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  • br ACCEPTED MANUSCRIPT br Abbreviations Electronic medical record EMR confidence

    2022-05-06


    ACCEPTED MANUSCRIPT
    Abbreviations: Electronic medical record (EMR), confidence interval (CI), relative risk (RR)
    ACCEPTED MANUSCRIPT
    CAPSULE SUMMARY
    What is known: The benefit of teledermatology for triaging potential skin cancers is not adequately understood.
    Knowledge gained: The quality of the viewed image and the addition of dermoscopy drives outcomes.
    Clinical practice impact/patient care changes: With the right equipment, teledermatology can offer excellent cancer detection with reduced wait times, fewer biopsies and fewer non-essential dermatology clinic visits.
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    ABSTRACT
    Background. The effectiveness and value of teledermatology and face-to-face workflows for diagnosing lesions are not adequately understood. Objective. We compared the risks of biopsy and cancer diagnosis among two face-to-face workflows (direct referral, roving dermatologist) and four teledermatology workflows.
    Methods. Retrospective study of 59,279 primary care patients with a lesion, January-June 2017.
    Results. One teledermatology workflow achieved high resolution images using a dermatoscope-fitted digital camera, picture archiving and communication system, and image retrieval to a large computer monitor (in CH 223191 to a smartphone screen). Compared with direct referral, this workflow was associated with 9% greater probability of cancer detection (95% confidence interval [CI] 2% to 16%); 4% lower probability of biopsy (relative risk [RR] 0.96; CI 0.93-0.99); and
    Limitations. Differing proficiencies across teledermatology workflows and selection of patients for direct referral could have caused bias.
    Conclusion. Implementation is critical to the effectiveness of teledermatology
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    INTRODUCTION
    Teledermatology has become a reality, particularly for underserved populations. New technologies have been
    introduced, and workflows have changed in recent years, necessitating contemporary evaluations.1-4 Over the past decade, Kaiser Permanente Northern California has used four teledermatology modalities to triage cases presenting to primary care. We used this experience to conduct a retrospective comparative-effectiveness study of primary care patients receiving care through two face-to-face and four teledermatology workflows. Outcomes included the probabilities of biopsy, cancer diagnosis, and a dermatology visit that did not result in a diagnosis of skin cancer. Our null hypothesis was that the risks of outcomes were the same for each of the four teledermatology and two face-to-face diagnostic modalities. This knowledge is important for optimizing implementation of teledermatology.
    METHODS
    Setting. Kaiser Permanente Northern California is a pre-paid, integrated, closed system that provides healthcare
    using the Epic® electronic medical record (EMR) to 4.1 million diverse members.5 Access to dermatology is managed by primary care. Because of historic, geographic, and population differences, the mix of primary care workflows used to triage skin lesions were heterogeneous across the system’s medical centers (Figure 1). Face-to-face workflows include direct referral to the dermatology clinic and staffing of a “roving” dermatologist who comes to the pr imary care provider’s exam room to see the patient within minutes of receiving a referral request. Of the healthplan’s 23 medical centers, only 7 (30%) use roving as an option for dermatology referral. Roving is not always used, when available, because some patients cannot wait for the roving dermatologist, and the roving dermatologist is not always available. Among patients who receive teledermatology, only <0.7% request a face-to-face appointment, with most patients who insist on an appointment being directly referred.
    The teledermatology workflows are identified in Table I by the names of their store-and-forward technologies. Each medical center implements teledermatology based on the local context. All clinicans and support staff receive training in the technologies available at their medical center and on photo-taking. Re-training occurs when dermatologists identify consistently inadequate photos. Primary care physicians choose a workflow based on patient needs, local resources, local practices, and convenience. Stentor® (now Philips-iSite®) is a high-resolution pictu re archiving and
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    communications system originally purchased to store and transmit radiology images.6 As part of the Stentor® workflow, medical assistants are trained to take photos using a digital camera (Nikon, Canon) and a separate digital dermatoscopic camera (3Gen DermLite CH 223191 Cam), although the dermatoscopic camera was not used with some photos. Cortext® and Haiku®
    are text-messaging products that enable primary care physicians to send photographs from their smartphones.7, 8 Magnifying lenses (10x or 15x) were occasionally used with smartphones. Finally, patients can use the patient portal, a secure, online website and messaging system, to send their own photographs directly to their primary care physician or dermatologist, which offers convenience and eliminates co-payment.