BASIC/CLINICAL SCIENCE
Teletriage for Provision of Dermatologic Care: A Pilot Program in the Department of Veterans Affairs Jenna Lester and Martin A. Weinstock Background: The scarcity of dermatologists has prompted the creation of innovative methods for delivering dermatologic care. Methods: Teletriage is a method used in teledermatology to efficiently assess skin complaints in patients who do not have prompt access to conventional dermatologic care. Their primary care clinicians are provided with management recommendations, reassured that the lesion of concern is benign, or recommended to send their patient for a face-to-face dermatology visit. The Providence VA Medical Center conducted a pilot program testing the utility of teletriage for patients with skin complaints from June 2011 to August 2011. Results: The pilot program revealed that with the teletriage protocol, face-to-face visits were reduced by 38%. This program suggests that teletriage could be a useful tool for providing efficient dermatologic care, and has led to broader implementation. Conclusion: Teletriage is a potentially useful approach for efficiently addressing specific dermatologic complaints and improving access to care for those complaints. Contexte: Le manque important de dermatologistes a suscite´ la cre´ation de me´thodes novatrices de prestation de soins en dermatologie. Me´thode: Le te´le´triage est une me´thode employe´e en te´le´dermatologie permettant d9e´valuer efficacement des le´sions de la peau ´ la prestation usuelle de soins en dermatologie. Ainsi, on chez des patients qui doivent attendre longtemps avant d9avoir acce´s A ´ la nature be´nigne de la le´sion ou on leur conseille les me´decins de premier recours sur la prise en charge, on les rassure quant A recommande de faire voir directement leur patient par un dermatologue. Un programme pilote a e´te´ mene´ au Providence VA Medical ´ aouˆt 2011, afin que soit ve´rifie´e l9utilite´ du te´le´triage chez les patients pre´sentant des le´sions de la peau. Center, de juin 2011 A Re´sultats: Le programme pilote a re´ve´le´ que le protocole de te´le´triage s9e´tait traduit par une re´duction de 38% des consultations en personne. Aussi les re´sultats laissent-ils penser que le te´le´triage permettrait d9offrir une prestation efficace de soins en dermatologie, et ils ont conduit a` une mise en uvre e´largie. Conclusions: Le te´le´triage pourrait e´tre un bon moyen de fournir efficacement certains soins en dermatologie, et d9ame´liorer l9acce`s aux soins.
From the Dermatoepidemiology Unit, Providence VA Medical Center, and Departments of Dermatology and Epidemiology, Brown University, Providence, RI.
Teletriage is a method used in teledermatology to assess a patient’s need for face-to-face dermatologic care. It uses the store and forward method of teledermatology in that images are captured and stored for evaluation later at a different site. In teletriage, a dermatologist reviews patient images and other clinical data and makes a management recommendation or refers the patient for a face-to-face dermatology visit for more extensive evaluation. This article reports the experience of the teletriage pilot program at the Providence VA Medical Center. We describe the program, clinical outcomes, and patient and provider reactions to this pilot program.
Address reprint requests to: Martin A. Weinstock, MD, PhD, Dermatoepidemiology Unit, VA Medical Center, 11D, 830 Chalkstone Avenue, Providence, RI 02908; e-mail: [email protected].
Methods
ELEDERMATOLOGY is increasingly used in medical centers across the country, especially in areas with few dermatologists. By January 2012, there were at least 37 active teledermatology programs in the United States.1 Teledermatology brings specialty care to patients in dermatologist-scarce areas and has also decreased the need for clinic visits.2
T
DOI 10.2310/7750.2013.13086 # 2014 Canadian Dermatology Association
170
From June 15 to August 2, 2011, patients who presented to the Primary Care Clinic at the Providence VA Medical
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 170–173
Teletriage for Provision of Dermatologic Care
Center with a dermatologic complaint were triaged using the teletriage protocol. In this protocol, the provider seeing the patient contacted the teledermatology imaging technician to photograph a skin lesion or rash. The patient would then go to the imaging technician’s office in the clinic to have the images captured. If the patient was concerned about a lesion, the imager would take a number of photographs, including a half-body photograph, a clinical 1:1 image, and a contact immersion dermoscopy image. If the patient was concerned about a rash, the imager would take a half-body photograph and a number of close-up photographs of the involved skin areas. These photographs would be attached to the patient record. The imaging technician would conduct a brief structured interview of the patient to accompany the images. The dermatologist reader received a consultation request and reviewed the patient’s history along with the images. In this pilot program, the teledermatology technician was also present for the image review sessions. In the current teletriage protocol at the Providence VA Medical Center, the teledermatology technician is able to send information from the structured history to the dermatologist reader. After reviewing the images, the dermatologist reader either provided treatment or management recommendations for the primary care physician (PCP) or arranged for a face-to-face visit in the dermatology
clinic. This treatment/management recommendation may be to reassure the patient that the lesion of concern was benign and needed no further treatment or follow-up. Alternatively, the dermatologist could also recommend a protocol for the patient consisting of counseling and/ or medication recommendations. If the image was not adequate to make a diagnosis or if the lesion looked suspicious for skin cancer, the dermatologist would recommend that the patient be seen in the dermatology clinic. During this period, dermatologic complaints were not processed through teletriage if the imager was unavailable. For this study, the medical record of each teletriage patient was reviewed 12 months after the teletriage visit. This study was approved by the Providence VA Medical Center’s Institutional Review Board.
Results Sixty-three patients were evaluated through teletriage during the 7-week pilot program. Of these 63 patients, 62% (39) were recommended for further evaluation in the dermatology clinic. Thirty-five of the 39 patients had documented visits in the dermatology clinic (Figure 1). The diagnoses associated with the chief complaints of the 35 patients seen face to face are listed in Table 1. A
Figure 1. Final disposition of patients in the pilot program.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 170–173
171
Lester and Weinstock
Table 1. Diagnoses of Teletriage Chief Complaint Diagnosis
Number of Patients
Seborrheic keratosis Benign lesions (verrucae, acrochordons, seborrheic keratoses) Actinic keratosis Eruptive dermatitides Basal cell carcinoma Other
15 13 7 7 4 4
number of procedures were performed either to aid in the diagnosis or as a therapeutic measure (Table 2). In addition to the primary lesion identified by teletriage that required further evaluation in a face-to-face visit, there were other diagnoses made on full-body skin examination (FBSE) in the clinic (Table 3). These included two basal cell carcinomas. Twenty-four patients were managed using images alone. Thirteen of these patients were reassured that their skin complaint was not medically concerning. Neither these patients nor their providers mentioned their teletriage skin complaint in subsequent visits over the following 12 months. Eleven of the 24 patients managed through images alone were given specific treatment recommendations. The outcomes of these patients are described in Table 4.
Physician and Patient Satisfaction This program was well received by patients. Their opinions were not formally evaluated; however, many patients anecdotally expressed their satisfaction with the immediacy of care the teletriage program provided. Although they would ordinarily wait a number of weeks for an appointment in the dermatology clinic, teletriage allowed their concern to be addressed within a week. Patients with bothersome rashes or other pressing concerns were particularly grateful for this time course. Some were concerned that they could not ask questions of the dermatologist (as was observed in a previous teledermatology program evaluation that used the ‘‘surrogate dermatologist’’ model3) because the evaluation of Table 2. Procedures Performed on Teletriage Patients Procedure
Number of Patients
Liquid nitrogen treatment Biopsy Fulguration
172
17 10 1
Table 3. Diagnoses Made on Full-Body Skin Examination (Unrelated to Teletriage Chief Complaint) Diagnosis Basal cell carcinoma Actinic keratosis Atrophic lichen planus Other benign lesions (verrucae, acrochordons, seborrheic keratoses, epidermal inclusion cysts, nevi)
Number of Patients 2 5 1 11
their condition occurred at a different time and place; however, they were able to ask questions of their PCP. Others were concerned about their privacy with respect to the image capture, especially if the images involved a sensitive area of the body. Under these circumstances, the patients were informed about the privacy protections in place. PCPs involved in the teletriage pilot program were also satisfied with the immediacy of attention to their consultation request. In some cases, the PCPs were able to prescribe the recommended treatments before the patient left the medical center. Additionally, the PCPs were able to quickly provide reassurance to patients with dermatologic complaints that did not require further evaluation. Many of the negative assessments of the program from PCPs were related to the logistical aspects of the program. Some PCPs expressed frustration at the extra steps required to complete to obtain a consultation through the teletriage program. Some physicians felt that it was too much to have to page the telehealth imaging technician to capture images. This was addressed early in the pilot program by placing the telehealth imager in the primary care clinic so that patients could simply go down the hall to the imaging office, hence eliminating the need for the PCP to page the imager.
Discussion During the teletriage pilot, 38% of patients who were processed through this system were managed through recommendations alone. This improved access to the dermatology clinic for other patients with skin complaints that warranted a face-to-face visit. Although the number of patients processed through this pilot program was small, the impact of this program on a larger scale could be significant. After completion of this pilot program, the Providence VA Medical Center implemented teletriage on a larger
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 170–173
Teletriage for Provision of Dermatologic Care
Table 4. Outcomes of Patients Managed Using Images Alone Final Outcome Reassurance Problem resolved* Reconsulted to Dermatology
Number of Patients 13 5 6
1 had not filled recommended prescription 1. Rash unresponsive to Nystatin cream 2. Acne vulgaris unresponsive to doxycycline 3. Lipodermatosclerosis secondary to venous thrombosis that may be permanent 4. Hand dermatitis and stasis dermatitis treated with emollients and clobetasol 5. Mild intertrigo treated with ketoconazole cream 6. Tinea pedis
*Patients did not mention their teletriage skin complaint at subsequent visits.
scale, and 50% of the first 426 patients in this program did not need face-to-face dermatology visits. The teletriage model for teledermatology consultation is now being implemented in many medical centers in the Veterans Affairs (VA) health care system. We do not address potential issues of legal liability associated with the use of teletriage outside the VA health system. The teletriage encounter is a focused encounter and therefore may miss skin disease that is not imaged as part of the evaluated skin complaint. In this respect, a teletriage encounter is similar to other visits driven by a specific patient complaint, in which disease in another system may be missed. Two of the patients who were recommended for a faceto-face dermatology visit were incidentally found, on a routine FBSE, to have a skin cancer (both basal cell carcinoma) that was not related to their teletriage chief complaint and not imaged. This underscores the guidance (which is included in the current operations manual) that teledermatology, at least as currently practiced, does not provide an adequate substitute for an FBSE. Individuals who need this type of examination (such as patients with many dysplastic nevi) are therefore advised to have a faceto-face dermatology examination. A study by Kantor and Kantor showed that dermatologist-initiated FBSEs were responsible for discovering thinner melanomas when compared to FBSEs that were the result of a specific skin complaint.4 These FBSEs were initiated by the dermatologist and were done regardless of the patient’s presenting complaint. In this study, the majority of melanomas were discovered after a dermatologist-initiated FBSE, although the patient’s skin complaint may not have necessitated such an action. This study suggests that physicians can discover melanomas at an earlier stage and potentially have a better outcome if they
initiate an FBSE regardless of a patient’s reason for presentation. For this reason, many dermatologists routinely offer their patients an FBSE. PCPs may not typically perform an FBSE, but many believe that it should be part of their routine skin examination. On the other hand, it must be noted that the FBSE for detection of skin cancer or specifically melanoma is not currently recommended in general practice.5 If an annual FBSE (or biannual, as is currently practiced in Germany) is appropriate, it is not best accomplished through teletriage. Teletriage is a potentially useful approach for efficiently addressing specific dermatologic complaints and improving access to care for those complaints.
Acknowledgment Financial disclosure of authors and reviewers: None reported.
References 1. Armstrong AW, Wu J, Kovarik CL, et al. State of teledermatology programs in the United States. J Am Acad Dermatol 2012;67:939–44, doi:10.1016/j.jaad.2012.02.019. 2. Whited JD. Teledermatology research review. Int J Dermatol 2006;45: 220–9, doi:10.1111/j.1365-4632.2004.02427.x. 3. Weinstock MA, Nguyen FQ, Risica P. Patient and provider satisfaction with teledermatology. J Am Acad Dermatol 2002;47: 68–72, doi:10.1067/mjd.2002.119666. 4. Kantor J, Kantor DE. Routine dermatologist-performed full-body skin examination and early melanoma detection. Arch Dermatol 2009;145:873–6, doi:10.1001/archdermatol.2009.137. 5. Screening for skin cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009;150:188–93, doi:10.7326/0003-4819-150-3-200902030-00008.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 170–173
173
Copyright of Journal of Cutaneous Medicine & Surgery is the property of Decker Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Teletriage for Provision of Dermatologic Care: A Pilot Program in the Department of Veterans Affairs Jenna Lester and Martin A. Weinstock Background: The scarcity of dermatologists has prompted the creation of innovative methods for delivering dermatologic care. Methods: Teletriage is a method used in teledermatology to efficiently assess skin complaints in patients who do not have prompt access to conventional dermatologic care. Their primary care clinicians are provided with management recommendations, reassured that the lesion of concern is benign, or recommended to send their patient for a face-to-face dermatology visit. The Providence VA Medical Center conducted a pilot program testing the utility of teletriage for patients with skin complaints from June 2011 to August 2011. Results: The pilot program revealed that with the teletriage protocol, face-to-face visits were reduced by 38%. This program suggests that teletriage could be a useful tool for providing efficient dermatologic care, and has led to broader implementation. Conclusion: Teletriage is a potentially useful approach for efficiently addressing specific dermatologic complaints and improving access to care for those complaints. Contexte: Le manque important de dermatologistes a suscite´ la cre´ation de me´thodes novatrices de prestation de soins en dermatologie. Me´thode: Le te´le´triage est une me´thode employe´e en te´le´dermatologie permettant d9e´valuer efficacement des le´sions de la peau ´ la prestation usuelle de soins en dermatologie. Ainsi, on chez des patients qui doivent attendre longtemps avant d9avoir acce´s A ´ la nature be´nigne de la le´sion ou on leur conseille les me´decins de premier recours sur la prise en charge, on les rassure quant A recommande de faire voir directement leur patient par un dermatologue. Un programme pilote a e´te´ mene´ au Providence VA Medical ´ aouˆt 2011, afin que soit ve´rifie´e l9utilite´ du te´le´triage chez les patients pre´sentant des le´sions de la peau. Center, de juin 2011 A Re´sultats: Le programme pilote a re´ve´le´ que le protocole de te´le´triage s9e´tait traduit par une re´duction de 38% des consultations en personne. Aussi les re´sultats laissent-ils penser que le te´le´triage permettrait d9offrir une prestation efficace de soins en dermatologie, et ils ont conduit a` une mise en uvre e´largie. Conclusions: Le te´le´triage pourrait e´tre un bon moyen de fournir efficacement certains soins en dermatologie, et d9ame´liorer l9acce`s aux soins.
From the Dermatoepidemiology Unit, Providence VA Medical Center, and Departments of Dermatology and Epidemiology, Brown University, Providence, RI.
Teletriage is a method used in teledermatology to assess a patient’s need for face-to-face dermatologic care. It uses the store and forward method of teledermatology in that images are captured and stored for evaluation later at a different site. In teletriage, a dermatologist reviews patient images and other clinical data and makes a management recommendation or refers the patient for a face-to-face dermatology visit for more extensive evaluation. This article reports the experience of the teletriage pilot program at the Providence VA Medical Center. We describe the program, clinical outcomes, and patient and provider reactions to this pilot program.
Address reprint requests to: Martin A. Weinstock, MD, PhD, Dermatoepidemiology Unit, VA Medical Center, 11D, 830 Chalkstone Avenue, Providence, RI 02908; e-mail: [email protected].
Methods
ELEDERMATOLOGY is increasingly used in medical centers across the country, especially in areas with few dermatologists. By January 2012, there were at least 37 active teledermatology programs in the United States.1 Teledermatology brings specialty care to patients in dermatologist-scarce areas and has also decreased the need for clinic visits.2
T
DOI 10.2310/7750.2013.13086 # 2014 Canadian Dermatology Association
170
From June 15 to August 2, 2011, patients who presented to the Primary Care Clinic at the Providence VA Medical
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 170–173
Teletriage for Provision of Dermatologic Care
Center with a dermatologic complaint were triaged using the teletriage protocol. In this protocol, the provider seeing the patient contacted the teledermatology imaging technician to photograph a skin lesion or rash. The patient would then go to the imaging technician’s office in the clinic to have the images captured. If the patient was concerned about a lesion, the imager would take a number of photographs, including a half-body photograph, a clinical 1:1 image, and a contact immersion dermoscopy image. If the patient was concerned about a rash, the imager would take a half-body photograph and a number of close-up photographs of the involved skin areas. These photographs would be attached to the patient record. The imaging technician would conduct a brief structured interview of the patient to accompany the images. The dermatologist reader received a consultation request and reviewed the patient’s history along with the images. In this pilot program, the teledermatology technician was also present for the image review sessions. In the current teletriage protocol at the Providence VA Medical Center, the teledermatology technician is able to send information from the structured history to the dermatologist reader. After reviewing the images, the dermatologist reader either provided treatment or management recommendations for the primary care physician (PCP) or arranged for a face-to-face visit in the dermatology
clinic. This treatment/management recommendation may be to reassure the patient that the lesion of concern was benign and needed no further treatment or follow-up. Alternatively, the dermatologist could also recommend a protocol for the patient consisting of counseling and/ or medication recommendations. If the image was not adequate to make a diagnosis or if the lesion looked suspicious for skin cancer, the dermatologist would recommend that the patient be seen in the dermatology clinic. During this period, dermatologic complaints were not processed through teletriage if the imager was unavailable. For this study, the medical record of each teletriage patient was reviewed 12 months after the teletriage visit. This study was approved by the Providence VA Medical Center’s Institutional Review Board.
Results Sixty-three patients were evaluated through teletriage during the 7-week pilot program. Of these 63 patients, 62% (39) were recommended for further evaluation in the dermatology clinic. Thirty-five of the 39 patients had documented visits in the dermatology clinic (Figure 1). The diagnoses associated with the chief complaints of the 35 patients seen face to face are listed in Table 1. A
Figure 1. Final disposition of patients in the pilot program.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 170–173
171
Lester and Weinstock
Table 1. Diagnoses of Teletriage Chief Complaint Diagnosis
Number of Patients
Seborrheic keratosis Benign lesions (verrucae, acrochordons, seborrheic keratoses) Actinic keratosis Eruptive dermatitides Basal cell carcinoma Other
15 13 7 7 4 4
number of procedures were performed either to aid in the diagnosis or as a therapeutic measure (Table 2). In addition to the primary lesion identified by teletriage that required further evaluation in a face-to-face visit, there were other diagnoses made on full-body skin examination (FBSE) in the clinic (Table 3). These included two basal cell carcinomas. Twenty-four patients were managed using images alone. Thirteen of these patients were reassured that their skin complaint was not medically concerning. Neither these patients nor their providers mentioned their teletriage skin complaint in subsequent visits over the following 12 months. Eleven of the 24 patients managed through images alone were given specific treatment recommendations. The outcomes of these patients are described in Table 4.
Physician and Patient Satisfaction This program was well received by patients. Their opinions were not formally evaluated; however, many patients anecdotally expressed their satisfaction with the immediacy of care the teletriage program provided. Although they would ordinarily wait a number of weeks for an appointment in the dermatology clinic, teletriage allowed their concern to be addressed within a week. Patients with bothersome rashes or other pressing concerns were particularly grateful for this time course. Some were concerned that they could not ask questions of the dermatologist (as was observed in a previous teledermatology program evaluation that used the ‘‘surrogate dermatologist’’ model3) because the evaluation of Table 2. Procedures Performed on Teletriage Patients Procedure
Number of Patients
Liquid nitrogen treatment Biopsy Fulguration
172
17 10 1
Table 3. Diagnoses Made on Full-Body Skin Examination (Unrelated to Teletriage Chief Complaint) Diagnosis Basal cell carcinoma Actinic keratosis Atrophic lichen planus Other benign lesions (verrucae, acrochordons, seborrheic keratoses, epidermal inclusion cysts, nevi)
Number of Patients 2 5 1 11
their condition occurred at a different time and place; however, they were able to ask questions of their PCP. Others were concerned about their privacy with respect to the image capture, especially if the images involved a sensitive area of the body. Under these circumstances, the patients were informed about the privacy protections in place. PCPs involved in the teletriage pilot program were also satisfied with the immediacy of attention to their consultation request. In some cases, the PCPs were able to prescribe the recommended treatments before the patient left the medical center. Additionally, the PCPs were able to quickly provide reassurance to patients with dermatologic complaints that did not require further evaluation. Many of the negative assessments of the program from PCPs were related to the logistical aspects of the program. Some PCPs expressed frustration at the extra steps required to complete to obtain a consultation through the teletriage program. Some physicians felt that it was too much to have to page the telehealth imaging technician to capture images. This was addressed early in the pilot program by placing the telehealth imager in the primary care clinic so that patients could simply go down the hall to the imaging office, hence eliminating the need for the PCP to page the imager.
Discussion During the teletriage pilot, 38% of patients who were processed through this system were managed through recommendations alone. This improved access to the dermatology clinic for other patients with skin complaints that warranted a face-to-face visit. Although the number of patients processed through this pilot program was small, the impact of this program on a larger scale could be significant. After completion of this pilot program, the Providence VA Medical Center implemented teletriage on a larger
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 170–173
Teletriage for Provision of Dermatologic Care
Table 4. Outcomes of Patients Managed Using Images Alone Final Outcome Reassurance Problem resolved* Reconsulted to Dermatology
Number of Patients 13 5 6
1 had not filled recommended prescription 1. Rash unresponsive to Nystatin cream 2. Acne vulgaris unresponsive to doxycycline 3. Lipodermatosclerosis secondary to venous thrombosis that may be permanent 4. Hand dermatitis and stasis dermatitis treated with emollients and clobetasol 5. Mild intertrigo treated with ketoconazole cream 6. Tinea pedis
*Patients did not mention their teletriage skin complaint at subsequent visits.
scale, and 50% of the first 426 patients in this program did not need face-to-face dermatology visits. The teletriage model for teledermatology consultation is now being implemented in many medical centers in the Veterans Affairs (VA) health care system. We do not address potential issues of legal liability associated with the use of teletriage outside the VA health system. The teletriage encounter is a focused encounter and therefore may miss skin disease that is not imaged as part of the evaluated skin complaint. In this respect, a teletriage encounter is similar to other visits driven by a specific patient complaint, in which disease in another system may be missed. Two of the patients who were recommended for a faceto-face dermatology visit were incidentally found, on a routine FBSE, to have a skin cancer (both basal cell carcinoma) that was not related to their teletriage chief complaint and not imaged. This underscores the guidance (which is included in the current operations manual) that teledermatology, at least as currently practiced, does not provide an adequate substitute for an FBSE. Individuals who need this type of examination (such as patients with many dysplastic nevi) are therefore advised to have a faceto-face dermatology examination. A study by Kantor and Kantor showed that dermatologist-initiated FBSEs were responsible for discovering thinner melanomas when compared to FBSEs that were the result of a specific skin complaint.4 These FBSEs were initiated by the dermatologist and were done regardless of the patient’s presenting complaint. In this study, the majority of melanomas were discovered after a dermatologist-initiated FBSE, although the patient’s skin complaint may not have necessitated such an action. This study suggests that physicians can discover melanomas at an earlier stage and potentially have a better outcome if they
initiate an FBSE regardless of a patient’s reason for presentation. For this reason, many dermatologists routinely offer their patients an FBSE. PCPs may not typically perform an FBSE, but many believe that it should be part of their routine skin examination. On the other hand, it must be noted that the FBSE for detection of skin cancer or specifically melanoma is not currently recommended in general practice.5 If an annual FBSE (or biannual, as is currently practiced in Germany) is appropriate, it is not best accomplished through teletriage. Teletriage is a potentially useful approach for efficiently addressing specific dermatologic complaints and improving access to care for those complaints.
Acknowledgment Financial disclosure of authors and reviewers: None reported.
References 1. Armstrong AW, Wu J, Kovarik CL, et al. State of teledermatology programs in the United States. J Am Acad Dermatol 2012;67:939–44, doi:10.1016/j.jaad.2012.02.019. 2. Whited JD. Teledermatology research review. Int J Dermatol 2006;45: 220–9, doi:10.1111/j.1365-4632.2004.02427.x. 3. Weinstock MA, Nguyen FQ, Risica P. Patient and provider satisfaction with teledermatology. J Am Acad Dermatol 2002;47: 68–72, doi:10.1067/mjd.2002.119666. 4. Kantor J, Kantor DE. Routine dermatologist-performed full-body skin examination and early melanoma detection. Arch Dermatol 2009;145:873–6, doi:10.1001/archdermatol.2009.137. 5. Screening for skin cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2009;150:188–93, doi:10.7326/0003-4819-150-3-200902030-00008.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 18, No 3 (May/June), 2014: pp 170–173
173
Copyright of Journal of Cutaneous Medicine & Surgery is the property of Decker Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
