Pediatric Dermatology Vol. 32 No. 3 363–368, 2015
Pediatric Teledermatology: A Survey of Usage, Perspectives, and Practice Alexander L. Fogel, B.S.,* and Joyce M. C. Teng, M.D., Ph.D.†,‡ *School of Medicine, Departments of †Dermatology and ‡Pediatrics, Stanford University, Palo Alto, California
Abstract: Pediatric dermatology is one of the smallest subspecialties, and expanding the availability of care is of great interest. Teledermatology has been proposed as a way to expand access and improve care delivery, but no current assessment of pediatric teledermatology exists. The objective of the current study was to assess usage and perspectives on pediatric teledermatology. Surveys were distributed electronically to all 226 board-certified U.S. pediatric dermatologists; 44% (100/226) responded. Nearly all respondents (89%) have experience with teledermatology. Formal teledermatology reimbursement success rates have increased to 35%. Respondents were positive about teledermatology’s present and future prospects, and 41% want to use teledermatology more often, although they viewed teledermatology as somewhat inferior to inperson care regarding accuracy of diagnosis and appropriation of management plans. Significant differences were found between formal teledermatology users and nonusers in salary structure, practice environment, sex, and region. Substantial increases in pediatric teledermatology have occurred in the last 5 to 10 years, and there remains cause for optimism for teledermatology’s future. Concerns about diagnostic confidence and care quality indicate that teledermatology may be best for care of patients with characteristic clinical presentations or management of patients with established diagnoses.
Teledermatology, the exchange of medical information from one location to another with the goal of improving skin health (1), is of great interest in the dermatology community (2). Teledermatology has been used for patient care (2), skin cancer screenings (3), triage (4), consultation (2), and expansion of
access (5). Comparisons between teledermatology care and in-person care have shown acceptable levels of diagnostic concordance (6,7), satisfaction of patients (6,8), and lower resource utilization (4,9). Given the well-documented undersupply of dermatologic (10) and pediatric dermatologic services (11), the
Address correspondence to Joyce M. C. Teng, M.D., Ph.D., Department of Dermatology, School of Medicine, Stanford University, 700 Welch Road, Suite 301G, Palo Alto, CA 94304, or e-mail: [email protected]. Preliminary results were presented at the 11th Annual American Medical Association Research Symposium, November 15–16, 2013. DOI: 10.1111/pde.12533
© 2015 Wiley Periodicals, Inc.
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364 Pediatric Dermatology Vol. 32 No. 3 May/June 2015
importance of medical cost minimization, and the visual nature of the specialty, teledermatology has the potential to become an important component of practice (8). Pediatric dermatology is one of the smallest medical subspecialties, with 226 board-certified providers serving the nation’s 73.8 million children (12,13). Pediatric skin complaints are common, with 20% to 30% of pediatric visits involving a skin complaint or finding (14) and with 27% of the average general dermatology practice composed of children (15,16). This is problematic for many patients, because research indicates that 36% of referrals that pediatric dermatologists receive were initially misdiagnosed or improperly treated (15). Because it is likely that the number of board-certified providers will remain stable (11), alternative methods to expand the availability of care are needed. Teledermatology may allow more effective triage and expand access to pediatric dermatology. Because no recent assessment of the status of pediatric teledermatology exists, we designed this study to assess the current use of teledermatology by boardcertified U.S. pediatric dermatologists and their perspectives on it. METHODS Stanford University’s Institutional Review Board approved the electronic distribution and analysis of these surveys as exempt. Nonparticipant colleagues reviewed surveys for clarity and appropriateness and the surveys were implemented using Qualtrics software (Qualtrics, Provo, UT). Surveys were distributed from June to September 2013 to all 226 practicing U.S. board-certified pediatric dermatologists as identified by the American Board of Medical Specialties (12). Fisher exact tests were performed using R 3.0.1 (R Project, Vienna, Austria). Survey questions used standardized, well-defined terminology (1) modeled on similar assessments (17,18). Survey Definitions Teledermatology Systems Formal teledermatology: the use of a secure, encrypted system specifically designed for the purposes of telemedicine consultation. Informal teledermatology: the use of images, video, or patient information transmitted over systems not designed specifically for telemedicine, such as e-mail or text message, for the purposes of telemedicine consultation.
Teledermatology Modalities Live interactive: the interaction of physician and patient in real time using video consultation. Store-and-forward: the physician’s use of still images of the patient to participate in the patient’s care. Hybrid: a combination of live interactive and storeand-forward. RESULTS Respondents represented 44% (100/226) of all practicing board-certified pediatric dermatologists in the United States, encompassing physicians from 36 states in all major continental U.S. geographic regions and all major practice types (Table 1). Respondents were largely representative of the overall field with respect to sex (respondents: 76% female; overall: 72% female), academic practice (respondents: 56%; overall: 54%), and region (respondents: 28% Midwest, 23% Northeast, 25% South, 24% West; overall: 23% Midwest, 29% Northeast, 26% South, 23% West). Usage Respondents were queried about their use of teledermatology; 89% reported experience with informal TABLE 1. Comparison of Formal Teledermatology Users and Nonusers
Characteristic Practice environment, n* Dermatology-only private practice Multispecialty private practice Academic Managed care Have formal teledermatology at work or affiliated with teledermatology company, n (%) Salaried compensation model, n (%) Sex, n (%) Male Female Geographic region, n (%) West Nonwest Practice environment, n (%)† Private practice Academic or managed care
Users, n = 32 (32%)
Nonusers, n = 68 (68%)
1 1
20 1
18
38
5
2
20 (63)
6 (9)
30 (94)
52 (76)
p-Value
0.049
13 (54) 19 (25)
0.01
13 (54) 19 (25)
0.04
2 (8) 23 (37)
0.009
p-Values computed using Fisher exact tests. *Analysis restricted to respondents who indicated only one practice type (e.g., academic only). †Analysis restricted to respondents who indicated only practice in one category (e.g., academic, managed care, or both).
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TABLE 2. Participant Characteristics and Teledermatology Usage Patterns Formal teledermatology
Informal teledermatology†
Respondents who 32 (32) have used formal teledermatology, n (%) % of time reimbursed, 34.6 (8.9) mean (SD) Respondents by frequency of use*, n (%)
Pediatric Teledermatology: A Survey of Usage, Perspectives, and Practice Alexander L. Fogel, B.S.,* and Joyce M. C. Teng, M.D., Ph.D.†,‡ *School of Medicine, Departments of †Dermatology and ‡Pediatrics, Stanford University, Palo Alto, California
Abstract: Pediatric dermatology is one of the smallest subspecialties, and expanding the availability of care is of great interest. Teledermatology has been proposed as a way to expand access and improve care delivery, but no current assessment of pediatric teledermatology exists. The objective of the current study was to assess usage and perspectives on pediatric teledermatology. Surveys were distributed electronically to all 226 board-certified U.S. pediatric dermatologists; 44% (100/226) responded. Nearly all respondents (89%) have experience with teledermatology. Formal teledermatology reimbursement success rates have increased to 35%. Respondents were positive about teledermatology’s present and future prospects, and 41% want to use teledermatology more often, although they viewed teledermatology as somewhat inferior to inperson care regarding accuracy of diagnosis and appropriation of management plans. Significant differences were found between formal teledermatology users and nonusers in salary structure, practice environment, sex, and region. Substantial increases in pediatric teledermatology have occurred in the last 5 to 10 years, and there remains cause for optimism for teledermatology’s future. Concerns about diagnostic confidence and care quality indicate that teledermatology may be best for care of patients with characteristic clinical presentations or management of patients with established diagnoses.
Teledermatology, the exchange of medical information from one location to another with the goal of improving skin health (1), is of great interest in the dermatology community (2). Teledermatology has been used for patient care (2), skin cancer screenings (3), triage (4), consultation (2), and expansion of
access (5). Comparisons between teledermatology care and in-person care have shown acceptable levels of diagnostic concordance (6,7), satisfaction of patients (6,8), and lower resource utilization (4,9). Given the well-documented undersupply of dermatologic (10) and pediatric dermatologic services (11), the
Address correspondence to Joyce M. C. Teng, M.D., Ph.D., Department of Dermatology, School of Medicine, Stanford University, 700 Welch Road, Suite 301G, Palo Alto, CA 94304, or e-mail: [email protected]. Preliminary results were presented at the 11th Annual American Medical Association Research Symposium, November 15–16, 2013. DOI: 10.1111/pde.12533
© 2015 Wiley Periodicals, Inc.
363
364 Pediatric Dermatology Vol. 32 No. 3 May/June 2015
importance of medical cost minimization, and the visual nature of the specialty, teledermatology has the potential to become an important component of practice (8). Pediatric dermatology is one of the smallest medical subspecialties, with 226 board-certified providers serving the nation’s 73.8 million children (12,13). Pediatric skin complaints are common, with 20% to 30% of pediatric visits involving a skin complaint or finding (14) and with 27% of the average general dermatology practice composed of children (15,16). This is problematic for many patients, because research indicates that 36% of referrals that pediatric dermatologists receive were initially misdiagnosed or improperly treated (15). Because it is likely that the number of board-certified providers will remain stable (11), alternative methods to expand the availability of care are needed. Teledermatology may allow more effective triage and expand access to pediatric dermatology. Because no recent assessment of the status of pediatric teledermatology exists, we designed this study to assess the current use of teledermatology by boardcertified U.S. pediatric dermatologists and their perspectives on it. METHODS Stanford University’s Institutional Review Board approved the electronic distribution and analysis of these surveys as exempt. Nonparticipant colleagues reviewed surveys for clarity and appropriateness and the surveys were implemented using Qualtrics software (Qualtrics, Provo, UT). Surveys were distributed from June to September 2013 to all 226 practicing U.S. board-certified pediatric dermatologists as identified by the American Board of Medical Specialties (12). Fisher exact tests were performed using R 3.0.1 (R Project, Vienna, Austria). Survey questions used standardized, well-defined terminology (1) modeled on similar assessments (17,18). Survey Definitions Teledermatology Systems Formal teledermatology: the use of a secure, encrypted system specifically designed for the purposes of telemedicine consultation. Informal teledermatology: the use of images, video, or patient information transmitted over systems not designed specifically for telemedicine, such as e-mail or text message, for the purposes of telemedicine consultation.
Teledermatology Modalities Live interactive: the interaction of physician and patient in real time using video consultation. Store-and-forward: the physician’s use of still images of the patient to participate in the patient’s care. Hybrid: a combination of live interactive and storeand-forward. RESULTS Respondents represented 44% (100/226) of all practicing board-certified pediatric dermatologists in the United States, encompassing physicians from 36 states in all major continental U.S. geographic regions and all major practice types (Table 1). Respondents were largely representative of the overall field with respect to sex (respondents: 76% female; overall: 72% female), academic practice (respondents: 56%; overall: 54%), and region (respondents: 28% Midwest, 23% Northeast, 25% South, 24% West; overall: 23% Midwest, 29% Northeast, 26% South, 23% West). Usage Respondents were queried about their use of teledermatology; 89% reported experience with informal TABLE 1. Comparison of Formal Teledermatology Users and Nonusers
Characteristic Practice environment, n* Dermatology-only private practice Multispecialty private practice Academic Managed care Have formal teledermatology at work or affiliated with teledermatology company, n (%) Salaried compensation model, n (%) Sex, n (%) Male Female Geographic region, n (%) West Nonwest Practice environment, n (%)† Private practice Academic or managed care
Users, n = 32 (32%)
Nonusers, n = 68 (68%)
1 1
20 1
18
38
5
2
20 (63)
6 (9)
30 (94)
52 (76)
p-Value
0.049
13 (54) 19 (25)
0.01
13 (54) 19 (25)
0.04
2 (8) 23 (37)
0.009
p-Values computed using Fisher exact tests. *Analysis restricted to respondents who indicated only one practice type (e.g., academic only). †Analysis restricted to respondents who indicated only practice in one category (e.g., academic, managed care, or both).
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TABLE 2. Participant Characteristics and Teledermatology Usage Patterns Formal teledermatology
Informal teledermatology†
Respondents who 32 (32) have used formal teledermatology, n (%) % of time reimbursed, 34.6 (8.9) mean (SD) Respondents by frequency of use*, n (%)
