BackgroundTele-Derm is a program run by the Australian College of Rural and Remote Medicine (ACRRM) to provide specialist dermatology support and education to rural and remote GPs. The program began in 2003, building on an existing relationship that ACRRM had developed with a dermatologist. Through the dermatologists work providing training for the College, he realised that many cases could be diagnosed very quickly using very basic information (i.e. pictures). This realisation led to a proposal to one Queensland fundholder (now called General Practice Queensland) for the provision of teledermatology services for rural and remote Queensland doctors.
At the time, there was extra funding in the fundholder’s budget which allowed for the service to be rolled out as a trial. Initially, only doctors from Queensland were allowed to use the service due to funding and medical licensing restrictions. Because of the success of the program the trial was expanded to the rest of the country and funding was transferred to the national DoHA office. In order to achieve this expansion, the medical licensing for the dermatologist was increased to allow him to practice in all states. At the same time, through the MSOAP funding, ACRRM added a teleradiology service in addition to the Tele-Derm program.
Program structureThe Tele-Derm program has been integrated as part of the Rural and Remote Education Online (RRMEO) portal. RRMEO provides access to a broad range of tools that support education and development for rural and remote doctors. Including Tele-Derm within the portal allows for the infrastructure and audience that has already been developed for RRMEO to be directly integrated with MSOAP. ACRRM has approximately 3,000 members, with an additional 7,000 people who are members of organisations that have purchased access to RRMEO, including groups such as registrars and John Flynn Scholars. Of the ~10,000 people with access to RRMEO, greater than 7,500 would be eligible to register for Tele-Derm.
For individuals that are eligible to register for RRMEO, a separate registration process is still required to participate in Tele-Derm. As part of the funding that MSOAP provides, any doctor eligible for MSOAP funding can apply for access to Tele-Derm. For doctors who register through MSOAP, they are provided access solely to the Tele-Derm portion of the RRMEO portal.
There are two main components to the Tele-Derm portal, a specific telemedicine component and a telehealth component. Telemedicine in this case is defined as traditional clinical medical services provided over a distance using electronic communication. With Tele-Derm, the telemedicine component is delivered through a store and forward (asynchronous) method where a doctor submits pictures and case information to the site for the dermatologist to diagnose and respond. This type of service is in contrast to ‘real-time’ telemedicine where a live teleconference occurs between patients and doctors. Telehealth in this case is defined as the use of information and communication technology for administration and education in addition to clinical services. ACRRM has made education a major component of Tele-Derm, indicating that the educational component is as or more important than the direct clinical services that are provided through the program.
The telemedical component of the program is based on the store and forward model, where cases are submitted by doctors and then at a later time the dermatologist provides a response that can then be accessed by the doctor. A doctor will submit a set of pictures and case information to the website, a process which feedback has indicated takes around 20-40 minutes for the GP to prepare. The GP does not receive any payment from ACRRM or Medicare for this service. Once the case is submitted, the ACRRM dermatologist accesses the case and writes a response that is made available to both the submitting doctor and all other Tele-Derm users. The case information is always left deidentified, but ACRRM does keep a record of the doctor who submitted the case.
In general, responses by the dermatologist are returned within 24 hours of initial submission, though the turnaround can be significantly shorter. A new feature has been developed for urgent cases to use SMS notification to speed up the process. When an urgent case is submitted, the dermatologist receives a SMS notifying him of the submission. When he responds, the doctor who submitted the request receives a SMS to alert them that a response has been posted.Top of page
Within the Tele-Derm portal there are several main areas that can be accessed by registered users: submitted cases, a dermoscopy atlas, a condition index, tips from the dermatologist and discussion forums. All cases that have been submitted can be viewed by all registered users of the program. Overall, there are 543 standard cases plus 186 dermoscopy cases that can be viewed by doctors to read and learn from, including the ability to guess at diagnoses and then have the answer revealed. Both the dermoscopy atlas and the condition access are designed to allow doctors to educate themselves on conditions and improve their self-diagnostic capabilities without having to submit every case directly. There is also an educational section written by the dermatologist to provide tips and tricks related to dermatology. For example, there is information on procedures, including biopsies and cryosurgery, how to take a good skin history from a patient, how to take good dermatology photographs and a list of other useful websites. Finally, the online discussion forums allow for doctors and the dermatologist to interact, learn and discuss dermatology cases.
Evidence indicates that many of the users of the portal are there for educational purposes rather than a direct clinical need. For example, registrars will often visit to learn and study for their training. Medical students can use the portal for similar purposes.
In order to generate interest and participation in the program, ACRRM has a case of the week that is e-mailed to all users. This involves a picture and a short description. Users can then click on the case to read the full details and then submit a response of their diagnosis of the case. At the end of the week, the ACRRM dermatologist provides a full discussion and diagnosis of the case in addition to responding to all of the comments posted throughout the week. Overall, the dermatologist provides about 1,000 comments per year in response to postings in the forums. General marketing of the Tele-Derm program is through the ACRRM website and advertisements are placed in all of the state specialist directories.
Rural and Remote Education Online (RRMEO) portalRRMEO is a unique online portal for education that ACRRM has internally developed. In order to access the portal users must register with ACRRM. Depending on their membership and eligibility, they will be provided access to portions of the portal. Everything that ACRRM accredits is available and searchable, such as classes (online and in person), workshops, training posts and educational resources. A learning planner is also provided for ACRRM members that allow educational activities and documentation to be tracked and stored for easy submission to accreditation organisations. The other main component of RRMEO is the online modules. Tele-Derm is one of these, in addition to other educational tools in a variety of clinical areas and live learning through virtual classrooms. Other features of the portal include the ability to download clinical guidelines on mobile devices, take tests online and many other components that allow rural and remote doctors to be educated and trained without leaving their community.
FundingFunding for Tele-Derm is currently through MSOAP and is provided as part of a contract with ACRRM to support the service. The budget has remained fairly stable through the course of the program and has only increased marginally to adjust for inflation. The amount of funding received is defined by DoHA and specifies the exact levels of expenditure for individual components of the program such as wages and promotional activities. While the overall budget provided to ACRRM includes both Tele-Derm and teleradiology, the funding for each is clearly defined.
The dermatologist that ACRRM employs for the program is paid an hourly wage that is defined by MSOAP based on a standard rate for specialist services. Payments are then made to the dermatologist on a sessional basis. National licensing that is required for the services to be provided are reimbursed for the dermatologist by ACRRM from their budget.
UsageCurrently there are around 1,500 subscribers to the ACRRM Tele-Derm program. Subscribers include doctors, registrars and medical students amongst others. In order to register for the Tele-Derm program a user must be a member of ACRRM, a member organisation that subscribes to RRMEO or be a doctor that is eligible for MSOAP (i.e. not in a major city). As part of the budget DoHA provides funding to support subscription of eligible doctors to the Tele-Derm portal. Of the 1,500 subscribers to the service, approximately 300 are registered through the eligibility that MSOAP provides. Many participants access the program for educational purposes and do not submit any cases directly. Anecdotal evidence indicates that many doctors would like to submit cases, but due to time constraints or other barriers have not done so. However, once a doctor submits a case and become familiar with the process, they seem to subsequently submit cases consistently.
The program grew rapidly after its initial introduction, quickly attracting 500-600 members. By the 2005-06 financial year there were 20,000 hits to the site and over 150 cases submitted Australian College of Rural and Remote Medicine 2010, 'ACRRM Medical Specialist Outreach Assistance Program Annual Plan', Report to DoHA.. Currently, the website attracts between 4,500 and 7,000 hits per month (Table 26) and receives approximately one new case per day.
Table 26 – Tele-Derm web site hits
Dermatologist experienceDr. Jim Muir is the dermatologist employed by ACRRM to provide the clinical support for the Tele-Derm program. As previously discussed he responds to cases, supports the online education and responds to online posts by doctors. He has been involved with the Tele-Derm program since its inception in 2003, with additional involvement with ACRRM prior to the commencement of the program. During his early career Dr. Muir was involved in outreach to rural locations and also participated in one year of video based telemedicine services.
The idea for telemedicine began through Dr. Muir’s involvement in receiving e-mails of cases from rural doctors early in his career. The catalyst came when he received an e-mail with a photo of necrosis and saw that he could diagnose acute cases through e-mail. There are other doctors and hospitals that provide dermatologically based telemedicine programs, but their scope is limited and they do not provide any educational services.
Benefits of store and forwardThe use of store and forward provides significant benefits for dermatology relative to real time telemedicine services. Currently, most models of real time telemedicine require both the patient and a clinician to be present for the consultation with a specialist. Logistically and resource wise, this arrangement is both costly and difficult to arrange. Due to rebates, some dermatologists provide real time telemedicine services, but often ask for high resolution photos and a case history prior to the video conference. The use of store and forward allows the case to be brought forward anytime of the day, it uses higher quality images and responses can be sent back rapidly and made available to the referring doctor at their convenience.
Relationship between visiting services and Tele-DermTop of pageDermatology is fairly unique in the medical field in that diagnosis is the most challenging aspect of the practice. Generally, prescribing and treatment are fairly straightforward. What this means is that the speciality is extraordinarily well suited to telemedicine as such a large percentage of cases can be diagnosed through pictures and case histories. This means that a significant portion of visiting dermatology service can be replaced with Tele-Derm.
The other important issue in telemedical services is the treatment and follow up of issues that have been diagnosed. Traditional visiting services required patients to wait for the visiting specialist to return or for their local doctor to follow up with their care. Often the visits by the specialist could be far apart and the local doctor might not have sufficient initiative, knowledge or information to provide comprehensive care.
Tele-Derm addresses a lot of these issues through the combination of education and telemedicine services. Having the doctor take pictures and a case history involves the doctor in the case directly, providing both knowledge, ownership and initiative in the treatment of the patient. Furthermore, the availability of educational resources on the Tele-Derm site provides the resources to allow GPs to perform many procedures that are essential for dermatology. Many of these are straightforward and most competent doctors can already do or learn them through the tutorials Dr. Muir has provided online. Cases can also be addressed through the back log of cases provided online, allowing GPs to research a condition and make a diagnosis without consulting a dermatologist directly.
The overall assessment of telemedicine versus visiting dermatology services is that they do not have to be as good as face to face, they just have to be better than what is currently available. In the public sector, there are six month to year long waiting lists for dermatology, whereas Tele-Derm can have a turnaround of less than a day. Most dermatologists are located in major cities or large regional centres, meaning that a significant amount of travel time is required by rural patients. Tele-Derm only requires them to travel to their local GP. Overall, the service offers significant benefit and provides no more risk of misdiagnosis or mistreatment than a face to face consultation with a dermatologist. One final benefit of the Tele-Derm program is that it can reduce professional isolation for doctors, increase their confidence in diagnosis and help them to feel more connected to the medical profession.
Improvement and expansionIn order to improve and expand the service, the goal would be to minimise work for the referring doctor as possible. While it might be easier for the patient to participate in Tele-Derm, it is still less time and effort to refer the patient to a dermatologist directly, since referring GPs are not paid for the time they put into Tele-Derm. If the system could engage an assistant to take some case history and pictures, then there is the opportunity to get more GPs involved.
Areas where there is room for expansion of services includes:
- nursing homes
- inpatient units
- ships at sea
- locations where it is logistically or economically not feasible to visit
- follow up services
- anywhere where waitlists are long
- emergency consultation.
Function and future directionsThe program seems to be well accepted by dermatologists as there are a small number that are practicing in Australia, with most having a waiting list of around six months. The role that the dermatologist plays for ACRRM does not threaten other practices and is not the result of a tech savvy business, but rather the desire to meet a strong need that exists in the community.
The experience of ACRRM is that teledermatology could not replace outreach, but could further integrate and coordinate the services that are going out. A wider adoption of the Tele-Derm program could first and foremost reduce the number of cases that need direct outreach by a dermatologist. The educational component of the program could upskill many GPs who could diagnose more cases without specialist referral and could send additional cases to the online system for remote diagnosis. For other cases, information could be sent prior to visits so that dermatologists were better prepared to make efficient use of time during outreach visits. Potentially, a whole electronic coordination and diagnostic system could be developed to direct patients and doctors to the most efficient path for diagnosis and treatment. The current program run by ACRRM has the capability to expand further to cover more cases and doctors across Australia and provide additional services to aide in dermatology outreach in general.Top of page