Store-and-forward teledermatology consultations for primary care providers: A pilot at Henry Ford Health System

Store-and-forward teledermatology consultations for primary care providers: A pilot at Henry Ford Health System

P7593 P8390 New diagnostic toll for the diagnosis of pigmented skin lesion via multispectral imaging Leonardo Pescitelli, MD, Department of Surgery ...

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New diagnostic toll for the diagnosis of pigmented skin lesion via multispectral imaging Leonardo Pescitelli, MD, Department of Surgery and Translational Medicine, Section of Clinical, Preventive and Oncology Dermatology, Florence, Italy; Alessandro Piva, University of Florence, Florence, Italy; Anna Pelagotti, CNRINO, Florence, Italy; Francesca Prignano, MD, PhD, Department of Surgery and Translational Medicine, Section of Clinical, Preventive and Oncology Dermatology, Florence, Italy; Gianni Gerlini, MD, Plastic Surgery Unit, Regional Melanoma Referral Center; Tuscan Tumor Institute (ITT), Santa Maria Annunziata Hospital, Florence, Italy; Lorenzo Borgognoni, MD, Plastic Surgery Unit, Regional Melanoma Referral Center, Tuscan Tumor Institute (ITT); Santa Maria Annunziata Hospital, Florence, Italy; Pasquale Ferrara, CNR-INO, Florence, Italy A new device for early diagnosis of melanomas has been developed using a multispectral imaging system acquiring high spatial and spectral resolution images in the visible, and NIR range. Electromagnetic radiation propagate into the skin and reache different depths depending on its wavelength, such a system is capable of imaging layers of structures placed at increasing depths. This allows to image many properties less or not visible to the naked eye. In collaboration with the Tuscany Regional Melanoma Referral Center, for each pigmented lesion analyzed, a clinical and a dermoscopic image and a set of images at different wavelengths were acquired. Suspicious lesions were removed and histopathologic data were provided. With the system developed, the pigment network is much better visible, not only the contrast is increased, but some of the overlaying structure are not present in the multispectral images related to deeper layers. Moreover, with this new technique, the main difference detectable between malignant melanomas and healthy nevi is the fact that in the first case dark structures are still discernible in deeper layers. The blue-white veil that also represents an important dermoscopic feature in the diagnosis of melanoma can be easily recognized, by this new technique, since it become obvious in the presence of a bright-to-dark transition between the wavebands in the violet to the blue range. Therefore, a new semeiotic is needed to correctly and accurately describe the content of such multispectral images. Dermoscopic criteria can be easily applied to describe each image, however interimage correlation needs new suitable descriptors. New criteria are then proposed in order to take into account the structure layering. The first set of new parameters describe how the classic ones, such as area, perimeter, dark area ratio, etc, vary across different images taken at increasing wavelengths. More features are then introduced (eg, the longest wavelength where structures can be detected gives an estimate of the maximum depth reached by the pigmented lesion). While the presence of a bright-to-dark transition between the wavebands in the violet to blue range, reveals the presence of blue-whitish veil, and is a further malignancy marker.

Survey of an academic dermatology department with electronic medical records Janet Tcheung, MD, Duke University Medical Center, Durham, NC, United States; Claire Pipkin, MD, Duke University Medical Center, Durham, NC, United States; Russell Hall, MD, Duke University Medical Center, Durham, NC, United States Electronic medical records (EMRs) hold the promise of improved patient safety, efficiency, and productivity, yet many physicians are reluctant to embrace their use. Barriers to adoption include perception of compromised productivity, ongoing expense, unreliability, and workflow limitations. Among all subspecialties, dermatology has one of the lowest rates of EMR use; therefore, published literature on the impact of EMR in dermatology is scarce. A fully functional EMR (Epic), complete with order-entry and clinical decision support capabilities, was implemented in October 2012. We conducted an anonymous survey of Duke Dermatology medical staff to assess the impact of EMR implementation on attitudes and perceptions. We used a pre/poststudy design and sent a 16-item survey before and 4 months after implementation. Sixty-three people were surveyed and response rates for baseline and postimplementation surveys were 65% and 52%, respectively. Respondents included clinical providers (attending physicians, physician assistants, and residents) and support staff (nurses, medical assistants, and front desk staff); attending physicians comprised 42% of those surveyed. Among attending physicians surveyed, 79% responded before and 64% responded after implementation. Postimplementation, 58% felt that documentation in the new EMR was burdensome, and 87% felt that time spent documenting had increased. More than half of respondents (53%) felt that patient volume had worsened. In terms of common functions, including finding clinic notes, prescribing medications, entering laboratory orders, and placing referral requests, the majority of respondents felt that these functions were worse compared to the previous system. These results are limited by their timing during the active learning phase of the new EMR but provide important insights in the perceptions and attitudes of ‘‘front line’’ users. Our staff perceived negative impacts of the new EMR on aspects of work efficiency and patient throughput. Future surveys should be implemented to assess the durability of these initial negative perceptions and capture changes in staff acceptance with the passage of time. Commercial support: None identified.

Commercial support: None identified.

P8203 Store-and-forward teledermatology consultations for primary care providers: A pilot at Henry Ford Health System Venessa Pena-Robichaux, MD, Henry Ford Health System, Detroit, MI, United States; Adrienne Choksi, MD, Henry Ford Health System, Detroit, MI, United States Background: Dermatology is a specialized field with a high demand fueled by its current workforce shortage. Unfortunately, this often results in long wait times for patient appointments. Teledermatology consultations allow for health care providers to exchange patient information (photographs, medical history, etc) via secured communication technologies and may provide a means to bridge the gap between patient and dermatologist. In a large state such as Michigan, which has many rural regions, teledermatology may also serve as way to increase access to specialized care for patients that live in these areas. We have started a teledermatology pilot within Henry Ford Health System (HFHS) at 6 primary care sites using a store-and-forward (S&F) model in order to assess patient and provider feedback and analyze other process measures with an ultimate goal of using this information to improve the process and extend this service to other areas in Michigan. Methods: From September 16, 2012 to June 24, 2013 patients seen by primary care providers (PCPs) at 6 participating HFHS sites were offered a teledermatology consultation if they had a non-urgent dermatologic complaint that needed further evaluation by a specialist. Turnaround time to consult completion, dermatology referrals avoided, and patient and PCP feedback via survey have been gathered. Results: Twenty-one S&F teledermatology consults were completed from September 16, 2012 to June 24, 2013. Average turnaround time to consult completion was 2 days and 71% (15/21) of teledermatology consultations did not require a referral to dermatology. Of all PCPs surveyed, 67% (6/9) responded and 83% (5/6) agreed that the teledermatology consultation service is a useful resource for their practice, that it added to their education, and would recommend it to other PCPs. Of all patients surveyed, 48% (10/21) responded and 90% (9/10) agreed that they were satisfied with the results of their consultation, would recommend this service to a friend or family member, and that is an important service offered by HFHS. In addition, of the patients surveyed 90% (9/10) reported that their skin condition was better.

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Conclusions: Preliminary data suggest that S&F teledermatology consultations may provide a way to improve access to dermatologic care. PCPs and patients seem to find teledermatology consultations acceptable and important. As our pilot continues we are finding ways to improve the efficiency of this service, including integrations with Epic and iPhone technologies.

Teledermatology, a year of experience at the VA Boston Neal Kumar, Tufts University School of Medicine, Boston, MA, United States; Nellie Konnikov, MD, VA Boston Healthcare System, Boston, MA, United States Teledermatology, defined as the use of secure digital photography, videoconferencing, and data transmission to provide dermatologic care from a distance, has increasingly become a subject of study in recent years. Both the American Academy of Dermatology and the American Telemedicine Association have published support of teledermatology and guidelines to promote the safety, privacy, and efficacy in the use of teledermatology. As of January 2012, 27% of the 37 active teledermatology programs in the United States were based at Veterans Administration programs. Given the prevalence of teledermatology programs in the VA setting, we sought to analyze the diagnostic accuracy of teledermatology for skin malignancies at the VA in Boston. Accuracy was defined as matching of teledermatology diagnosis with histopathology diagnosis. A retrospective analysis was performed using the first year of teledermatology consults at the VA in Boston from May 31, 2012 to June 3, 2013. 242 cases were conducted during this period using the store-and-forward modality. Cases were divided into 2 categories: rashes or lumps and bumps. Consults for rashes were excluded from the analysis so as to only include cases with a potential for skin cancer. After excluding all rash consults and 2 consults with unacceptable image quality, 164 cases were eligible for analysis. In 32% of cases (53/164), a biopsy was recommended for suspicion of malignancy. In 10% of cases (17/164), the patient was referred to clinic for further evaluation of the need for a biopsy. Out of 53 biopsies recommended, 22 were performed by the time of this analysis (30 days after the last consult). Seventeen of 22 of the biopsies performed for suspicion of malignancy were read by a pathologist as positive for skin cancer, for a positive predictive value of 77%. When the differential given by the teledermatologist recommending a biopsy only included skin cancer, 12 out of 12 of these biopsies were skin cancer on pathology. When the differential included both skin cancer and other nonmalignant entities, 5 out of 7 biopsies were skin cancer on pathology. This analysis presents potential for continued use as well as improvement of teledermatology for identifying skin cancer from a distance. Limitations included the first year of experience for staff involved, isolated patient demographic seen at the VA, and several biopsies not yet performed, which may have altered the predictive value.

Commercial support: None identified.

Commercial support: None identified.

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J AM ACAD DERMATOL

MAY 2014