This Sunday, we bring to you an article from our archives section. Many Indian dermatologists are considering teleconsultation as a way to reach out to more patients, especially those living in remote areas, and even more so during COVID-19. In this article, Dr. Harshal Ranglani explains its models of practice, medicolegal implications, and how despite certain limitations, teledermatology can indeed help an already strained health infrastructure in the country.

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During the pandemic, geriatric and paediatric patients with skin conditions have been comfortably managed via telemedicine, thus averting the need for this high-risk subset of patients stepping out and risking possible exposure to COVID cases. Notably, there has been a rise in stress-aggravated skin conditions such as acne and hair fall due to the pandemic. Dermatology, being an inherently visual specialty, is particularly suited to telemedicine, perhaps more so than other specialities.

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Virtual consultation during the pandemic

According to a recent survey of Indian dermatologists, virtual consults have increased by almost three times during the pandemic. While in pre-pandemic times, a majority of the tele-consults were mainly for follow ups, at present, dermatologists are increasingly adopting telemedicine for new appointments.

There are numerous advantages of teledermatology:

1. Most skin conditions can be managed via telemedicine. The concordance between virtual consults and in-patient consults has been found to be 95% in a recent study.
2. Several skin conditions tend to be chronic in nature, with patients following up with their doctors every few months mainly for prescription refills and changes to medications, if any. These can easily be addressed virtually, making dermatological care easy, more affordable and conveniently accessible to patients.
3. It also serves as a ‘triage’ system wherein non-essential visits can be avoided and the patients’ concerns addressed virtually, having them visit the clinic only when indicated. Of note, dermatological emergencies such as acute skin failure from erythroderma, Stevens- Johnson’s syndrome and toxic epidermal necrolysis, widespread vesiculobullous disorders, drug reactions, etc. need to be managed at a hospital.

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Teledermatology is even particularly suited to aesthetic dermatology where skin concerns can be addressed at a teleconsult and the subsequent treatments planned in such a way that in-clinic visits are optimised only for treatments. For example, for cases of keloids, hair loss, scars and many others, smartphone images of the patients’ lesions can be used to screen and determine the suitability of the lesions for treatment by procedural interventions.

Pre-treatment counselling can also be done virtually and patients’ queries are addressed before the day of the procedure so that the in-clinic time is minimised. Post-procedure, too, patients can be easily followed up digitally to address any complications.

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Aiding a strained infrastructure

Teledermatology is a great option for patients in tier 2 and tier 3 cities, especially since dermatologists are concentrated in and around urban areas. Several patients have expressed happiness at being able to access their dermatologist digitally, without having to travel long distances. Thus, teledermatology has taken the load of dermatology patients off the already strained health infrastructure in many cities.

The other advantage is that multiple e-pharmacy platforms make delivery of medications to far off areas easy, especially for smaller cities and towns, where they may not always have access to a dermatologist and specialised skin products. However, rising concerns of patient data retained by the third party point to privacy issues, along with manipulation and diversion of patients.

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What are the modes of practice?

The two modes of practising telemedicine are via real-time video consultation and the store and forward (SAF) method. SAF uses smartphone images clicked by the patients and shared with their doctor. It is cheaper, easier to practise and requires minimal equipment in the form of a smartphone.

1. Whatsapp texting has been the most commonly used application for teleconsults, as per a recent survey of Indian dermatologists. In comparison to video consultations, this asynchronous SAF method has shown to have better concordance rates due to high-resolution pictures clicked on smartphones.
2. Video calls, on the other hand, offer a real-time assessment of the patient. The time taken for consultation is the least for SAF and the most for a video consultation. Although a video consult is the closest to an in-clinic consult, major deterrents to its use include internet speed, network and connectivity issues along with the considerably longer time required. Its advantage lies in real-time elicitation of a detailed history. It would be best to have an integrated approach, with SAF used mainly for obtaining the basic data, clinical images and previous prescriptions of the patients and real-time video appointments set up for more detailed and specific history that needs to be elicited.
3. Then, there are platforms which empanel doctors and are supported by a tech team and marketing team. Availability of such third-party teledermatology platforms makes specialist care more affordable to the end-user: the patient. These work on the principle of store and forward images, along with a detailed questionnaire to be filled by the patients, pertaining to their skin conditions. Here, a fixed percentage of the revenue generated is given to the doctors as payment for their services whereas the rest is reserved for the company itself, for providing its services as a platform. The advantage of these platforms for doctors is that they limit patient-doctor communication to the application itself, as opposed to a direct one-to-one teleconsult which would often result in patients expecting round-the-clock care from their doctor. For patients, these tend to be user-friendly and at nominal rates.

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Limitations

Teledermatology is not without its limitations. The foremost being lack of good-quality images. It may turn out to be difficult for certain conditions where more diagnostic aids such as dermoscopy or Wood’s lamp examination are needed. Here are a few patient-directed instructions which can help circumvent this problem:

• Have someone else click the photographs, if possible, for a better angle and view
• Click the pictures in adequate, natural lighting
• Do not use flash
• Face the source of light (like a window) and do not stand against it

Patient satisfaction may be sub-optimal as patients are generally used to having traditional in-clinic face-to face consults. Certain patients may be particularly wary and need substantial amounts of time for counselling and show of empathy, which may not be possible at a virtual visit. Many a time, there are patients who, dissatisfied with a virtual consult, do still wish to come into the clinic to allay their anxiety.

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How does teledermatology help doctors?

Apart from patient care, teledermatology also allows for exchange of information and interaction between dermatologists. The existence of several dermatology-focused groups both on Facebook and Whatsapp is a testament to the popularity of telemedicine being used for learning. It helps open up a world of possibilities to young dermatologists and residents, with a chance to learn from peers and seniors they would not otherwise have had access to.

Clinical case discussion and video demonstrations of procedures impart fresh knowledge to residents, especially with regards to procedures not being done at their own institutes. This creates a wealth of information available to dermatologists, on the go, constantly keeping them abreast of the latest developments.

Medicolegal implications

1. With this explosion of teledermatology, we are likely to see more complications pertaining to issues of litigation in the future. This is particularly relevant to drugs like isotretinoin and methotrexate, which require adequate monitoring and follow-up.
2. There is also a real possibility of prescriptions being misused by the patients and/or their relatives.
3. Doctors have been particularly frustrated due to payment issues as well, with some patients’ refusal of paying consultation fees after having done the consultation. The majority of doctors engaging in teledermatology are young ones, employed in private institutes in tier 1 cities.

From the point of medicolegal liability and data privacy/security, there needs to be better standard operating procedures in place, recommended by the medical authorities in order to create a conducive, hassle-free environment for telemedicine practice and address any hesitation from physicians.

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Teledermatology- Here to stay, even in the post-COVID era

According to a survey of Indian dermatologists, more than half the dermatologists are willing to continue teleconsultations after the pandemic is over. The ultimate goal would be to make specialist skin care accessible to the majority of the population, especially in the rural areas of the country. There is no aspect of human life that is untouched by the pandemic and the practice of medicine in India is likely to undergo significant transformation over the next decade.

Teledermatology was already well-established in other nations like the US and Australia before the pandemic. Physicians in India, especially the older generation, ought to be equipped to embrace this change. Dermatologists are particularly suited to gain from this as the specialty allows for easy virtual diagnosis, unlike internal medicine or ophthalmology a thorough physical examination is often needed. Since it is just the beginning, we do need more specific rules and regulations pertaining to dermatology so that patient care can be optimised. It is still an evolving area but the road ahead is promising.

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This article was originally published on October 30, 2020.

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Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.