lessons on teledermatology from covid-19 and planning the
TRANSCRIPT
Lessons on Teledermatology from COVID-19 and Planning the Future
Jules Lipoff, MDAssistant Professor
Department of DermatologyUniversity of Pennsylvania
@juleslipoffjuleslipoff.com
Jules Lipoff, MDU003 – Lessons on Teledermatology from COVID-19 and Planning the Future
DISCLOSURESHavas Life Medicom: Consultant – Honoraria
AcneAway: Advisor – No Compensation Received
DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY
My telemedicine advocacy and COI
¨ Outgoing Chair¤ AAD Teledermatology Task Force
¨ Member of AAD ¤ COVID-19 Task Force¤ Emerging Practice Models Committee (outgoing)¤ Augmented Intelligence Task Force (outgoing)
Telemedicine surge in COVID-19
¨ In a pandemic, telemedicine¤ Increases access and allows care to continue
if in person not possible¤ Triages, decides who gets in person care¤ Saves personal protective equipment¤ All while social distancing to minimize risk
for viral transmission
Telemedicine surge in COVID-19
Pre-pandemic US teledermatology
¨ Mobile teledermatology established as acceptably equivalent in diagnosis and management
¨ However, teledermatology pre-pandemic not widely used because of barriers to implementation¤ Non-reimbursement¤ Concerns about liability¤ Restrictions imposed by medical licensing
¨ Unclear what long-term policy changes will be post-COVID-19
¨ Mobile teledermatology established as acceptably equivalent in diagnosis and management
¨ However, teledermatology pre-pandemic not widely used because of barriers to implementation¤ Non-reimbursement¤ Concerns about liability¤ Restrictions imposed by medical licensing
¨ Unclear what long-term policy changes will be post-COVID-19
PARITY FOR VIDEO VISITS!
WAIVER OF HIPAA AND USE OF ALL PLATFORMS!
LICENSING RECIPROCITY!
Pre-pandemic US teledermatology
¨ Purpose and Methods¤ To document how AAD members were increasing their use of
teledermatology¤ May and June 2020¤ Subgroup surveyed members about effects of COVID-19 on
teledermatology¤ The AAD administered the survey via email, collected and maintained data,
and provided deidentified data for analysis¤ Randomly selected 5000 participants from the group of 12,070 practicing
US dermatologist members, 591 dermatologists completed surveys (13.5% response rate)
Teledermatology Task Force survey
Teledermatology Task Force surveyLetters
RESEARCH LETTER
Dermatologist Perceptions of TeledermatologyImplementation and Future Use After COVID-19:Demographics, Barriers, and InsightsTeledermatology is an effective method for delivering healthcare, with strong evidence supporting its use, yet barriers havestalled implementation, including lack of reimbursement, li-ability concerns, and licensing restrictions.1,2 The coronavi-
rus disease 2019 (COVID-19)pandemic crisis led to rapidadoption of telemedicine to
continue care while minimizing in-person contact.3
Historically, most teledermatology studies have focusedon store-and-forward models, whereas during the COVID-19pandemic, regulatory changes from the US Centers for Medi-care and Medicaid Services prompted an increase in live-interactive video visits. These changes granted parity in reim-bursements between video and in-person visits, removingeligibility and geographic restrictions.4,5 We sought to assessdermatologists’ perceptions of and experiences with teleder-matology in the context of the COVID-19 pandemic and thesenew changes.
Methods | In May and June 2020, an American Academy of Der-matology (AAD) Teledermatology Task Force subgroup sur-veyed AAD members regarding the effects of COVID-19 on tele-dermatology. Topics included modes used; situationalappropriateness; and opinions regarding reimbursement, per-ceived need, barriers, and anticipated future use. Questionswere tested for face validity and readability and approved bythe Task Force and AAD representatives (see Supplement fordetailed methods). The AAD administered the survey via email,collected and maintained data, and provided deidentified datafor analysis. Participant representativeness based on age, sex,
practice type, practice location, employment type, and priorteledermatology use was evaluated. This study was deemedexempt by the University of Utah Institutional Review Board.
Results | Of the randomly selected 5000 participants from thegroup of 12 070 practicing US dermatologist members of theAAD, 591 dermatologists completed surveys (13.6% responserate). Mean participant age was 49.3 years (95% CI, 48.4-50.3), with most practicing in dermatology-based group (257of 571, 45.0%) and solo (141 of 571, 24.7%) practice. Prior to theCOVID-19 pandemic, 82 of 582 (14.1%) respondent dermatolo-gists had used teledermatology, compared with 572 of 591(96.9%) during the COVID-19 pandemic; 323 of 557 (58.0%) ex-pected to continue teledermatology use after the COVID-19pandemic. Live-interactive was the most common modality,for 538 of 572 respondents (94.1%), and 406 of 564 (72.0%)of respondents perceived the hybrid model combining videoand stored photographs as having the greatest accuracy. Themost common barriers to implementation included technol-ogy/connectivity issues during visits (223 of 570, 39.1%), lowreimbursement (398 of 570, 69.8%), concerns regarding mal-practice/liability (154 of 570, 27.0%), and government regula-tions (132 of 570 23.2%). The majority of respondents (357 of419, 85.2%) felt reimbursement for store-and-forward tele-dermatology was too low. When asked about the appropriate-ness of teledermatology for 5 common complaints (total bodyskin examination, concerning lesion, acne, rash, bleedingmole), 512 of 535 (95.7%) felt that skin checks required in-person examination, compared with 14 of 549 (2.6%) for acne(Figure).
Older dermatologists were less likely to report reimburse-ment concerns (odds ratio [OR] = 0.96; 95% CI, 0.94-0.99;P = .02) or malpractice/liability concerns (OR = 0.98; 95% CI,0.96-0.99; P = .02). Male respondents were more likely to re-
Figure. Dermatologist Recommendation of Visit Type According to Skin Complaint
100
80
60
40
20
0
Perc
ent o
f phy
sici
ans s
urve
yed
Type of visitLO or LVLO LO or LV or SDP LVLO or SDP SDPLV or SDP
Bleeding mole
Concerning lesion
Acne
Rash
Total body skin examination
Dermatologists were asked what visittype(s) were appropriate for a totalbody skin examination (darkest blue),a bleeding mole (slate blue), aconcerning lesion (medium blue), arash (paler blue), or acne (lightestblue). For a total body skinexamination, 95.7% ofdermatologists felt only a live,in-office visit (LO) was appropriate.Conversely, for acne, only 2.6% ofdermatologists felt that an in-officevisit was the only appropriateselection, with the remainder notingeither teledermatology or in-officevisit (52.5%) or teledermatologyalone (44.8%). Abbreviations: LO,live office visit; LV, live video visit;SDP, stored digital photography.
Supplemental content
jamadermatology.com (Reprinted) JAMA Dermatology Published online March 31, 2021 E1
jamanetwork/2021/der/03_31_2021/dld210001pap PAGE: right 1 SESS: 20 OUTPUT: Mar 5 9:59 2021© 2021 American Medical Association. All rights reserved.
Letters
RESEARCH LETTER
Dermatologist Perceptions of TeledermatologyImplementation and Future Use After COVID-19:Demographics, Barriers, and InsightsTeledermatology is an effective method for delivering healthcare, with strong evidence supporting its use, yet barriers havestalled implementation, including lack of reimbursement, li-ability concerns, and licensing restrictions.1,2 The coronavi-
rus disease 2019 (COVID-19)pandemic crisis led to rapidadoption of telemedicine to
continue care while minimizing in-person contact.3
Historically, most teledermatology studies have focusedon store-and-forward models, whereas during the COVID-19pandemic, regulatory changes from the US Centers for Medi-care and Medicaid Services prompted an increase in live-interactive video visits. These changes granted parity in reim-bursements between video and in-person visits, removingeligibility and geographic restrictions.4,5 We sought to assessdermatologists’ perceptions of and experiences with teleder-matology in the context of the COVID-19 pandemic and thesenew changes.
Methods | In May and June 2020, an American Academy of Der-matology (AAD) Teledermatology Task Force subgroup sur-veyed AAD members regarding the effects of COVID-19 on tele-dermatology. Topics included modes used; situationalappropriateness; and opinions regarding reimbursement, per-ceived need, barriers, and anticipated future use. Questionswere tested for face validity and readability and approved bythe Task Force and AAD representatives (see Supplement fordetailed methods). The AAD administered the survey via email,collected and maintained data, and provided deidentified datafor analysis. Participant representativeness based on age, sex,
practice type, practice location, employment type, and priorteledermatology use was evaluated. This study was deemedexempt by the University of Utah Institutional Review Board.
Results | Of the randomly selected 5000 participants from thegroup of 12 070 practicing US dermatologist members of theAAD, 591 dermatologists completed surveys (13.6% responserate). Mean participant age was 49.3 years (95% CI, 48.4-50.3), with most practicing in dermatology-based group (257of 571, 45.0%) and solo (141 of 571, 24.7%) practice. Prior to theCOVID-19 pandemic, 82 of 582 (14.1%) respondent dermatolo-gists had used teledermatology, compared with 572 of 591(96.9%) during the COVID-19 pandemic; 323 of 557 (58.0%) ex-pected to continue teledermatology use after the COVID-19pandemic. Live-interactive was the most common modality,for 538 of 572 respondents (94.1%), and 406 of 564 (72.0%)of respondents perceived the hybrid model combining videoand stored photographs as having the greatest accuracy. Themost common barriers to implementation included technol-ogy/connectivity issues during visits (223 of 570, 39.1%), lowreimbursement (398 of 570, 69.8%), concerns regarding mal-practice/liability (154 of 570, 27.0%), and government regula-tions (132 of 570 23.2%). The majority of respondents (357 of419, 85.2%) felt reimbursement for store-and-forward tele-dermatology was too low. When asked about the appropriate-ness of teledermatology for 5 common complaints (total bodyskin examination, concerning lesion, acne, rash, bleedingmole), 512 of 535 (95.7%) felt that skin checks required in-person examination, compared with 14 of 549 (2.6%) for acne(Figure).
Older dermatologists were less likely to report reimburse-ment concerns (odds ratio [OR] = 0.96; 95% CI, 0.94-0.99;P = .02) or malpractice/liability concerns (OR = 0.98; 95% CI,0.96-0.99; P = .02). Male respondents were more likely to re-
Figure. Dermatologist Recommendation of Visit Type According to Skin Complaint
100
80
60
40
20
0
Perc
ent o
f phy
sici
ans s
urve
yed
Type of visitLO or LVLO LO or LV or SDP LVLO or SDP SDPLV or SDP
Bleeding mole
Concerning lesion
Acne
Rash
Total body skin examination
Dermatologists were asked what visittype(s) were appropriate for a totalbody skin examination (darkest blue),a bleeding mole (slate blue), aconcerning lesion (medium blue), arash (paler blue), or acne (lightestblue). For a total body skinexamination, 95.7% ofdermatologists felt only a live,in-office visit (LO) was appropriate.Conversely, for acne, only 2.6% ofdermatologists felt that an in-officevisit was the only appropriateselection, with the remainder notingeither teledermatology or in-officevisit (52.5%) or teledermatologyalone (44.8%). Abbreviations: LO,live office visit; LV, live video visit;SDP, stored digital photography.
Supplemental content
jamadermatology.com (Reprinted) JAMA Dermatology Published online March 31, 2021 E1
jamanetwork/2021/der/03_31_2021/dld210001pap PAGE: right 1 SESS: 20 OUTPUT: Mar 5 9:59 2021© 2021 American Medical Association. All rights reserved.
Bottom line
¨ COVID-19 caused a huge increase in teledermatology use among dermatologists – of course, but quantified:
¤ Pre-pandemic: 14.1%
¤ Since COVID: 96.9%
↓
¨ The most common barriers to implementation include:
¤ Technology/connectivity issues during visits (39.1%)¤ Low reimbursement (69.8%)¤ Concerns regarding malpractice/ liability (27.0%)¤ Government regulations (23.2%) ¤ Majority of respondents (85.2%) felt reimbursement for store-and-
forward teledermatology was too low.
Bottom line
What is teledermatology best suited for?
Letters
RESEARCH LETTER
Dermatologist Perceptions of TeledermatologyImplementation and Future Use After COVID-19:Demographics, Barriers, and InsightsTeledermatology is an effective method for delivering healthcare with strong evidence supporting use, yet barriers havestalled implementation, including lack of reimbursement, li-ability concerns, and licensing restrictions.1,2 The coronavi-
rus disease 2019 (COVID-19)pandemic crisis led to rapidadoption of telemedicine to
continue care while minimizing in-person contact.3
Historically, most teledermatology studies have focusedon store-and-forward models, whereas during the COVID-19pandemic, regulatory changes from the US Centers for Medi-care and Medicaid Services prompted an increase in live-interactive video visits. These changes granted parity in reim-bursements between video and in-person visits, removingeligibility and geographic restrictions.4,5 We sought to assessdermatologists’ perceptions of and experiences with teleder-matology in the context of the COVID-19 pandemic and thesenew changes.
In May and June 2020, an American Academy of Derma-tology (AAD) Teledermatology Task Force subgroup sur-veyed AAD members regarding the effects of COVID-19 on tele-dermatology. Topics included modes used; situationalappropriateness; and opinions regarding reimbursement, per-ceived need, barriers, and anticipated future use. Questionswere tested for face validity and readability and approved bythe Task Force and AAD representatives (see Supplement fordetailed methods). The AAD administered the survey via email,collected and maintained data, and provided deidentified datafor analysis. Participant representativeness based on age, sex,practice type, practice location, employment type, and prior
teledermatology use was evaluated. This study was deemedexempt by the University of Utah Institutional Review Board.
Of the randomly selected 5000 participants from the groupof 12 070 practicing US dermatologist members, 591 derma-tologists completed surveys (13.5% response rate). Mean (SD)participant age was 49.3 years (95% CI, 48.4-50.3), with mostpracticing in dermatology-based group (257 of 571, 45.0%) andsolo (141 of 571, 24.7%) practice. Prior to the COVID-19 pan-demic, 82 of 582 (14.1%) of respondent dermatologists had usedteledermatology, compared with 572 of 591 (96.9%) during theCOVID-19 pandemic; 323 of 557 (58.0%) expected to con-tinue teledermatology use after the COVID-19 pandemic. Live-interactive was the most common modality, for 538 of 572 re-spondents (94.1%), and 406 of 564 (72.0%) of respondentsperceived the hybrid model combining video and stored pho-tographs as having the greatest accuracy. The most commonbarriers to implementation included technology/connectiv-ity issues during visits (223 of 570, 39.1%), low reimburse-ment (X of X, 30.2%), concerns regarding malpractice/liability (154 of 570, 27.0%), and government regulations (132of 570 23.2%). The majority of respondents (357 of 419, 85.2%)felt reimbursement for store-and-forward teledermatology wastoo low. When asked about the appropriateness of telederma-tology for 5 common complaints (total body skin exam, con-cerning lesion, acne, rash, bleeding mole), 512 of 535 (95.7%)felt that skin checks required in-person examination, com-pared with 14 of 549 (2.6%) for acne (Figure).
Older dermatologists were less likely to report reimburse-ment concerns (odds ratio [OR] = 0.96; 95% CI, 0.94-0.99;P = .02) or malpractice/liability concerns (OR = 0.98; 95% CI,0.96-0.99; P = .02). Male respondents were more likely to re-port reimbursement being too low (OR = 1.95; 95% CI, 1.03-3.70; P = .04). Rural dermatologists were more likely to usenon-HIPAA compliant platforms (OR = 2.41; 95% CI, 1.04-
Figure. Dermatologist Recommendation of Visit Type According to Skin Complaint
100
80
60
40
20
0
Perc
ent o
f phy
sici
ans s
urve
yed
Type of visitLO or LVLO LO or LV or SDP LVLO or SDP SDPLV or SDP
Bleeding mole
Concerning lesion
Acne
Rash
Total body skin exam
Dermatologists were asked what visittype(s) were appropriate for a totalbody skin exam (darkest blue), ableeding mole (slate blue), aconcerning lesion (medium blue), arash (paler blue), or acne (lightestblue). For a total body skin exam,95.7% of dermatologists felt only alive, in-office visit (LO) wasappropriate. Conversely, for acne,only 2.6% of dermatologists felt thatan in-office visit was the onlyappropriate selection, with theremainder noting eitherteledermatology or in-office visit(52.5%) or teledermatology alone(44.8%). Abbreviations: LO, liveoffice visit; LV, live video visit; SDP,stored digital photography.
Supplemental content
jamadermatology.com (Reprinted) JAMA Dermatology Published online March 31, 2021 E1
jamanetwork/2021/der/03_31_2021/dld210001pap PAGE: right 1 SESS: 4 OUTPUT: Feb 24 11:42 2021© 2021 American Medical Association. All rights reserved.
Future implementation
¨ 70% dermatologists believed teledermatology will continue after COVID-19, while only 58% said they intended to continue use
¨ Thus, dermatologists perceive telederm’s importance, but have concerns¤ Highlights need for supportive reimbursements, regulations, and
technological innovation (connectivity and functionality were common concerns)
Future implementation
¨ Refinement of workflow by patient and visit-type selection (new vs. follow-up, acne vs. skin checks, etc.)
¨ Though new precedents set, future of telemedicine highly dependent on regulation, reimbursement, and technology moving forward
The digital divide
¨ Video visits require great bandwidth, and many poor/minorities¨ 26% of Americans with annual income under $30,000 are smartphone-
dependent for internet¨ Also, wealthier non-urgent patients with greater access take up more of
physicians’ limited time, with downstream effects
JAAD ONLINE: NOTES & COMMENTS
The digital divide: How COVID-19’stelemedicine expansion couldexacerbate disparities
To the Editor: In recent months, closure of nones-sential outpatient practices prompted the Centers forMedicare & Medicaid Services to ease regulations ontelemedicine. The resultant rapid adoption and in-vestment in telemedicine may normalize telemedi-cine for the mainstream by increasing patient andphysician familiarity and introduce clinical changesthat endure after the threat of COVID-19 subsides.
Advancement of teledermatology should intui-tively expand access to care, given its convenience,cost effectiveness, and triage capabilities.1 However,despite increasing access, we must consider howincreased telemedicine could paradoxically create orexacerbate health disparities, with early evidenceraising concern.2
Health disparities in dermatology already exist forminority patients and those with low income; forexample, for African American patients, this includesinadequate physician training with skin of color,unequal access, and increased mortality.3 For direct-to-patient telemedicine, not all patients have equalaccess. Consider the equipment needed for videovisits: smartphones, tablets, or computers and areliable internet connection. Device ownership andinternet use correlate with age, education, andincome: 26% of Americans with an annual incomeof less than $30,000 rely exclusively on smartphoneinternet access.4 Furthermore, US FederalCommunications Commission reports confirm sig-nificant household income differences betweenthose with and without broadband internet.5
Although most without internet access live in ruralareas, digital infrastructure barriers also affect urbansettings: in New York City, almost 50% of low-income households lack internet access.6 Not onlydoes poor infrastructure limit access, but wealthierconsumers’ use could drive up costs and crowd outphysicians’ limited clinical time from the under-served patients who need it most.
Beyond digital access, telehealth services mustmeet quality standards, and inconsistent quality mayburden vulnerable populations more. The AmericanTelemedicine Association’s guidelines for telederma-tology emphasize the importance of high-qualityimages, lighting, and positioning, with challengesfor evaluating moles (especially in difficult-to-photograph areas, such as hair-bearing skin). As weexpand, we must ensure that high quality standards
(including technologic and compliance with theHealth Insurance Portability and Accountability Act)remain paramount.
We concede that although we strive to provideexcellent care, ensuring internet access for everyone isbeyond our reach. Still, as telemedicine is poised totransform the clinical landscape, to encourage healthequity, we must advocate for digital equity, and wemust anticipate and address disparities before theygrow. Solutions may include greater use of store-and-forward telemedicine compared to video visits, whichrequire greater bandwidth; additional clinical appoint-ments for thosewithout proper devices; and nonprofitpartnerships to redistribute refurbished devices, as inpublic education. Beyond devices, physicians shouldencourage digital literacy as an acquired skill,providing educational training on telemedicine, andconsider technical support staff for practices. Further,as Congress considers increased broadband infra-structure in rural areas, we must remind lawmakersthat cities also have digital inequities.
Doctors and public health advocates shouldencourage equitable telemedicine access as it ex-pands now. Dermatology is especially poised tolead the way, given its large body of research andexperience. We must anticipate the risks of exacer-bating disparities and of delivering less and lower-quality care to our most underserved patients. If wedo not, internet access and device ownership couldbecome social determinants of health.
Mina Bakhtiar, BA,a Nada Elbuluk, MD, MSc,b andJules B. Lipoff, MDc
From the Perelman School of Medicine, Universityof Pennsylvania, Philadelphia, Pennsylvaniaa;Department of Dermatology, Keck School ofMedicine of University of Southern California,Los Angeles, Californiab; and Department ofDermatology, Perelman School of Medicine,University of Pennsylvania, Philadelphia,Pennsylvania.c
Funding sources: None.
Conflicts of interest: None disclosed.
IRB approval status: Not applicable.
Reprints not available from the authors.
Correspondence to: Jules B. Lipoff, MD, PennMedicine University City, 3737 Market St, Suite1100, Philadelphia, PA 19104
E-mail: [email protected]
J AM ACAD DERMATOL NOVEMBER 2020 e345
REFERENCES1. Lee J, English JC. Teledermatology: a review and update. Am J
Clin Dermatol. 2018;19(2):253-260.2. Eberly LA, Khatana SAM, Nathan AS, et al. Telemedicine
outpatient cardiovascular care during the COVID-19 pandemic:bridging or opening the digital divide? Circulation. 2020. https://doi.org/10.1161/CIRCULATIONAHA.120.048185.
3. Dawes SM, Tsai S, Gittleman H, Barnholtz-Sloan JS,Bordeaux JS. Racial disparities in melanoma survival. J AmAcad Dermatol. 2016;75(5):983-991.
4. Anderson M, Kumar M. Digital divide persists even aslower-income Americans make gains in tech adoption. PewResearch Center. Available at: https://www.pewresearch.org/fact-tank/2019/05/07/digital-divide-persists-even-as-lower-
income-americans-make-gains-in-tech-adoption/; 2019. AccessedMay 28, 2020.
5. Federal Communications Commission 2020 BroadbandDeployment Report. Available at: https://docs.fcc.gov/public/attachments/FCC-20-50A1.pdf; 2020. Accessed May28, 2020.
6. City of New York. De Blasio Administration Releases InternetMaster Plan For City’s Broadband Future. Available at: https://www1.nyc.gov/office-of-the-mayor/news/010-20/de-blasio-administration-releases-internet-master-plan-city-s-broadband-future; 2020.
https://doi.org/10.1016/j.jaad.2020.07.043
J AM ACAD DERMATOL
NOVEMBER 2020e346 Notes & Comments
JAAD ONLINE: NOTES & COMMENTS
The digital divide: How COVID-19’stelemedicine expansion couldexacerbate disparities
To the Editor: In recent months, closure of nones-sential outpatient practices prompted the Centers forMedicare & Medicaid Services to ease regulations ontelemedicine. The resultant rapid adoption and in-vestment in telemedicine may normalize telemedi-cine for the mainstream by increasing patient andphysician familiarity and introduce clinical changesthat endure after the threat of COVID-19 subsides.
Advancement of teledermatology should intui-tively expand access to care, given its convenience,cost effectiveness, and triage capabilities.1 However,despite increasing access, we must consider howincreased telemedicine could paradoxically create orexacerbate health disparities, with early evidenceraising concern.2
Health disparities in dermatology already exist forminority patients and those with low income; forexample, for African American patients, this includesinadequate physician training with skin of color,unequal access, and increased mortality.3 For direct-to-patient telemedicine, not all patients have equalaccess. Consider the equipment needed for videovisits: smartphones, tablets, or computers and areliable internet connection. Device ownership andinternet use correlate with age, education, andincome: 26% of Americans with an annual incomeof less than $30,000 rely exclusively on smartphoneinternet access.4 Furthermore, US FederalCommunications Commission reports confirm sig-nificant household income differences betweenthose with and without broadband internet.5
Although most without internet access live in ruralareas, digital infrastructure barriers also affect urbansettings: in New York City, almost 50% of low-income households lack internet access.6 Not onlydoes poor infrastructure limit access, but wealthierconsumers’ use could drive up costs and crowd outphysicians’ limited clinical time from the under-served patients who need it most.
Beyond digital access, telehealth services mustmeet quality standards, and inconsistent quality mayburden vulnerable populations more. The AmericanTelemedicine Association’s guidelines for telederma-tology emphasize the importance of high-qualityimages, lighting, and positioning, with challengesfor evaluating moles (especially in difficult-to-photograph areas, such as hair-bearing skin). As weexpand, we must ensure that high quality standards
(including technologic and compliance with theHealth Insurance Portability and Accountability Act)remain paramount.
We concede that although we strive to provideexcellent care, ensuring internet access for everyone isbeyond our reach. Still, as telemedicine is poised totransform the clinical landscape, to encourage healthequity, we must advocate for digital equity, and wemust anticipate and address disparities before theygrow. Solutions may include greater use of store-and-forward telemedicine compared to video visits, whichrequire greater bandwidth; additional clinical appoint-ments for thosewithout proper devices; and nonprofitpartnerships to redistribute refurbished devices, as inpublic education. Beyond devices, physicians shouldencourage digital literacy as an acquired skill,providing educational training on telemedicine, andconsider technical support staff for practices. Further,as Congress considers increased broadband infra-structure in rural areas, we must remind lawmakersthat cities also have digital inequities.
Doctors and public health advocates shouldencourage equitable telemedicine access as it ex-pands now. Dermatology is especially poised tolead the way, given its large body of research andexperience. We must anticipate the risks of exacer-bating disparities and of delivering less and lower-quality care to our most underserved patients. If wedo not, internet access and device ownership couldbecome social determinants of health.
Mina Bakhtiar, BA,a Nada Elbuluk, MD, MSc,b andJules B. Lipoff, MDc
From the Perelman School of Medicine, Universityof Pennsylvania, Philadelphia, Pennsylvaniaa;Department of Dermatology, Keck School ofMedicine of University of Southern California,Los Angeles, Californiab; and Department ofDermatology, Perelman School of Medicine,University of Pennsylvania, Philadelphia,Pennsylvania.c
Funding sources: None.
Conflicts of interest: None disclosed.
IRB approval status: Not applicable.
Reprints not available from the authors.
Correspondence to: Jules B. Lipoff, MD, PennMedicine University City, 3737 Market St, Suite1100, Philadelphia, PA 19104
E-mail: [email protected]
J AM ACAD DERMATOL NOVEMBER 2020 e345
Will telemedicine endure past COVID-19?
Barriers moving forward
¨ Policy changes¤ Only promised through public health emergency¤ Will state licensing reciprocity endure?¤ HIPAA flexibility unlikely to persist
¨ Reimbursement¤ Parity with video visits helps, but video visits aren’t necessarily more
efficient for providers¤ We need greater reimbursement for store-and-forward
Summary
n The COVID-19 pandemic put telemedicine and teledermatology in the spotlight, especially after government regulations were relaxed
n As the AAD Teledermatology Task Force survey indicates, teledermatologywas widely adopted by US dermatologists, but concerns remain about future use and implementation
n Despite limitations, telemedicine will likely find a permanent home in all practices, though appropriate use continues to be refined
n Despite proven efficacy of teledermatology, barriers to implementation remain (specifically reimbursement)
AAD Teledermatology resources
https://www.aad.org/member/practice/telederm/toolkit
Acknowledgments
n AAD Teledermatology Task Force subgroup
n Jonathan Kennedy, BSn Siobhan Arey, MPH, MS, PA-Cn Ramsay Farah, MDn George Han, MD,n Linda Camaj Deda, BSn Rebecca Goldberg, BSn Trilokraj Tejasvi, MD*
* new Task Force chair
n Zachary Hopkins, MDn Jason Mathis, MDn Aaron Secrest, MD, PhDn Jules Lipoff, MD – outgoing Task Force chairn Rosie Balk, MA (data management)n Jeff Miller, PhD (data management)n Martha Wojtowycz, PhD (survey question validation)
