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Craig C. Miller, MD, PhD Brian C. Madden, PhD 13 November 2006
Distributed Specialty Care a telemedicine model for delivery of dermatology specialty care in VISN 2 Craig C. Miller, MD, PhD Brian C. Madden, PhD 13 November 2006
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Overview Why? Imbalance between supply of dermatology specialists and demand for treatment of skin diseases in VISN 2 How? Distributed Specialty Care model Three-tiered system for delivery of skin care Primary care provider Skin Evaluation Clinic Teledermatology consultant
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Shortage of dermatology assets in VISN 2
Dermatology demand Over 12,000 patient visits per year Requirement to provide veterans with “specialty care” Time constraints: rule Dermatology supply Limited VA staff dermatologists Disconnect between VA and civilian sectors Non-priority Lack of acceptable non-VA care Limited availability--unacceptable delays Expensive
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VISN2 Dermatology Assets
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DSC model: goals Allows for more efficient utilization of dermatology specialty assets Maintains high quality of care for skin related disease Timely Efficacious
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DSC model: key features
Store-forward technology Skin Evaluation Clinic Trained non-specialist skin care providers Intermediaries between primary care and the specialist Performance measures Dynamic adaptive system Continuous enhancement
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Telemedicine methodology
Real-time Video with synchronous (“face-to-face”) patient-consultant encounters Low resolution, high bandwidth Inefficient utilization of consultant Store-forward Still images with asynchronous patient-consultant encounters High resolution, low bandwidth Efficient utilization of consultant Dependent upon skills of non-specialist Obtain proper history Decide on what is “image worthy” Self-initiate therapeutics and/or diagnostic procedures
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DSC: Three-tier delivery system
Primary Care Provider Service Agreement Skin Evaluation Clinic Rules of Engagement Teledermatology Consultant
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Tier 1: Primary care provider
Identify patient with skin complaint Utilize Skin Evaluation consult menu to direct patient care Initiate consultation with Skin Evaluation Clinic (when appropriate)
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Skin Evaluation consult menu
Decision Tree for managing patients with skin dz Determines appropriateness of consultation Directs patient flow Service Agreement Directs initial therapeutic approach for established skin diseases Prioritizes unknown skin conditions Suggests alternative approaches for skin disorders that are not referable to SEC Skin Evaluation consult request form Asks for reason for consult and whether patient has been seen previously in SEC
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Dermatology Decision Tree: an algorithm for skin dz patient flow
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Components of Service Agreement
Part A Known conditions and treatments Part B Priorities of unknowns and areas of concern Part C Uncovered items (limited resources)
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Tier 2: Skin Evaluation Clinic
Evaluate patient Initiate treatment or perform diagnostic tests Acquire images according to the “rules of engagement” Enter teledermatology consult (when appropriate)
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Skin evaluation clinic providers
Various backgrounds Nurse practitioners/Physician assistants Dermatology residents Primary care physicians Training Training in dermatology clinic Approach to the dermatology patient Rudimentary dermatology differential diagnosis Introduction to dermatology therapeutics Hands-on training in techniques Biopsy--shave, punch Cryotherapy Electrodessication and curettage Hands-on training in image acquisition Access to dermatology educational resources Feedback
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Rules of Engagement Initial consult that specifically refers to evaluation of a lesion for suspected malignancy Any patient in which there is a question as to the diagnosis that may affect treatment approach such that the consequence of proceeding along one of alternative lines of therapy could result in a delay in appropriate and prognostically significant care Any patient that requires a biopsy Any patient that will be started on systemic medications that require monitoring Patch test evaluation
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The Camera 8 MP SLR camera Macro lens Macro flash Back-up available
The Canon EOS Digital Rebel with the Canon EF 100mm f/2.8 USM Macro Lens and Canon Macro Twin Lite 8 MP SLR camera Macro lens Macro flash Back-up available Technical support
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Image acquisition/capture
Patient ID Contextual (anatomic context) Morphological (diagnostic close-up) Image capture Client software/access Card reader
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Image quality Literature Standards for image resolution/color
supports the validity of teledermatology in diagnosis of skin lesions Standards for image resolution/color DSC standards >> American Academy of Dermatology and the American Telemedicine Association Future DICOM standard Techniques to ensure image quality Standard and simple image acquisition process Calibration for “true” colors Training Feedback Validation
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Tier 3: Teledermatology consultant
Review SEC note Emphasis on history View images VistA Image Display Document Link to Teledermatology consultation Template Code
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DSC: Three-tier delivery system
Primary Care Provider Service Agreement Skin Evaluation Clinic Rules of Engagement Teledermatology Consultant
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Performance Training Validation
Basic dermatology therapeutics/procedures Image acquisition Resources Reference materials Continuing education Validation Diagnostic accuracy JCAHO requirement Business plan Cost effective Healthcare product of sufficient quality Patient satisfaction Morbidity/mortality statistics
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DSC: Strategy for success
Personnel Primary care provider (PCP) Skin evaluation clinic non-specialist provider Teledermatology consultant VISN2 Telemedicine consultant Process Patient management via CPRS Image acquisition Store-forward teledermatology Coding Performance Training Resources Validation Performance Personnel Process
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VISN2 Teledermatology Initiative
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