Covid19: A catalyst for innovative hybrid teledermatology workflows to increase access and improve patient care at a large group practice.

To the Editor: In response to COVID-19 restrictions, we developed a hybrid photo- and video-based (“store-and-video evaluation” or “SAVe”) electronic health record Epic-integrated workflow (Fig 1 ) to rapidly transition a large multispecialty group from a completely office-based dermatology practice to one that can support virtual care. The SAVe approach addresses challenges associated with asynchronous/“store-and-forward” workflows (no real-time assessment, absence of patient-provider interaction, and unclear reimbursement strategies) and synchronous/“live interactive” workflows (logistical/execution challenges and poor image quality).1, 2, 3 In 2018, only 14 United States teledermatology programs used photo-video workflows.

Fig 1

Schematic describing the journey of all key participants in the SAVe (“store-and-video evaluation”) workflow. The SAVe workflow is triggered by an appointment request from a patient or a physician referral. A scheduling team screens the chief complaint. If the concern is not acute (key words: rapidly growing, painful, bleeding, genital problem, blistering disease, draining pus) and is not concerning a full-body examination, the scheduling team offers a SAVe or in-person visit. SAVe encounters trigger the staff to send patient instructions for: (1) logging into an acceptable synchronous video platform and (2) taking and submitting suitable images using the EPIC patient portal. Majority of previsit communications are through the EPIC patient portal, with supplemental telephone support as needed. Prior to the scheduled visit, a medical assistant checks for the presence and quality of patient-submitted photographs (up to 9) and contacts the patient if additional photographs are required. Immediately prior to the encounter, the MA calls the patient to (1) ensure video connectivity, (2) intake history, and (3) “room” the patient. The patient and provider then connect via a video-capable platform (most commonly Vidyo integrated with EPIC). After the visit, the provider notifies the scheduling team if any additional in-person or virtual follow up is required. Dotted white arrow (in previsit patient box): Direct patient scheduling of SAVe visits started on 8/4/2020, allowing patients to bypass the scheduling team (staff screen patients' chief complaints to ensure appropriateness for SAVe visits). EPIC, Epic Systems Corporation; MA, medical assistant; SAVe, store-and-video evaluation visit type.

This retrospective descriptive study conducted from 3/16/2020 to 8/31/2020 analyzed 74,411 dermatology cases (20.8% digital and 79.2% in-person; Fig 2 ) encountered by 89 providers to care for 46,024 patients. SAVe was the predominant digital encounter type (88.8%), followed by telephone/message encounters. At the initial pandemic peak (April 2020), SAVe encounters increased to 71.5% of all encounters (from 0% prior to 3/16/2020) and was sustained at 11.5% upon full-clinic reopening (June-August). Extrapolation of the 9.5% steady-state SAVe utilization (July-August) represents 21,385/year teledermatology consultations versus 263/year teledermatology consultations (range: 20-20,000) reported across United States programs. As 81% (n = 25) providers wanted to continue SAVe indefinitely, we speculate that the drop in virtual care from the peak utilization was because of postponed full-body skin examinations and familiarity with traditional clinic visits once COVID-19 safety protocols were in place.

Fig 2

Dermatology outpatient volume based on visit type. Stacked area graph displays weekly volume of in-person encounters (blue), SAVe virtual encounters (orange), and telephone or messaging portal encounters (yellow) during pre-COVID-19 baseline period (1/6/2020-3/15/2020, dates in black) and after California shelter-in-place study period (3/16/20-8/31/20, dates in red). The purple dashed curve represents the percentage of digital encounters (SAVe + phone/message visits) of all encounters types. Among digital-only encounters, the SAVe ratios, compared with the telephone/message encounter ratios, rapidly shifted from 11%:89% during week 1 of shelter-in-place orders (3/16/20-3/23/20) to 61%:39% on week 2, followed by 78%:22% on week 4, and subsequently increased to an average of 94-95% SAVe visits compared with 4-5% telephone/message visits for the remainder of the observation period. Of note, in-person care availability was limited during March 16-May 31, 2020, because of pandemic-associated safety protocols, but tiered increases in-person capacity to pre-COVID-19 volume were in effect during June 1-August 31, 2020. SAVe, Store-and-video evaluation visit type.

The implementation of SAVe increased access to dermatologic care. The wait time for referrals was shorter for SAVe (mean = 14.3 days) than for in-person (26.8 days, P < .0001) encounters. Despite significant staff reduction, the in-person referral wait times during the study period were shorter as compared with those in the 2019 timeframe (26.8 vs 56.4 days, P ≤ .0001), possibly because SAVe encounters made more in-person appointments available.

During COVID-19, SAVe allowed for flexibility to match the needs of providers (with increased responsibilities as parents, spouses, and caretakers), patients (with fears of leaving the house), and clinics (with low personal protective equipment and strict spacing guidelines). One region's safety protocols allowed only 3 of 12 available providers to be on site, but SAVe enabled 9 additional providers to provide virtual care remotely. Since only 4.3% of SAVe required immediate (≤7 days) in-person follow up and >80% of SAVe visits were performed from home, clinic capacity was increased for required in-person evaluations/procedures.

Among patient demographics (Supplementary Table 1 available via Mendeley at https://data.mendeley.com/datasets/mjt7fk9ps7/1), the most striking difference was in age. Patients aged ≤30 years were more likely to use SAVe than those aged >65 years (P < .0001). This could be attributed to differences in ease with technology or chief complaints. Compared with in-person diagnoses, diagnoses performed via SAVe were more likely to be of rash (30% vs 24%, P < .001) and acne (17% vs 3%, P < .001, Supplementary Fig 1 available via Mendeley at https://data.mendeley.com/datasets/mjt7fk9ps7/1), which may be more amenable to virtual care. The most common in-person diagnostic category was growth (27% vs 10%, P < .001), which is more likely triaged to in-person evaluation.

SAVe was designed by and created for dermatologists to provide a secure and integrated teledermatology model to complement in-person workflows to preserve access and quality of care.

Conflicts of interest

None disclosed.