Craig C. Miller, MD, PhD Brian C. Madden, PhD 13 November 2006

1. Distributed Specialty Carea telemedicine model for delivery of dermatology specialty care in VISN 2 Craig C. Miller, MD, PhD Brian C. Madden, PhD 13 November 2006

2. Overview • Why? • Imbalance between supply of dermatology specialists and demand for treatment of skin diseases in VISN 2 • How? • Distributed Specialty Care model • Three-tiered system for delivery of skin care • Primary care provider • Skin Evaluation Clinic • Teledermatology consultant

3. Shortage of dermatology assets in VISN 2 • Dermatology demand • Over 12,000 patient visits per year • Requirement to provide veterans with “specialty care” • Time constraints: 30-30-20 rule • Dermatology supply • Limited VA staff dermatologists • Disconnect between VA and civilian sectors • Non-priority • Lack of acceptable non-VA care • Limited availability--unacceptable delays • Expensive

4. VISN2 Dermatology Assets

5. DSC model: goals • Allows for more efficient utilization of dermatology specialty assets • Maintains high quality of care for skin related disease • Timely • Efficacious

6. DSC model: key features • Store-forward technology • Skin Evaluation Clinic • Trained non-specialist skin care providers • Intermediaries between primary care and the specialist • Performance measures • Dynamic adaptive system • Continuous enhancement

7. Telemedicine methodology • Real-time • Video with synchronous (“face-to-face”) patient-consultant encounters • Low resolution, high bandwidth • Inefficient utilization of consultant • Store-forward • Still images with asynchronous patient-consultant encounters • High resolution, low bandwidth • Efficient utilization of consultant • Dependent upon skills of non-specialist • Obtain proper history • Decide on what is “image worthy” • Self-initiate therapeutics and/or diagnostic procedures

8. DSC: Three-tier delivery system Primary Care Provider Service Agreement Skin Evaluation Clinic Rules of Engagement Teledermatology Consultant

9. Tier 1: Primary care provider • Identify patient with skin complaint • Utilize Skin Evaluation consult menu to direct patient care • Initiate consultation with Skin Evaluation Clinic (when appropriate)

10. Skin Evaluation consult menu • Decision Tree for managing patients with skin dz • Determines appropriateness of consultation • Directs patient flow • Service Agreement • Directs initial therapeutic approach for established skin diseases • Prioritizes unknown skin conditions • Suggests alternative approaches for skin disorders that are not referable to SEC • Skin Evaluation consult request form • Asks for reason for consult and whether patient has been seen previously in SEC

14. Dermatology Decision Tree: an algorithm for skin dz patient flow

23. Components of Service Agreement • Part A • Known conditions and treatments • Part B • Priorities of unknowns and areas of concern • Part C • Uncovered items (limited resources)

29. Tier 2: Skin Evaluation Clinic • Evaluate patient • Initiate treatment or perform diagnostic tests • Acquire images according to the “rules of engagement” • Enter teledermatology consult (when appropriate)

30. Skin evaluation clinic providers • Various backgrounds • Nurse practitioners/Physician assistants • Dermatology residents • Primary care physicians • Training • Training in dermatology clinic • Approach to the dermatology patient • Rudimentary dermatology differential diagnosis • Introduction to dermatology therapeutics • Hands-on training in techniques • Biopsy--shave, punch • Cryotherapy • Electrodessication and curettage • Hands-on training in image acquisition • Access to dermatology educational resources • Feedback

31. Rules of Engagement • Initial consult that specifically refers to evaluation of a lesion for suspected malignancy • Any patient in which there is a question as to the diagnosis that may affect treatment approach such that the consequence of proceeding along one of alternative lines of therapy could result in a delay in appropriate and prognostically significant care • Any patient that requires a biopsy • Any patient that will be started on systemic medications that require monitoring • Patch test evaluation

32. The Canon EOS Digital Rebel with the Canon EF 100mm f/2.8 USM Macro Lens and Canon Macro Twin Lite The Camera • 8 MP SLR camera • Macro lens • Macro flash • Back-up available • Technical support

33. Image acquisition/capture • Image acquisition • Patient ID • Contextual (anatomic context) • Morphological (diagnostic close-up) • Image capture • Client software/access • Card reader

34. Image quality • Literature • supports the validity of teledermatology in diagnosis of skin lesions • Standards for image resolution/color • DSC standards >> American Academy of Dermatology and the American Telemedicine Association • Future DICOM standard • Techniques to ensure image quality • Standard and simple image acquisition process • Calibration for “true” colors • Training • Feedback • Validation

37. Tier 3: Teledermatology consultant • Review SEC note • Emphasis on history • View images • VistA Image Display • Document • Link to Teledermatology consultation • Template • Code

43. DSC: Three-tier delivery system Primary Care Provider Service Agreement Skin Evaluation Clinic Rules of Engagement Teledermatology Consultant

44. Performance • Training • Basic dermatology therapeutics/procedures • Image acquisition • Resources • Reference materials • Continuing education • Validation • Diagnostic accuracy • JCAHO requirement • Business plan • Cost effective • Healthcare product of sufficient quality • Patient satisfaction • Morbidity/mortality statistics

45. DSC: Strategy for success • Personnel • Primary care provider (PCP) • Skin evaluation clinic non-specialist provider • Teledermatology consultant • VISN2 Telemedicine consultant • Process • Patient management via CPRS • Image acquisition • Store-forward teledermatology • Coding • Performance • Training • Resources • Validation Performance Personnel Process

46. VISN2 Teledermatology Initiative