Implementation and Evaluation of a Store-and-Forward Teledermatology Workflow in an Urgent Care Center

From the 2019 HVPAA National Conference

Mr. Christian Carr (UT Southwestern Medical Center), Dr. Melissa Mauskar (UT Southwestern Medical Center), Dr. Benjamin Chong (UT Southwestern Medical Center), Dr. Jeffrey Metzger (UT Southwestern Medical Center), Dr. Catherine Neal (UT Southwestern Medical Center), Dr. Arturo Dominguez (UT Southwestern Medical Center)

Background

Teledermatology is rapidly becoming a popular method for expanding care in Dermatology. Implementation of a store-and-forward (SAF) teledermatology program has been shown to reduce time to dermatology visit and have good diagnostic reliability. However, its role in the emergency department has not been evaluated as rigorously. Previous studies have shown that teledermatology has the potential to reduce unnecessary hospitalizations in the emergency department (ED) and that responses can be provided quickly.

Objective

Evaluate the effect of a SAF teledermatology program on Urgent Care (UCC)/ED dwell time and time to teledermatology consult response.

Methods

In 2018, we implemented a SAF teledermatology system within EPIC™, the existing electronic health record at Parkland Health and Hospital System (PHHS). Providers in the UCC were able to enter a teledermatology consult where they completed a questionnaire and uploaded digital images using Epic Haiku or Canto. An automated alert was then sent to a pager carried by an on-call teledermatologist, who provided a diagnosis, recommendations for treatment and triage within two hours. If a diagnosis could not be made or if the condition was thought to be urgent, the patient was seen in-person by the inpatient dermatology consult service.

Retrospective chart review was performed on all teledermatology consults during 2018, and compared to patients seen in the UCC who were subsequently referred to the outpatient dermatology clinic in 2017. Information regarding patient demographics, UCC/ED arrival time, discharge time, time to response by dermatology, and dwell time were extracted for comparison. Univariate measures were evaluated for extracted variables to compare the two cohorts.

Results

In total, 339 patients were assessed using the SAF teledermatology system in 2018 compared to 1070 patients referred to the outpatient dermatology clinic from the UCC 2017. Both cohorts consisted of a diverse set of patients with a plurality of patients of Hispanic ethnicity. Mean age was 46 in 2018 and 43 in 2017.

For patients assessed by a teledermatologist, median response time was 31 minutes (IQR=15-55 minutes). Median dwell time in the UCC/ED for patients assessed by a teledermatologist was 294 minutes (IQR=234-356 minutes) compared to 183 minutes (IQR=133-243) for patients in 2017. Median time from arrival to placement of referral order was 125 minutes (IQR=83-177 minutes) in the teledermatology group and 142 minutes (IQR=93-194 minutes) in 2017. Median time to discharge from receipt of teledermatology response was 112 minutes (IQR=71-165 minutes) compared to 32 minutes (IQR=22-48 minutes) from referral placement to discharge in 2017.

Overall, 82% of patients assessed in 2018 were managed through teledermatology alone. The remaining 18% required an in-person evaluation by the inpatient consult team. In total, 36% of patients were referred for a follow-up visit to our outpatient dermatology clinics.

Conclusions

SAF teledermatology in the UCC/ED can provide rapid assessment by a dermatologist, although it may have led to an increase in UCC/ED dwell time compared to patients referred to outpatient dermatology the prior year. Future analysis will evaluate whether the apparent increase in dwell time by teledermatology may be offset by a reduction in the number of repeat visits to the UCC/ED for the same cutaneous complaint.

Clinical Implications

Despite an increase in dwell time, patients receiving assessment from a teledermatologist received rapid consultation on diagnosis and management. In addition, 82% of patients in the 2018 cohort were managed only through teledermatology.

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