Virtual Supervision in Graduate Medical Education: A Systematic Review

Background Despite the increased use of telemedicine, the evidence base on virtual supervision in graduate medical education (GME) is not well described. Objective To systematically review the impact of virtual supervision on trainee education, patient care, and patient satisfaction in Accreditation Council for Graduate Medical Education (ACGME)-accredited specialties. Methods Two databases (PubMed, EMBASE) were searched from database inception to December 2022. Inclusion criteria were peer-reviewed, full-text, English-language articles reporting the use of virtual supervision in GME in ACGME-accredited specialties. Exclusion criteria were studies involving direct supervision, supervisors who were not credentialed physicians, or non-GME trainees. Two investigators independently extracted data and appraised the methodological quality of each study using the Mixed Methods Appraisal Tool (MMAT). The reporting of this systematic review was guided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement. Results Of 5278 records identified, 26 studies met the eligibility criteria. Virtual supervision was predominantly utilized in operating rooms and inpatient settings, facilitating clinical examinations or surgical procedures through videoconferencing software in specialties such as dermatology, neurosurgery, and orthopedics. However, some studies reported technical challenges that hindered effective teaching and communication. Based on self-reported surveys, supervisor and trainee satisfaction with virtual supervision was mixed, while patient satisfaction with the care was generally high. The MMAT ratings suggested limitations in sampling strategy, outcome measurement, and confounding factors. Conclusions Virtual supervision was applicable to various specialties and settings, facilitating communication between supervisors and trainees, although there were some technological challenges.

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

Purpose: To improve patient access to skin care, the Department of Veterans Affairs (VA) developed a patient-facing asynchronous mobile teledermatology application (app), which allows patients to follow up remotely with dermatologists. To understand how the app would be received in VA, we examined Organizational Readiness for Change (ORC), an important prelude to effective implementation, which includes the shared resolve and collective ability of organizational members to implement a change. Methods: We used a mixed-methods multiple case study approach to assess ORC at three VA facilities. Data derived from a site process call, surveys, and semistructured telephone interviews of VA staff, field notes, and administrative data. Results: Participants at all three facilities supported the intervention and recognized the value of using the app to increase patients' access to dermatologists, but expressed concerns largely related to disruption of the pre-existing clinical workflow. Participants at the facility most actively using the app had the highest overall ORC score and reported the most facilitators. Facility leadership support when guided by a clinical champion minimized barriers by recognizing the complexities of health care provision at specialty clinics. Discussion: While provider buy-in remained a barrier, leadership, guided by the clinical champion, played a critical role instituting implementation strategies. The strong association between the ORC survey score and the presence of facilitators and barriers suggests that the ORC survey may be a rapid, convenient, and effective tool for health care systems to identify favorable sites for wider implementation of mobile telehealth care. Clinical Trials Identifier: NCT03241589.

The utility of augmented teledermatology to improve dermatologist diagnosis of cellulitis: a cross-sectional study

Dermatology consultation for cases of presumed cellulitis improves diagnostic accuracy and management. However, access to in-person consultation remains limited, a gap that could be filled with teledermatology. Augmented teledermatology may improve outcomes. In this cross-sectional study, 20 dermatologists (60% of whom reported conducting inpatient consults > 1 month per year) reviewed 10 real-life cases representing either cellulitis or pseudocellulitis as diagnosed by in-person dermatology consultation. For each case, respondents recorded their diagnosis, confidence, and management decisions after viewing the history and standard teledermatology photos, the responses to a physician-reported cellulitis questionnaire, and finally thermal images. Overall mean diagnostic accuracy increased from 84 ± 4% with the history and physical to 89 ± 3% when adding a cellulitis questionnaire and thermal images (p = 0.23). Accuracy for cellulitis cases specifically significantly increased from 76 ± 6% to 88 ± 4% when adding a cellulitis questionnaire and thermal images (p = 0.049). Accuracy for pseudocellulitis was consistently ≥ 94%. Augmented teledermatology with a standardized questionnaire and thermal images improved diagnostic accuracy for cases of cellulitis and may increase physician confidence. Dermatologists were able to accurately diagnose regardless of experience with inpatient consults, increasing the pool of potential dermatologists who could diagnose cellulitis remotely.

Inpatient Teledermatology: a Review

Purpose of Review

Inpatient teledermatology is a rapidly growing field with significant potential to add value and streamline patient care. This review summarizes the current literature on inpatient teledermatology, primarily focusing on its diagnostic and clinical management utility as compared to live dermatologic evaluation.

Recent Findings

The COVID-19 pandemic has accelerated the adoption of inpatient teledermatology, which has been shown to be comparable to live hospitalist evaluation for triage, diagnosis, and management of hospitalized patients for a wide variety of conditions. Despite its comparative cost-effectiveness and recent changes in reimbursement practices, inpatient teledermatology still lacks sufficient reimbursement incentive for widespread implementation.

Summary

Inpatient teledermatology is an effective, efficient, accurate, and cost-effective means of managing the hospital burden of skin disease, especially in areas where access to dermatologic care is limited. It is essential that dermatologists and referring providers comprehend the use and potential pitfalls of inpatient teledermatology to effectively incorporate it into hospital practice.

Cost-minimization analysis of teledermatology versus conventional care in the Brazilian National Health System

Aims: Cost-minimization analysis (CMA) comparing the teledermatology service of the State of Santa Catarina, Brazil with the provision of conventional care, from the societal perspective. Patients & methods: All costs related to direct patient care were considered in calculation of outpatient costs. The evaluation was performed using the parameters avoided referrals and profile of hospitalizations. The economic analysis was developed through a decision tree. Results: Totally, 40% of 79,411 tests performed could be managed in primary care, avoiding commuting and expanding the patients' access. The CMA showed the teledermatology service had a cost per patient of US$196.04, and the conventional care of US$245.66. Conclusion: In this scenario, teledermatology proved to be a cost-saving alternative to conventional care, reducing commuting costs.

Teledermatology Addressing Disparities in Health Care Access: a Review

Purpose of Review

Dermatologists have been at the forefront of researching telemedicine to expand access to care. The current COVID-19 pandemic has prompted even greater expansion and implementation of teledermatology. This review discusses the research examining the potential impact of teledermatology addressing disparities in care.

Recent Findings

Teledermatology appears to increase access to dermatology given expanded means to deliver care. Specifically, recent studies have found increased access among Medicaid-insured, resource-poor urban and rural, and elderly populations. Teledermatology implementation also facilitates education among providers at different levels of training. Still, as some patients have inconsistent access to the required technology, increased reliance on telemedicine may also potentially increase disparities for some populations.

Summary

Teledermatology may serve to reduce disparities in health care access in many underserved and marginalized communities. Future research should continue to study implementation, especially given the expansion during the COVID-19 pandemic. Ultimately, teledermatology may play an important role in ensuring equitable care access for all.

Prospective Implementation of a Consultative Store-and-Forward Teledermatology Model at a Single Urban Academic Health System with Real Cost Data Subanalysis

Background: Teledermatology may increase access to care but has not been widely implemented due, in part, to lack of insurance coverage and reimbursement. We assessed the impact of implementing a consultative store-and-forward teledermatology model on access to care, medical cost, and utilization. Materials and Methods: Prospective implementation of teledermatology occurred at five University of Pennsylvania Health System primary care practices from June 27, 2016, to May 25, 2017. Primary outcomes included time to case completion, proportion of patients completing in-person dermatology visits, and total outpatient costs. Medical and pharmacy claims data were used for utilization and cost subanalysis. Results: The study included 167 patients and 1,962 controls with a 6-month follow-up. Median time to definitive dermatologist response was 0.19 days (interquartile range [IQR]: 0.03-2.92) for intervention and 83.60 days (IQR: 19.74-159.73) for controls. In medical claims subanalysis, no significant differences in mean outpatient costs ($3,366 vs. $2,232, p = 0.1356) or total medical costs ($3,535 vs. $2,654, p = 0.2899) were detected. Conclusions: Implementation of teledermatology improved access to care, and within this small sample, remained comparable in terms of cost and utilization. Thus, these data suggest teledermatology may improve access without increasing utilization or cost.

Maintaining High-Quality Multidisciplinary Pain Medicine Fellowship Programs: Part II: Innovations in Clinical Care Workflow, Clinical Supervision, Job Satisfaction, and Postgraduation Mentorship for Pain Fellows During the COVID-19 Pandemic

Background

Pain fellowship programs are facing unique challenges during the COVID-19 pandemic. Restrictions by state governments and the Centers for Disease Control and Prevention have resulted in a rapidly changing and evolving learning environment for today’s fellows. Innovative solutions must be sought to maintain proper education and ensure the well-being of our trainees.

Methods

: We assembled a panel of pain program directors who serve as officers/board members of the Association of Pain Program Directors, offering guidance and recommendations to pain fellowship directors nationwide. Panel members evaluate best available evidence and expert opinion on use of remote and virtual platforms in clinical care, adaptability to alterations in clinic and referral management, and provide guidance on post-graduate impact.

Conclusions

The country is in the midst of an unprecedented pandemic. The impact on pain management fellowships has been significant and will likely last for months, resulting in extraordinary challenges to the administration of pain fellowship programs and the education of our fellows. Several strategies will help address these challenges, including employing telehealth capabilities to continue clinical experiences, and providing trainees with opportunities to continue their professional growth beyond fellowship completion. Together, we can implement innovative solutions to overcome these challenges.

Use of teledermatology by dermatology hospitalists is effective in the diagnosis and management of inpatient disease

Background

Patient outcomes are improved when dermatologists provide inpatient consults. Inpatient access to dermatologists is limited, illustrating an opportunity to utilize teledermatology. Little is known about the ability of dermatologists to accurately diagnose and manage inpatients using teledermatology, particularly utilizing non-dermatologist generated clinical data.

Methods

This prospective study assessed the ability of teledermatology to diagnose and manage 41 dermatology consults from a large urban tertiary care center utilizing internal medicine referral documentation and photos. Twenty-seven dermatology hospitalists were surveyed. Interrater agreement was assessed by the kappa statistic.

Results

There was substantial agreement between in-person and teledermatology assessment of the diagnosis with differential diagnosis (median kappa = 0.83), substantial agreement in laboratory work-up decisions (median kappa = 0.67), almost perfect agreement in imaging decisions (median kappa = 1.0), and moderate agreement in biopsy decisions (median kappa = 0.43). There was almost perfect agreement in treatment (median kappa = 1.0), but no agreement in follow-up planning (median kappa = 0.0). There was no association between raw photo quality and the primary plus differential diagnosis or primary diagnosis alone.

Limitations

Selection bias and single-center nature.

Conclusions

Teledermatology may be effective in the inpatient setting, with concordant diagnosis, evaluation, and management decisions.

Implementing and Optimizing Inpatient Access to Dermatology Consultations via Telemedicine: An Experiential Study

Background/Introduction: In-house dermatology consultation services for hospitalized patients are not universally available in acute care hospitals. We encountered an unanticipated access gap for in-person dermatology consultations in our tertiary care hospital that routinely cares for complex high acuity patients with multiple comorbidities. To bridge this gap in specialist expertise in a timely manner, we expeditiously designed and implemented a telemedicine-supported inpatient dermatology consultation service. Methods: We conducted a retrospective review of 155 teledermatology consultations conducted between November 2017 and March 2019 as well as periodic prospective multidisciplinary process improvement meetings to optimize service-associated process maps and workflows. Results: Teledermatology consultations changed the working diagnosis of the primary team in 52.3% of cases and most commonly recommended medical management (61.9% of cases). In total 100% of patients accepted telemedicine support and rated their experience as positive. The first three periodic process improvement meetings led to significant improvements in teledermatology-related process maps and workflows. Discussion: Diagnostic concordance rates between the primary team and the teledermatologist were similar to those reported in the literature for in-person dermatology consultations. Important process improvements include establishing central responsibility of preparing and overseeing the consultation process, mandating the presence of a primary team representative during consultation and patient chart review by the teledermatologist before teleconsultation. Conclusion: Inpatient teledermatology consultation services can be instituted timely and continuously improved to reliably and effectively bridge access gaps, improve diagnostic accuracy and differentiate therapeutic approaches while maintaining patient satisfaction.

Inpatient teledermatology: Diagnostic and therapeutic concordance among a hospitalist, dermatologist, and teledermatologist using store-and-forward teledermatology

BACKGROUND

Inpatient dermatology has been shown to improve patient outcomes at a reduced cost. Few hospitals have dermatologists available. Teledermatology may allow dermatologists to assess hospitalized patients remotely.

OBJECTIVE

To examine the diagnostic concordance between a hospitalist, dermatologist, and teledermatologist using store-and-forward teledermatology.

METHODS

For 100 consecutive patients requiring inpatient dermatology consultation, a survey was conducted by all 3 raters to convey diagnostic impressions and therapeutic recommendations. Complete and partial agreements were assessed using the Cohen kappa statistic.

RESULTS

Inpatient dermatology consultation often resulted in a change in diagnosis (50.9%) and a change in systemic therapy (41.5%). Likewise, virtual teledermatology consultation would have resulted in a change in diagnosis (54.7%) and a change in systemic therapy (47.2%) at similar rates. Comparing the dermatologist and teledermatologists, diagnostic complete and partial agreement were 52.8% and 84.9%, respectively. Systemic therapy agreement was 77.4%. Teledermatologists recommended biopsy more often (68.5% vs 43.5%).

LIMITATIONS

Small sample size, tertiary academic medical center, single rater for inpatient teledermatology with specific inpatient niche.

CONCLUSION

Teledermatologists performed comparably to an in-person dermatologist for the diagnosis and management of hospitalized patients with skin conditions. Teledermatology may be a suitable alternative for delivery of inpatient care if no dermatologist is available.

Access to Dermatological Care with an Innovative Online Model for Psoriasis Management: Results from a Randomized Controlled Trial

Background:Many patients with chronic skin diseases lack regular access to dermatologists in the United States and suffer poor clinical outcomes.Introduction:We performed a 12-month randomized controlled trial to evaluate the impact of an online, collaborative connected health (CCH) model for psoriasis management on access to specialty care.Materials and Methods:The 300 enrolled patients were randomized to online or in-person care. We compared distance traveled as well as transportation and in-office waiting time between the two groups and obtained patient and provider perspectives on CCH.Results:At baseline, no differences existed between the groups in difficulties obtaining specialty care. Over 12 months, the mean (standard deviation [SD]) distance traveled to and from appointments was 174.8 (±577.4) km/person for the in-person group and 2.2 (±14.2) km/person for the online group (p = 0.0003). The mean (SD) time spent on transportation and in-office waiting for in-person appointments was 4.0 (±4.5) h/person for the in-person group and 0.1 (±0.4) h/person for the online group (p = 0.0001). Patients found CCH to be safe, accessible, equitable, efficient, effective, and patient-centered. Providers found CCH to be useful for providing psoriasis care.Discussion:The CCH model resulted in significantly less distance traveled as well as transportation and in-office waiting time compared to in-person care. Both patients and providers were highly satisfied with CCH.Conclusions:The CCH model resulted in increased access to specialty care and enabled patient-centered, safe, and effective management of psoriasis patients.

Effect of Dermatology Consultation on Outcomes for Patients With Presumed Cellulitis: A Randomized Clinical Trial

Importance

Each year, cellulitis leads to 650 000 hospital admissions and is estimated to cost $3.7 billion in the United States. Previous literature has demonstrated a high misdiagnosis rate for cellulitis, which results in unnecessary antibiotic use and health care cost.

Objective

To determine whether dermatologic consultation decreases duration of hospital stay or intravenous antibiotic treatment duration in patients with cellulitis.

Design, Setting, and Participants

This randomized clinical trial was conducted in a large urban tertiary care hospital between October 2012 and January 2017, with 1-month follow-up duration. Patients were randomized to the control group, which received the standard of care (ie, treatment by primary medicine team), or the intervention group, which received dermatology consultation. Medical chart review of demographic information and hospital courses was performed. Adult patients hospitalized with presumed diagnosis of cellulitis were eligible. A total of 1300 patients were screened, 1125 were excluded, and 175 were included. Statistical analysis was employed to identify significant outcome differences between the 2 groups.

Interventions

Dermatology consultation within 24 hours of hospitalization.

Main Outcomes and Measures

Length of hospital stay and duration of intravenous antibiotic treatment.

Results

Of 175 participants, 70 (40%) were women and 105 (60%) were men. The mean age was 58.8 years. Length of hospital stay was not statistically different between the 2 groups. The duration of intravenous antibiotic treatment (<4 days: 86.4% vs 72.5%; absolute difference, 13.9%; 95% CI, 1.9%-25.9%; P = .04) and duration of total antibiotic treatment was significantly lower in patients who had early dermatology consultation (<10 days: 50.6% vs 32.5%; absolute difference, 18.1%; 95% CI, 3.7%-32.5%; P = .01). Clinical improvement at 2 weeks was significantly higher for those in the intervention group (79 [89.3%] vs 59 [68.3%]; absolute difference, 21.0%; 95% CI, 9.3%-32.7%; P < .001). There was no significant difference in 1-month readmission rate between the groups (4 [4.5%] vs 6 [6.9%]; absolute difference, -2.4%; 95% CI, -9.3% to 4.5%; P = .54). In the intervention group, the rate of cellulitis misdiagnosis was 30.7% (27 of 88 participants). Among the entire cohort, 101 (57.7%) patients were treated with courses of antibiotics longer than what is recommended by guidelines.

Conclusions and Relevance

Early dermatologic consultation can improve outcomes in patients with suspected cellulitis by identifying alternate diagnoses, treating modifiable risk factors, and decreasing length of antibiotic treatment.

Trial Registration

clinicaltrials.gov Identifier: NCT01706913.

Recent trends in teledermatology and teledermoscopy

Teledermatology is a useful alternative where specialized dermatological assistance is not available and has been used successfully to support health professionals in a wide range of settings worldwide, in either an asynchronous store-and-forward format or a real-time video conferencing format. Teledermoscopy, which includes dermoscopic images in the teleconsultation, is another addition that improves remote assessments of pigmented lesions. A more recent variant is mobile teledermoscopy, which uses a smartphone to deliver the same type of service.

Teledermoscopy’s greatest strength may be as a triage and monitoring tool, as it can reduce the number of unnecessary referrals, wait times, and the cost of providing and receiving dermatological care. While face-to-face (FTF) care remains the gold standard for diagnosis, drawbacks of not using FTF care as the primary method can be mitigated if teleconsultants are willing to refer to FTF care whenever there is uncertainty. Teledermatology has generally been well accepted by patients and practitioners alike.

Barriers to the large-scale use of teledermatology remain. Assigning medicolegal responsibility and instituting a reimbursement system are critical to promoting widespread use by medical professionals, while privacy and security features and a mechanism to link teleconsultations to patients’ existing health records are essential to maximize patient benefit. Direct-to-consumer services also need attention from regulators to ensure that consumers can enjoy the benefits of telemedicine without the dangers of unregulated or untested platforms.

International inter-rater agreement in scoring acne severity utilizing cloud-based image sharing of mobile phone photographs

BACKGROUND

Cloud-based image sharing technology allows facilitated sharing of images. Cloud-based image sharing technology has not been well-studied for acne assessments or treatment preferences, among international evaluators. We evaluated inter-rater variability of acne grading and treatment recommendations among an international group of dermatologists that assessed photographs.

METHODS

This is a prospective, single visit photographic study to assess inter-rater agreement of acne photographs shared through an integrated mobile device, cloud-based, and HIPAA-compliant platform. Inter-rater agreements for global acne assessment and acne lesion counts were evaluated by the Kendall's coefficient of concordance while correlations between treatment recommendations and acne severity were calculated by Spearman's rank correlation coefficient.

RESULTS

There was good agreement for the evaluation of inflammatory lesions (KCC = 0.62, P < 0.0001), noninflammatory lesions (KCC = 0.62, P < 0.0001), and the global acne grading system score (KCC = 0.69, P < 0.0001). Topical retinoid, oral antibiotic, and isotretinoin treatment preferences correlated with photographic based acne severity.

CONCLUSIONS

Our study supports the use of mobile phone based photography and cloud-based image sharing for acne assessment. Cloud-based sharing may facilitate acne care and research among international collaborators.

Practice Guidelines for Teledermatology

Previous American Telemedicine Association (ATA) Teledermatology Practice Guidelines were issued in 2007. This updated version reflects new knowledge in the field, new technologies, and the need to incorporate teledermatology practice in a variety of settings, including hospitals, urgent care centers, Federally Qualified Health Centers, school-based clinics, public health facilities, and patient homes.