Part 2 of this article will focus on the principles that control the exercise of SAF teledermatology and its implications on daily practices.
1. Differences and similarities between LI and SAF teledermatology
As described in Part 1, LI teledermatology refers to dermatology services provided to patients over real-time teleconference interactive sessions. While the remote nature of the communication still remains for SAF, the consultation does not involve a direct interaction between users.
SAF focuses on the study and analysis of patient cases based on images submitted by a referring provider (another medical professional) or patients themselves.1 This approach requires the active participation of patients by providing high quality images of areas of concern on their skin. For this purpose, the utilization of mobile dermoscopes such as MoleScope play a crucial role for appropriate imaging quality.
Similarly, imagery obtained with mobile dermoscopes can be combined with advanced analytics tools available in DermEngine and other intelligent dermatology software, allowing for a full cycle of care without the need for primary physical interaction. While the immediateness of LI teledermatology can be a sought-after trait for some, the convenience and active involvement of patients in providing their own images makes SAF a powerful alternative with a focus on dermoscopic analysis, a feature absent in LI.
2. 5 regulatory areas for store-and-forward teledermatology practices as convened by AAD
Similar to LI teledermatology, SAF also has been regulated by a position statement formulated by AAD to protect the integrity of services offered to patients and insure best quality practices.2 Although the same 6 areas listed for LI are present in the regulation of SAF teledermatology, there are some significant differences given the distinctive nature of both techniques.
Depending on who initiates the consultation, SAF services can be divided into three categories:
a) Teletriage: for consultations transmitted by referring providers, a recommendation is provided as to which case requires in-clinic revision;
b) Teleconsultation: consultations transmitted by referring providers, who are in turn responsible for patient follow up and treatment;
c) Direct patient telemedicine: a consultation initiated by a patient submitting their case for analysis and diagnosis.
- Technical Equipment Necessary: a digital camera is required to provide SAF services. A hand-held dermoscopic device is also necessary for referring providers/patients to capture dermoscopic imaging. A minimum screen resolution of 800x600 pixel is suggested for proper analysis and a standard 128-bit encryption recommended for safely transmitting data online.
- Credentialing & Privacy Regulation: since professionals who offer SAF are deemed as “consultants” by AAD, they may not need to be credentialed, although interstate variations exist. Additionally, privacy is regulated by the Health Insurance Portability and Accountability Act (HIPAA) and all patient information collection, handling and storage must be compliant of the principles established in such act. Similarly, encryption of online networks is not mandatory, but highly recommended to avoid data loss or breaches.
- Licensing: given the geographical variation of regulations, it is mandatory to consult the law applicable to the state where SAF teledermatology services are provided. However, as a general rule, doctors can only offer teledermatology services for patients residing in the geographical area for which, by law, they are licensed to practice.
- Reimbursement Policy: although still an evolving matter, currently there are only demonstration projects in Hawaii and Alaska for reimbursement of SAF services. In the rest of the country, many Medicare Advantage plan private insurers are offering reimbursements, however this varies. Doctors are advised to consult with their insurance companies if they want to start offering SAF teledermatology services.2
- Liability: the degree of responsibility and liability vary on case-to-case and state-to-state bases. However, for teletriage and teleconsultation approaches, the responsibility is shared between the referring provider and the consultant dermatologist. For patient direct teleconsultation, however, the responsibility and potential liability falls directly on the teledermatologist. Proper follow up is also expected to be offered by the same consultant.
Teledermatology services constitute an increasing alternative to serve patients who cannot follow the traditional workflows of in-clinic dermatology consultations. In this regard, both approaches, LI and SAF services offer patients and doctors the chance to have consultations with no need of physical interaction. To guarantee highest quality standards in the care provided, AAD has established regulatory guidelines for active practitioners. As teledermatology continues to grow and develop, only regulated services that comply with the highest levels of care will provide the scalable opportunities needed to benefit a wider number of patients with the availability of this practice.
-The MetaOptima Team
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