of Dermatology at the Icahn School of Medicine at Mount Sinai.

Because of the stay-at-home orders needed to control the spread of the virus, telemedicine has gone from a convenience and a question of access to a necessity for many, Han says.

“Telemedicine is more important now than ever. With the pandemic, we in dermatology are trying to continue care for our patients with psoriasis while minimizing their exposure to others,” Han says. He points out that psoriasis requires a continuum of care, and teledermatology is a way that patients can continue their care without having to take the health risks associated with going out in public spaces during a pandemic.

Research has shown that people with psoriatic disease are at greater risk for several comorbidities, including cardiovascular disease, obesity, type 2 diabetes, hypertension, anxiety and depression. It’s important that these comorbid conditions be managed and treated as well, especially during the pandemic. Telemedicine is a way that “health care providers can rise to the occasion,” Han says.

Does Telemedicine Work for Those with Psoriasis?

For the most part, psoriasis is a condition that lends itself well to teledermatology, Han says. Telemedicine is particularly good for follow-up visits because patients can show their doctors their skin with video and/or photographs. As long as the images are clear, their doctors can see any changes in skin appearance “and determine what’s going on,” he says.

“The technology hasn’t improved to the degree where you can visualize things as well [through video] as you can in person. But with a fairly good connection and high-quality images, we can get a good sense of what their psoriasis plaques look like and the extent of the body surface that’s involved,” Armstrong says. She notes that “it’s easier to see how red and scaly the plaques are than how indurated or elevated the scales are on camera.” But the camera provides enough information to help clinicians assess their patients’ conditions and manage their disease, she says.

In fact, Armstrong says a good deal of the value of any doctor visit lies in the conversation with the patient. “With synchronous telemedicine, you really get a chance to dialogue with the patient. In video chats, as in person, you can tell if someone doesn’t understand something or has any concerns,” she says.

Patients don’t need to be particularly tech savvy to pull off successful telemedicine visits. Generally, staff from the provider’s team reach out to patients ahead of time and help them set up anything that may be needed. Some dermatologists use specialized apps that their patients can download. “Some telemedicine platforms have built-in features letting you send photos to your provider via a secure email,” Han adds.

Other practices just use common apps such as FaceTime, Skype, Google Hangouts, Microsoft Teams, or Zoom. Patients who can’t master an app or who don’t have the infrastructure at home for a clear or consistent video connection can always speak with their providers on the phone and share photos ahead of time via email if necessary. While not necessarily as good as a “face-to-face” synchronous call, it can work, Armstrong says.

In the case of Mills, the nurse from her doctor’s office called her a few minutes before her scheduled virtual visit to confirm her cellphone number. “So, I was ready and waiting when the doctor called,” Mills says. “We used Google to connect. It was easy.”

Why Is Telemedicine Possible Now?

During the pandemic, the U.S. Department of Health and Human Services temporarily relaxed its privacy rules regarding patient information so that providers may use apps without fear of punishment. Ordinarily, Health Insurance Portability and Accountability Act (HIPAA) regulations require that a patient’s health records – including those needed for virtual visits – be encrypted, to avoid security breaches.

In addition, most major private health insurers now cover telemedicine visits. In March, the Centers for Medicare & Medicaid Services (CMS) temporarily lifted regulations that prevented reimbursement for telemedicine visits outside of rural areas. CMS also now allows providers to treat patients across state lines. This includes audio-only as well as audio/video calls.

It’s not clear whether any or all of these temporary flexibilities will be extended beyond the public health emergency. “The National Psoriasis Foundation is currently leading a telehealth working group through one of our federal coalitions to make these telehealth flexibilities permanent fixtures in our health care system as we move past this public health emergency,” says Hannah Lynch, NPF associate director of federal government relations and health policy.

“The nonenforcement of HIPAA violations will almost certainly be temporary, so it’s a good time to at least explore the options for HIPAA-compliant telemedicine platforms,” Han adds.

What Are the Limitations?

Teledermatology does have limitations. Some body parts are more difficult than others for patients to show on camera – the scalp is one, and genitals are another. However, Armstrong says patients can get help from family members photographing their scalp and back, if necessary. And patients never have to do anything that makes them uncomfortable.

“We can work around the patient’s comfort level,” Han says. Patient comfort is a good reason the virtual visit should be conducted in “a relatively private area. We could be discussing very personal information, and we may need to see areas that are normally covered up,” he adds.

Also, if patients need bloodwork or biopsies, they will have to schedule in-person appointments. Obviously, neither can be done via teledermatology, Han says.

Han finds that most patients who try virtual visits like them. Both Mills and Herron believe their televisits were a fine substitute for the in-person care they were accustomed to, given the circumstances.

Herron even felt the televisit strengthened the doctor-patient relationship because she had her doctor’s undivided attention. “It was directly one-on-one for 15 minutes,” she says. When she’s in the doctor’s office, Herron says, “there are distractions that are not there during telehealth visits.”

Mills, who has had psoriasis for more than 20 years, says she might even consider doing televisits when the pandemic is over. “It was easier not to have to leave my home, waste gas and expose myself [to COVID-19],” she says.

Not everyone is on board, though. In April, Dan Schreiber of Middleton, Wisconsin, who has psoriasis, visited his dermatologist via his laptop because he is in a high-risk group for COVID-19. Schreiber is 72, and his wife has a lung condition. “So, we’ve been very, very cautious about avoiding the coronavirus,” he says. He agrees with Mills and Herron that the televisit “was better than nothing,” but felt it wasn’t nearly as effective as face to face. He says that when he meets his doctor in her office, “you can see her body language, and you feel more connected.”

Where Will Telemedicine Go?

Even though many dermatology offices have been able to fully reopen, telemedicine remains a good option for those who may be concerned about going for in-person visits, Armstrong says. “If patient visits are not possible or advisable, then synchronous or asynchronous visits can be used effectively in these situations.”

Han isn’t sure how many dermatology patients who are able to visit their provider in person will continue to use telemedicine after the pandemic. “Some will want to go back to what they’re comfortable with, especially if they had less than ideal exposure to telemedicine during the pandemic,” he says. “But there are those of us who were trying to champion telemedicine before the pandemic, and we will want to continue to do so, especially in areas of the country where patients have few – if any– other options.”

Beth W. Orenstein of Northampton, Pennsylvania, is a freelance medical writer and contributor to the National Psoriasis Foundation.

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Beth W. Orenstein

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