Sure, subjective and objective data can be gathered through appropriate questioning and video or pictures - but without the in-person touch, can telemedicine really capture comprehensive detail? Evidence suggests that teledermatology is finding a way to assure care quality while extending healthcare’s reach.
In the old days, it was done on paper – that SOAP note that medical students learn as a foundation of patient care. Documenting Subjective and Objective findings from the history and physical leads to a clinical Assessment and development of a Plan of care. And today, even if it’s not done on paper, you can be sure that some iteration of this quality care foundation is integrated into the proliferation of EMR programs across the globe.
But what about the limitations that telemedicine may place on the full SOAP picture? Sure, subjective and objective data can be gathered through appropriate questioning and video or pictures - but without the in-person touch, can needed detail really be captured comprehensively? It’s a hazard that some doctors are concerned about, both in terms of the quality of care, and the liability issues that may be attached. But in teledermatology, specialists and software providers are finding a way to address such concerns and improve access to quality care in the process.
First, let’s go over a few telemedicine basics – because they can directly how SOAP is integrated into the care process. There are two major types of modalities used in telemedicine:
1. Store-and-forward mode (SF) – involves sending images and patient data to a physician through a secure, web-based interface.
2. Live-interactive mode (LI) – provides real-time, synchronous interactions with a provider through a secure online platform.
Within these, various renditions of direct-to-patient and provider-to-provider connections are utilized. Direct-to-patient allows a patient to send information through a telemedicine platform to a physician. The provider-to-provider model allows another physician to send patient information to a specialist for either consultation or triage. Both have the potential to vastly expand the reach of physicians across the globe.
April Armstrong, MD, MPh, says she uses teledermatology extensively in her practice, focusing on the exclusive use of live-interactive telemedicine when the patient is with another provider at a coordinating site. She finds great potential in this model of care, and advocates for teledermatology’s voluntary initiative, AccessDerm. Its design allows volunteer American Academy of Dermatology (AAD) dermatologists to connect with underserved U.S. populations who have limited access to healthcare. Through it, remote dermatology consults are performed using mobile devices and a HIPPA compliant web-based platform – which gives primary care providers who work in participating clinics free access the expertise of AAD dermatologists. Licensure requirements limit consults to patients and specialists within the same state, and only 16 states are participating so far – which led to 962 consults to underserved patients by February 18, 2014.
It’s a sign that this field has come a long way since 1999, when Dr. Joseph Kvedar, the Founder and Director of the Center for Connected Health, was accused of cheapening the specialty of dermatology for his work on a web application that would allow uploading of images and history to a physician who could then make a diagnosis. He notes the incredible progress to the present, when dermatologists share images through a variety of telemedicine applications thousands of times a day. But even in the midst of his enthusiasm, he notes a number of continued challenges:
- The ability to form authentic relationships with patients
- The definition of quality care in the telemedicine environment
- The availability of necessary technology to get it right
It’s why Dr. Kvedar recommends a specific set of criteria for online care that will optimize the quality of the care experience:
- Identify a medical problem that has a diagnostic data set, easily and reliably acquired by a consumer/patient.
- Assure that the patient is capable of understanding that the online interaction is problem specific and may carry risks, particularly for omission of care involving other health problems.
- Assure that the treatment decisions for the specific condition at hand are algorithmic and do not require an authentic relationship (i.e., the problem is transactional or of low emotional value to both provider and patient).
Two direct patient-to-provider online dermatology companies that Kvedar says are using such criteria are Direct Dermatology and DermatologistsOnCall. Both use a version of the store-and-forward mode in which information and pictures are uploaded to a secure site, through which a dermatologist then responds within a specific period with a diagnosis and treatment plan.
Since studies show that telemedicine offers the same level of quality as in-person care - with lower costs and equal to higher rates of patient satisfaction - it seems teledermatology and other telespecialities are finding a way to get it right and extend the healthcare reach – including critical care, cardiology, radiology and pediatrics.
In primary care, Dr. Alan Rosenthal, a board-certified internist, says he usually gets enough information through a telemedicine consult, but if he doesn’t, he still recommends an in-person visit.
“Telemedicine requires you to be as good a history taker as you could ever imagine yourself being. In the vast majority of cases in medicine today – whether telemedicine or not – you can actually make a very accurate diagnosis predicted on history.”
An essential component of quality care includes providing it according to accepted clinical guidelines and standards of practice – which is why the ATA has developed practice standards and guidelines for a variety of specialties and applications, including teledermatology.
With this month’s JAMA report supporting the reliability and efficiency of teledermatology in clinical care, this specialty continues to lead the way in providing quality telemedicine – even if they’re doing it with a little less SOAP.
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