Organizational Readiness for Patient-Facing Mobile Teledermatology to Care for Established Veteran Patients in the United States

Barriers and Facilitators to Teledermatology and Tele-Eye Care in Department of Veterans Affairs Provider Settings: Qualitative Content Analysis

BACKGROUND

Veterans Affairs health care systems have been early adopters of asynchronous telemedicine to provide access to timely and high-quality specialty care services in primary care settings for veterans living in rural areas. Scant research has examined how to expand primary care team members' engagement in telespecialty care.

OBJECTIVE

This qualitative study aimed to explore implementation process barriers and facilitators to using asynchronous telespecialty care (teledermatology and tele-eye care services).

METHODS

In total, 30 participants including primary care providers, nurses, telehealth clinical technicians, medical and program support assistants, and administrators from 2 community-based outpatient clinics were interviewed. Semistructured interviews were conducted using an interview guide, digitally recorded, and transcribed. Interview transcripts were analyzed using a qualitative content analysis summative approach. Two coders reviewed transcripts independently. Discrepancies were resolved by consensus discussion.

RESULTS

In total, 3 themes were identified from participants' experiences: positive perception of telespecialty care, concerns and challenges of implementation, and suggestions for service refinement. Participants voiced that the telemedicine visits saved commute and waiting times and provided veterans in rural areas more access to timely medical care. The mentioned concerns were technical challenges and equipment failure, staffing shortages to cover both in-person and telehealth visit needs, overbooked schedules leading to delayed referrals, the need for a more standardized operation protocol, and more hands-on training with formative feedback among supporting staff. Participants also faced challenges with appointment cancellations and struggled to find ways to efficiently manage both telehealth and in-person visits to streamline patient flow. Nonetheless, most participants feel motivated and confident in implementing telespecialty care going forward.

CONCLUSIONS

This study provided important insights into the positive perceptions and ongoing challenges in telespecialty care implementation. Feedback from primary care teams is needed to improve telespecialty care service delivery for rural veterans.

Implementation of Direct-to-Patient Mobile Teledermatology in VA

BACKGROUND

Innovative technology can enhance patient access to healthcare but must be successfully implemented to be effective.

OBJECTIVE

We evaluated Department of Veterans Affairs' (VA's) implementation of My VA Images, a direct-to-patient asynchronous teledermatology mobile application enabling established dermatology patients to receive follow-up care remotely instead of in-person.

DESIGN /PARTICIPANTS/APPROACH

Following pilot testing at 3 facilities, the app was introduced to 28 facilities (4 groups of 7) every 3 months using a stepped-wedge cluster-randomized design. Using the Organizational Theory of Implementation Effectiveness, we examined the app's implementation using qualitative and quantitative data consisting of encounter data from VA's corporate data warehouse; app usage from VA's Mobile Health database; bi-monthly reports from facility representatives; phone interviews with clinicians; and documented communications between the operational partner and facility staff.

KEY RESULTS

Implementation policies and practices included VA's vision to expand home telehealth and marketing/communication strategies. The COVID-19 pandemic dominated the implementation climate by stressing staffing, introducing competing demands, and influencing stakeholder attitudes to the app, including its fit to their values. These factors were associated with mixed implementation effectiveness, defined as high quality consistent use. Nineteen of 31 exposed facilities prepared to use the app; 10 facilities used it for actual patient care, 7 as originally intended. Residents, nurse practitioners, and physician assistants were more likely than attendings to use the app. Facilities exposed to the app pre-pandemic were more likely to use and sustain the new process.

CONCLUSIONS

Considerable heterogeneity existed in implementing mobile teledermatology, despite VA's common mission, integrated healthcare system, and stakeholders' broad interest. Identifying opportunities to target favorable facilities and user groups (such as teaching facilities and physician extenders, respectively) while addressing internal implementation barriers including incomplete integration with the electronic health record as well as inadequate staffing may help optimize the initial impact of direct-to-patient telehealth. The COVID pandemic was a notable extrinsic barrier.

CLINICAL TRIALS REGISTRATION

NCT03241589.

Using the RE-AIM framework to assess national teledermatology expansion

Background

Teledermatology has been utilized in the United States Department of Veterans Affairs (VA) for decades but continues to have incomplete penetration. VA has funded an initiative to enhance access to dermatology services since 2017 to support asynchronous teledermatology for Veterans living in rural areas. As part of an ongoing evaluation of this program, we assessed the teledermatology activity between the fiscal years 2020 and 2022. We focused on the second cohort of the initiative, comprising six VA facilities and their 54 referral clinics.

Methods

We studied teledermatology programs at cohort facilities using the reach, effectiveness, adoption, implementation, and maintenance framework. We used a mixed-methods design including annual online reports completed by participating facilities and VA administrative data. When possible, we compared the data from the 3 years of teledermatology funding with the baseline year prior to the start of funding.

Findings

Reach: Compared with the baseline year, there was a 100% increase in encounters and a 62% increase in patients seen at the funded facilities. Over 500 clinicians and support staff members were trained. Effectiveness: In FY 2022, primary or specialty care clinics affiliated with the funded facilities had more dermatology programs than primary or specialty care clinics across the VA (83% vs. 71% of sites). Adoption: By the end of the funding period, teledermatology constituted 16% of dermatology encounters at the funded facilities compared with 12% nationally. This reflected an increase from 9.2% at the funded facilities and 10.3% nationally prior to the funding period. Implementation: The continued funding for staff and equipment facilitated the expansion to rural areas. Maintenance: By the end of the funding period, all facilities indicated that they had fully implemented their program for patients of targeted primary care providers. The Program Sustainability Index scores generally increased during the funding period.

Conclusions

Targeted funding to support asynchronous teledermatology implementation for rural Veterans increased its reach, adoption, and implementation, ultimately improving access. Providing program guidance with staffing and training resources can increase the impact of these programs. Ongoing efforts to maintain and increase communication between primary care and dermatology will be needed to sustain success.

Advancing Dermatological Care: A Comprehensive Narrative Review of Tele-Dermatology and mHealth for Bridging Gaps and Expanding Opportunities beyond the COVID-19 Pandemic

Mobile health (mHealth) has recently had significant advances in tele-dermatology (TD) thanks to the developments following the COVID-19 pandemic. This topic is very important, as telemedicine and mHealth, when applied to dermatology, could improve both the quality of healthcare for citizens and the workflow in the health domain. The proposed study was centered on the last three years. We conducted an overview on the opportunities, the perspectives, and the problems involved in TD integration with mHealth. The methodology of the narrative review was based on: (I) a search of PubMed and Scopus and (II) an eligibility assessment, using properly proposed parameters. The outcome of the study showed that during the COVID-19 pandemic, TD integration with mHealth advanced rapidly. This integration enabled the monitoring of dermatological problems and facilitated remote specialist visits, reducing face-to-face interactions. AI and mobile apps have empowered citizens to take an active role in their healthcare. This differs from other imaging sectors where information exchange is limited to professionals. The opportunities for TD in mHealth include improving service quality, streamlining healthcare processes, reducing costs, and providing more accessible care. It can be applied to various conditions, such as (but not limited to) acne, vitiligo, psoriasis, and skin cancers. Integration with AI and augmented reality (AR), as well as the use of wearable sensors, are anticipated as future developments. However, integrating TD with mHealth also brings about problems and challenges related to regulations, ethics, cybersecurity, data privacy, and device management. Scholars and policymakers need to address these issues while involving citizens in the process.