J Clin Aesthet Dermatol. 2023;16(8):42–43.
by Clayton B. Green, MD, PhD; Chavy Chiang, BA; and Molly E. Plovanich, MD
Drs. Green and Plovanich are with the Department of Dermatology at the University of Rochester Medical Center in Rochester, New York. Mr. Chiang is with the School of Medicine and Dentistry, at the University of Rochester Medical Center in Rochester, New York.
FUNDING: No funding was provided for this article
DISCLOSURES: Dr. Green is a section author for UpToDate. Both other authors report no conflicts of interest relevant to the content of this article.
ABSTRACT: We report a retrospective chart review of 112 images submitted from 85 patients through the Epic electronic medial record to determine disposition of patient complaints and to estimate cost savings. The study represents a single practice at a tertiary care university practice. Sixty (53.6%) were resolved electronically. The remaining 52 (46.4%) were deemed to require an in-person office visit. Of the 60 electronically resolved, 23 (38.3%) involved reassurance of a self-limited condition while 37 (61.7%) involved prescription management. The encounters resolved through MyChart were not billed and provided a cost savings of $2,052.29 and $4,664.96 for Level 3 and 4 office visit equivalents, respectively, for a total of $6,717.25. Patients needing an office visit were on average seen 18.3 days from the date of photo submission. After adjusting for patient-initiated rescheduling of the earliest appointment date provided, this was slightly reduced to 16.0 days. We observed diagnostic concordance in 88/112 (78.6%) eConsults. Krippendorff’s alpha was 0.773 (95% confidence interval of 0.691- 0.846), indicating a tentative conclusion of modest reliability between the two raters.5 Concordance regarding the need for an appointment as determined by the two raters was observed in 71/112 (63.4%) eConsults. We conclude that patient-submitted eConsults is a viable means of resolving just over half of patient-submitted dermatologic concerns while offering cost savings; there is modest inter-rater reliability.
Keywords: Store and forward dermatology; teledermatology
Store and forward teledermatology is a well-established model of care that improves access to care1 and reduces patient costs.2 The most common formalized model is for primary care providers to submit photos to a dermatology pool when patients present with a rash. Dermatologists then review the photos to determine the next best steps in management. These store and forward encounters are termed “eConsults”.
Smartphones and patient access to electronic medical records enable patients to send high quality photos of skin findings directly to dermatologists. However, it has been found that only 55.1 percent of patient-submitted photos are useful for decision-making.3 Nonetheless, this model of patient-initiated photos likely offers similar benefits of cost savings and improved access to specialty care.
We performed a cross-sectional study analyzing various parameters of all established-patient-initiated photos sent to dermatology from January 1, 2021 to June 30, 2022 via the Epic electronic health record (Epic Systems Corporation). Only Dr. Green’s patients from a multidisciplinary academic dermatology clinic were included. Cost savings were estimated based on the assumption that encounters requiring a prescription were equivalent to a Level 4 established patient visit (CPT® Code 99214), and eConsults involving reassurance of a self-limited condition +/- over-the-counter recommendations were equivalent to a Level 3 established patient visit (CPT® Code 99213). Corresponding 2022 Medicare allowable rates from cms.gov in upstate New York were $126.08 and $89.23, respectively. For those determined to require a subsequent in-person evaluation, we calculated the time from initial photo submission to office visit. The diagnostic concordance rate between two dermatologists was assessed after both independently reviewed all cases. Krippendorff’s alpha, calculated via R software (R Core Team, 2022) using the package icr [4], was used to analyze inter-rater reliability.
We reviewed 112 photos submitted from 85 patients during the study period. Sixty encounters (53.6%) were resolved electronically, a percentage amount mirroring the 55.1 percent of patient-submitted photos found by Jiang et al3 to be useful for decision-making. The remaining 52 (46.4%) were deemed to require an in-person office visit. Of the 60 electronically resolved encounters, 23 (38.3%) involved reassurance of a self-limited condition while 37 (61.7%) involved prescription management. Remotely managed encounters, and thus not billed, provided a cost savings of $2,052.29 and $4,664.96 for Level 3 and 4 office visit equivalents, respectively, for a total of $6,717.25. Patients needing an office visit were on average seen 18.3 days from the date of photo submission. After adjusting for patient-initiated rescheduling of the earliest appointment date provided, this was slightly reduced to 16.0 days. We observed diagnostic concordance in 88/112 (78.6%) photographs between the two dermatologists. Krippendorff’s alpha was 0.773 (95% confidence interval of 0.691-0.846), indicating a tentative conclusion of reliability worth considering between the two raters.5 Concordance regarding the need for an appointment as determined by the two raters was observed in 71/112 (63.4%) of the encounters. We conclude that managing skin conditions using patient-submitted photographs is a viable means of resolving acute dermatologic concerns while offering cost savings and improving access to specialty care.
References
- Kim GE, Afanasiev OK, O’Dell C, et al. Implementation and evaluation of Stanford Health Care store-and-forward teledermatology consultation workflow built within an existing electronic health record system. J Telemed Telecare. 2020;26(3):125–131
- Yang X, Barbieri JS, Kovarik CL. Cost analysis of a store-and-forward teledermatology consult system in Philadelphia. J Am Acad Dermatol. 2019;81(3):758-764.
- Jiang SW, Flynn MS, Kwock JT, et al. Quality and Perceived Usefulness of Patient-Submitted Store-and-Forward Teledermatology Images. JAMA Dermatol. 2022;158(10):1183-1186.
- Staudt A, L’Ecuyer P. Package ‘icr’. 2020. https://cran.r-project.org/web/packages/icr/icr.pdf.
- Krippendorff K. Content Analysis: An Introduction to Its Methodology. Fourth Edition ed. Thousand Oaks, California, 2019.