Improving Standards – National standard development in

tele-dermatology

C.A. Morton,Consultant Dermatologist, NHS Forth Valley, Stirling

colin.morton@nhs.net

Teledermatology in Scotland – current status

• Accumulating evidence of benefit:Store-and-forward

(Real-time)

• Multiple small projects - Highlands, Forth Valley, Lanarkshire, Lothian, Tayside, Elgin – predominantly to assist lesion triage

• Limited current role in delivery of dermatology service - reluctance to move from face-to-face consultation….

SDS Position Statement 2010: Store and Forward Teledermatology

Advantages Disadvantages

Rapid response to GP requests can provide therapy advice and be of educational value Images can be viewed at a time convenient to the dermatologist – compared with need to co-ordinate link-up times for real time TDSFTD is typically cheaper than real time TD TD can reduce travel for patients providing imaging is available close to home - a proportion of referrals might be avoided, or therapy initiated more rapidly by using TDHigh levels of diagnostic concordance are reported with face-to-face consultations of 81-88% in systems with good image qualityIncreased efficiency in correct prioritization of suspected cancer lesions to improve access times for patients with skin cancer, with evidence of some benefit in triage of non-lesion referralsTriage SFTD can direct patients to the most appropriate part of a service, increasing the rate of delivery of definitive care at first visit to the specialist team, and in certain circumstances increase service capacity at a lower cost than extension of the conventional serviceTriage SFTD offers the ability to re-direct referrals to other specialties for definitive treatment, increasing efficiency and shortening the patient journey

Loss of aspects of face-to-face consultation if no clinic follow-up to TD, including ability to expand history, palpate lesions, examine surrounding skin, discuss related concerns of patient, and convey preventive health adviceAlthough a proportion of referrals can be filtered from attending specialist clinics, this reduction is at the expense of providing a TD service for all referralsIncreased risk of mismanagement of skin cancer unless images are assessed by an experienced skin cancer physician with opportunity for clinical assessment where there is diagnostic doubtTD is best suited to easily visualised lesions and rashes, and therefore not suitable for many referralsTravel/inconvenience for patients if the TD images are not acquired locallyAdditional costs associated with a TD service, for photography and image processing, and time commitments for GPs, nurses and other ancillary staff.The process of interpreting triage images, and providing advice requires consultant time with scheduling in job plans Concerns remain over the medico-legal responsibilities around remote assessment

Skin Cancer – The challenge

• Increasing referrals for suspected skin cancer across Scotland

• Ageing population, fairer skin, increased intermittent + total sun

• A healthcare model in Scotland with few dermatologists…

• NHS system is swamped – do we just keep running faster?

How Teledermatology is used…

• To facilitate care for patients in remote locations, to minimize long journeys and promote quicker assessment in areas with infrequent specialist clinics

• To enhance a telephone advice service for GPs, either avoiding, or delivering interim therapy to patients waiting for, specialist assessment

• To assist in the triage of referrals to assist correct prioritization and/or to direct patients into one-stop therapy clinics

Quality standards for teledermatology 2012

• A reference guide for both commissioners and providers of care

• Set out what constitutes a good-quality service and outline the procedures that need to be followed to ensure patient safety and confidentiality of data

• Supplement to Quality Standards for Dermatology: Providing the Right Care

for People with Skin Conditions, BAD 2011

• Intended as a precursor to, as well as to help inform, any future NICE quality standards on teledermatology.

• Wide stakeholder engagement: Primary+Secondary Care, RCGP, BAD, DOH

Quality standards - Draft

• Standard 1: Selecting patients for teledermatology • Standard 2: Gaining the patient’s informed consent

• Standard 3: Suitable images and patient history • Standard 4: Information governance

• Standard 5: Appropriately trained staff

• Standard 6: Models of care and links to other services

• Standard 7: Audit and quality control

• Standard 8: Communication between referrer and specialist

Quality standards – DraftFrom ‘Models of Care’

The role of TD will usually fall within one of the following definitions:

• Traige telederatology - a triage tool to ensure that patients are seen in the right place by the right person in a timely fashion. All patients are seen but an image is used to direct the referral

• Full teledermatology - an alternative to a face-to-face consultation • Intermediate teledermatology - a mix of both the above according

to patient need. Some patients are triaged to an appropriate specialist appointment whilst others receive (via the referring clinician) diagnostic and management advice that negates the need for a face-to-face specialist consultation

Quality standards – DraftFrom ‘Selecting Patients’

Patients with pigmented lesions for diagnosis• Patients with pigmented lesions should be referred via TD only if:• there are facilities to include with the referral a dermoscopic image

taken by a person trained in the use of a dermatoscope and• the reporting skin specialist is trained in the interpretation of

macroscopic and dermoscopic pigmented lesion images

Rationale The use of a dermoscope to increase diagnostic accuracy of skin malignancy is widely accepted in dermatological practice

Key performance indicator• Percentage of TD referrals for pigmented

lesion diagnosis that have included a good qualitydermoscopic image (Standard 100%)

Response to consultation - draft standards

• There remains concern regarding the risk that demand for dermoscopic imaging even for 'pure' phototriage use…

For pigmented lesions for FULL teldermatology when it replaces F2F, that a dermoscopic image is essential….preferable in other settings…

Response to consultation - draft standards

• ''Teledermatology should not therefore be seen as a substitute for face-to-face consultations, but as a complementary service to best use resources. A teledermatology service should ideally be part of an integrated local dermatology service and should not destabilise local specialist services but work with them to optimise patient care. Any potential compromise in quality of clinical assessment should be offset by the immediacy and convenience of service to the patient”

Response awaited to removal of ‘ideally’

Response to consultation - draft standards

• Intense audit requirement might 'kill off' enthusiasm for GPs to engage in new initiatives, accepting that they receive no funds for participating in phototriage services in Scotland

Final response awaited…but opportunity for STUG/SCTT to support/facilitate a standardized approach to audit?

Standards – The consequences?

• Quality evidence-based TD practice

• A supported audit process to safe delivery

• Challenge for early adopters where lack of resource to support development of service

• ‘Resourcing’ needed in Primary Care to take pictures and dermoscopic images as well as participate in audit

• Shift in cost-benefit balance ….. less attractive to innovate?