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Distributed Specialty Care
a telemedicine model for delivery of
dermatology specialty care in VISN 2
Craig C. Miller, MD, PhD
Brian C. Madden, PhD
13 November 2006
Overview
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Why?
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Imbalance between supply of dermatology
specialists and demand for treatment of skin
diseases in VISN 2
How?
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Distributed Specialty Care model
• Three-tiered system for delivery of skin care
• Primary care provider
• Skin Evaluation Clinic
• Teledermatology consultant
Shortage of dermatology
assets in VISN 2
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Dermatology demand
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Over 12,000 patient visits per year
Requirement to provide veterans with “specialty care”
Time constraints: 30-30-20 rule
Dermatology supply
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Limited VA staff dermatologists
• Disconnect between VA and civilian sectors
• Non-priority
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Lack of acceptable non-VA care
• Limited availability--unacceptable delays
• Expensive
VISN2 Dermatology Assets
DSC model: goals

Allows for more efficient utilization of
dermatology specialty assets
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Maintains high quality of care for skin
related disease
• Timely
• Efficacious
DSC model: key features
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Store-forward technology
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Skin Evaluation Clinic
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Trained non-specialist skin care providers
Intermediaries between primary care and the
specialist
Performance measures
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Dynamic adaptive system
Continuous enhancement
Telemedicine methodology
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Real-time
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Video with synchronous (“face-to-face”) patientconsultant encounters
• Low resolution, high bandwidth
• Inefficient utilization of consultant
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Store-forward
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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
DSC: Three-tier delivery system
Primary Care Provider
Service Agreement
Skin Evaluation Clinic
Rules of Engagement
Teledermatology
Consultant
Tier 1: Primary care provider

Identify patient with skin complaint
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Utilize Skin Evaluation consult
menu to direct patient care
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Initiate consultation with Skin
Evaluation Clinic (when
appropriate)
Skin Evaluation consult menu
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Decision Tree for managing patients with skin dz
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Service Agreement
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Determines appropriateness of consultation
Directs patient flow
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
Dermatology Decision Tree: an algorithm for skin dz patient flow
Disease Decision Tree for Dermatology
Patient with Skin Problem
Presents to PCP
Q1: Is it emergent?
N
Y
Send to ED
Q2: Is it a known Dx?
Y
N
Q3: Is it appropriate
for dermatology?
Send to Skin Evaluation
N
Y
Send to Other
Service / Off Service
Q4: Is it treatable?
Y
N
Send to Skin Evaluation
Q5: Is it responsive?
N
Send to Skin Evaluation
Y
Discharge or maintenance
(patient remains with PCP)
Components of Service
Agreement
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Part A
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Part B
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Known conditions and treatments
Priorities of unknowns and areas of concern
Part C
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Uncovered items (limited resources)
APPENDIX 1:
PCP/SEC Service Agreement Ğ Protocol for Scheduling Consults
Will accept referrals to the teledermatology service for some known conditions of the skin that
have failed treatment attempts (see part A) and conditions of the skin with uncertain diagnoses
(see part B) but will not accept referrals for some other skin conditions (see part C).
(A) Will accept referrals for
the following known conditions
only after initial therapy has
failed:
Psoriasis
Treatment needed prior to consultation:
Trunk/ext remities: fluocinonide ointment qhs and calcipotriene
ointment qam for 8 weeks.
Body folds: calcipotriene ointment and desonide ointment +/ketoconazole cream bid for 8 weeks.
Seborrheic dermatitis
Scalp: calcipot riene scalp solution qam, betamethsone valerate
foam qhs for 8 weeks.
Scalp: ketoconazole shampoo 2-3 times a week; betamethsone
valerate foam qhs prn itching for 6-8 weeks.
Face/ears/chest: ketoconazole and desonide creams bid for 6-8
weeks.
Rosacea
Stasis d ermatitis
Hand eczema
Dermatophyte infection (tinea
cruris, tinea pedis, tinea
corporis, tinea manum)
Acne
Acute (< 6 wks) urticaria
(ÒhivesÓ)
Initially try metronidazole cream bid to face for 6-8 weeks; if no
improvement, try clindamycin 1% solution or sulfacetamide/sulfur
lotion bid or, for more severe cases, tetracycline 500 mg PO bid for
8 weeks.
Leg elevation, compression stockings (20 mm Hg /below the knee-make sure there is no lower extremity arterial disease), and
triamcinolone 0.1% ointment qhs for 6-8 weeks; if ulcers are
present, try silvadene cream; if no improvement, refer to
Vascular/Wound Care Clinic.
Clobetasol ointment bid for 4 weeks. Tell patient to avoid irritants
(e.g. frequent hand washing/chemicals/detergents).
Loprox bid for 6-8 weeks.
For mild acne, use a topical antibiotic such as clindamycin solution
qam and a topical retinoid such as tretinoin 0.025% cream qhs for
6-8 weeks.
For more severe inflamm atory acne, use the above topicals in
addition to an 8 week course of an oral antibiotic such as
tetracycline 500 mg PO bid, doxycyc line 100 mg PO bid, or
minocycline 100 mg PO bid.
Oral antihistamines; consider prednisone taper (starting with 40-60
mg qam and tapering over 2 wks); identify and mitigate underlying
etiology (e.g., drugs, infection, foods)
Warts (non-genital)
Genital warts (male)
(B) Will accept referrals for
unknown conditions with the
following signs or symptoms:
Initially tr eat with topical salicylic acid plaster for 8 weeks and/or
liquid nitrogen for 3 treatments, 4 weeks apart.
Podophyllin solution M-W-F for 4 wks, cryotherapy (liquid nitrogen)
or imiquimod cream M-W-F for 4 wks.
Details:
SEC appointment priority:
Bliste ring | purpuric < 10% BSA and
non-systemic
Bliste ring | purpuric > 10% BSA or
systemic
Other
Any
+ABC D | ulcerated
Other
Ulcerated | multinodular | rapid
growth (< month)
Other
Pruritus / Dysesthesia
Deep dermal or sub-cutaneous
nodules with no overlying change
Masking of signs by dark skin tones
(Types V-VI)
w/i 24-48 hours
(C) Will not accept referrals
for:
Suggestions:
Consider referral to:
Removal of skin tags
Limited liquid nitrogen (try Òfreeze
clampÓtechnique - dip needle holder
in liquid nitrogen and then pinch skin
tags until f rozen down to the base).
Consider no treatment given the cost,
potential side effects of oral therapy,
and high rate of recurrence.
No treatment is necessary unless
clinically indicated.
Liquid nitrogen (requires less than
what a wart requires).
SURGERY/ENT/OPHTH O
Try podophyllin solution, liquid
nitrogen, or imiquimod cream.
Refer to Dermatology Note for any
restrictions on use
OB-GYN
Acute Rash
Chronic Rash
Pigmented Lesion
Non-Pigmented Lesion
No visible signs
Toenail onyc homycosis
(fungal nail)
Removal of benign
melanocytic nevi (ÒmolesÓ)
Removal of seborrheic
keratoses (we wi ll treat an
irritated/inflamed lesion that is
causing the patient discomfort;
please do not refer patients for
purely cosmetic reasons)
Treatment of genital warts
(female)
Topical medication renewal
send to ED promptly
w/i 1
w/i 4
w/i 1
w/i 4
w/i 2
week
weeks
week
weeks
weeks
w/i 4 weeks
w/i 4 weeks
w/i 4 weeks
w/i 4 weeks
PODIAT RY
SURGERY or ENT
SURGERY or ENT
N/A
Tier 2: Skin Evaluation Clinic
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Evaluate patient
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Initiate treatment or perform diagnostic tests
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Acquire images according to
the “rules of engagement”
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Enter teledermatology consult
(when appropriate)
Skin evaluation clinic providers
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Various backgrounds
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Nurse practitioners/Physician assistants
Dermatology residents
Primary care physicians
Training
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Training in dermatology clinic
• Approach to the dermatology patient
• Rudimentary dermatology differential diagnosis
• Introduction to dermatology therapeutics
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Hands-on training in techniques
• Biopsy--shave, punch
• Cryotherapy
• Electrodessication and curettage
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Hands-on training in image acquisition
Access to dermatology educational resources
Feedback
Rules of Engagement
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Initial consult that specifically refers to evaluation of a lesion for suspected
malignancy
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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
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Any patient that requires a biopsy
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Any patient that will be started on systemic
medications that require monitoring
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Patch test evaluation
The Camera
8 MP SLR camera
 Macro lens
 Macro flash
 Back-up available
 Technical support
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The Canon EOS Digital Rebel with the Canon EF 100mm
f/2.8 USM Macro Lens and Canon Macro Twin Lite
Image acquisition/capture
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Image acquisition
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Patient ID
Contextual (anatomic context)
Morphological (diagnostic
close-up)
Image capture
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Client software/access
Card reader
Image quality
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Literature
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Standards for image resolution/color
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supports the validity of teledermatology in diagnosis of skin
lesions
DSC standards >> American Academy of Dermatology and the
American Telemedicine Association
Future DICOM standard
Techniques to ensure image quality
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Standard and simple image acquisition process
Calibration for “true” colors
Training
Feedback
Validation
Tier 3: Teledermatology consultant
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Review SEC note
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View images
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VistA Image Display
Document
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Emphasis on history
Link to Teledermatology consultation
Template
Code
DSC: Three-tier delivery system
Primary Care Provider
Service Agreement
Skin Evaluation Clinic
Rules of Engagement
Teledermatology
Consultant
Performance
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Training
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Basic dermatology therapeutics/procedures
Image acquisition
Resources
• Reference materials
• Continuing education
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Validation
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Diagnostic accuracy
• JCAHO requirement
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Business plan
• Cost effective
• Healthcare product of sufficient quality
• Patient satisfaction
• Morbidity/mortality statistics
DSC: Strategy for success
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Personnel
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Performance
Process
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Primary care provider (PCP)
Skin evaluation clinic non-specialist provider
Teledermatology consultant
VISN2 Telemedicine consultant
Patient management via CPRS
Image acquisition
Store-forward teledermatology
Coding
Performance
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Training
Resources
Validation
Personnel
Process
VISN2 Teledermatology Initiative