The New York Times recently published an article about teledermatology and telehealth platforms that are disrupting skin care. Are these platforms good for expanding patient access to dermatology? How should dermatology clinicians address patient questions about these platforms?
For expert advice, I reached out to George Han, MD, PhD, associate professor of dermatology at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, and a frequent speaker on teledermatology.
Teledermatology has been around for decades, but what these teledermatology and telehealth platforms offer is new. What are the differences between traditional teledermatology and these online platforms?
While traditional practice-based telehealth tries to emulate a physical visit as much as possible in most specialties, dermatology is unique in that we often rely on high-quality images rather than video to make diagnoses via teledermatology. This opens up the possibility of providing asynchronous care, which unfortunately is not reimbursed very well through traditional fee-for-service insurance models. However, enterprising individuals have seen this as relatively low-hanging fruit in terms of designing a model where, in a relatively narrow scope, you can maximize the convenience of getting a treatment for acne or hair loss, for example. These models are based on the fundamental premise that even if the payment for such services is lower than a traditional office visit, they can be triaged in such a small amount of time that it’s made up for by volume. There’s no denying that this strikes somewhat of a chord with the general public, given how popular these platforms are.
How has the governmental and technological environment changed to make these platforms both accessible and attractive for patients?
From a technology standpoint, setting up a telehealth visit with a dermatologist through their office often involves more steps – sending in insurance information, registering for a platform with obscure complexity requirements for passwords, logging on at a predetermined time and perhaps waiting for a provider who is trying to juggle in-person with telehealth appointments. On the practice side, we have to try to set up the patient with the appointment and guide them through the technical part of the visit, verify insurance and referrals, and figure out a way to ask for static images, which is often not built into the telehealth platform because other specialties don’t need high-resolution static images. Contrast that with the experience of an online platform, which is designed around ease of user experience with a few focused questions and perhaps a built-in, easy to use, photo capture methodology, all at a pre-calculated “reasonable” price – it’s not hard to see why the general public may want to try one of these platforms first before going through the hassle of coming to a dermatologist’s office.
What are the advantages and disadvantages to patients in using these platforms?
The advantages for patients are that generally speaking, you can sit on your couch, input some information, pay a reasonable fee that’s similar to most people’s copays or less, and get prescription medication sent to you with minimal hassle. If the patient thinks that it’s not a big deal and should be straightforward, or especially if a friend or influencer is saying positive comments about a platform, they won’t see much issue with trying it. The hard part is that they’re missing a lot of the guardrails that we normally would put around even what seems like a straightforward condition. For example, if someone is experiencing hair loss, they’ll likely receive medication to treat androgenetic alopecia from one of these sites – but they won’t have their labs checked. What if the patient is experiencing hair loss from asymptomatic iron deficiency anemia? The challenge here is that the patients won’t necessarily know what they’re missing out on by not having a more appropriate, formal consultation with a dermatologist, and these platforms will miss some cases that should have been properly identified as something else.
Have patients asked you about these platforms? If so, how have you responded?
I have had patients see me who have mentioned they used these platforms in the past. For example, someone coming in for a skin check who asks, Can I just get my prescription for finasteride from you? I think when they ask about it, I let my patients know that it’s preferable to let us manage their skin issues because we have a better understanding of everything that is going on with the patient’s skin.
How should dermatology clinicians address patient questions about these platforms?
I think it’s important for us to not minimize our specialty and to stress the importance of having someone take the time to really evaluate each specific issue the patient is having. An online platform not only won’t be able to address the nuances of different types of acne as well as we can by speaking to the patient, they may also have other motives, such as selling their own compounded products and making money from the pharmacy/dispensing side as well.
Have you had patients use these platforms? If so, what have they told you about their experiences?
I think that for very straightforward cases, we can’t deny that some patients will benefit from the ease of access to care. However, these systems are not robust enough to appropriately diagnose challenging cases or manage them. I have had some patients try regimens from some of these telehealth platforms and not had much success, and I’m left trying to interpret a confusing regimen that doesn’t truly address the patient’s issues well.
Access to dermatologic care has been an issue that national dermatology organizations have been working to address for decades. In your opinion, are these teledermatology and telehealth platforms improving access to care?
I think that these platforms only go after the low-hanging fruit and offer convenience over access. Do they truly offer something that an experienced primary care provider in a rural area without much access to dermatology can’t provide? Because in those areas, the primary providers are already managing acne, straightforward hair loss, and such. These platforms cannot diagnose pemphigus, pustular psoriasis or discoid lupus, for example. If a patient “fails” the questionnaire they are sent, they are back to square one with advice to find a dermatologist and talk to them about their issues. I think the hard work of truly using telehealth to improve access falls upon us within the specialty rather than the businesspeople and entrepreneurs who generally develop these direct-to-consumer telehealth platforms. Some progress is being made with dermatologist-led national teledermatology platforms, but those don’t get nearly the amount of attention or press that the Hims and Hers of the world do.
Some dermatologists are attracted to working for these platforms due to better pay and hours. What are your thoughts on providing dermatology via platform?
You can’t blame specialists for working with these platforms to sign off on prescriptions and make easy revenue with the convenience of not having to commute or worry about denials from insurance companies and fighting them. However, I do wonder if this is sustainable. Before the pandemic, I was a big proponent of teledermatology, but most of the pushback when I tried to get my colleagues involved was centered around liability risk. You don’t know as much about the patient in the telehealth world as you would in person. You can’t run as many tests. You can’t touch their lesions. I wonder if it’s only a matter of time before we start to see some serious blowback from missing a diagnosis or patients experiencing adverse outcomes. In these telehealth platforms, you’re only getting answers to leading questions and, in some cases, limited photos. What if a patient is diagnosed with melanoma years later and then points back to the lesion being present in a photo they sent to a telehealth platform for acne? Are there enough protections built into the systems and the disclaimers to protect against this? I think the time is right for us to really decide what is the best way to offer teledermatology to help improve access to care, and if we don’t take charge of this space, we will continue to see these consumer-driven platforms proliferate and try to capture more patients with dermatologic concerns. Then we will be stuck either only seeing more complex cases or trying to right the wrongs of an algorithm that didn’t work right.
Traditional teledermatology grew in popularity during the pandemic. What’s the state of teledermatology usage by dermatology clinicians now?
While many dermatologists still maintain some telehealth hours or slots, I think a lot of our specialty is kind of glad that things are back to business as usual and are relegating teledermatology to relatively narrow scopes. We are back to teledermatology as a “convenience” offering rather than having it expand our scope of practice. No one relished the idea of providing tech support to patients when they were having issues connecting, or enjoyed trying to conduct a visit with blurry videos of patients while driving. I think part of the problem is that we weren’t really ready for widespread adoption of teledermatology overnight. The pieces weren’t really there to have good technology support and AI for image capture to ensure we get high-quality, well-lit, non-blurry photos to base diagnoses and treatment plans on. Whereas our colleagues in primary care and some other specialties are happy to have discussions via telehealth and don’t need to see things in detail, we really can’t adequately diagnose much over compressed, HIPAA-compliant video platforms.
What are your thoughts on the future of teledermatology and telehealth platforms for skin care?
I think one thing should be clear to us, seeing how popular these telehealth platforms for skin care are: If we don’t drive the conversation around what appropriate models of teledermatology should be, people in the business world will see dermatology as easy pickings to generate revenue from visits and prescriptions. They’ll try to squeeze a prescriber for as much efficiency as possible, take the lion’s share of profits and relegate us into what amounts to a widget in a skin care factory line. This not only cheapens our specialty, it is not really sustainable. I’d really like to see some reforms in terms of medical licensing across state lines, or if that’s not possible, at least a platform where dermatology providers can join and see patients in your own state to provide care to patients that might not otherwise be able to receive it. You could fill in time during the day when you have either a late cancellation or empty slots on your schedule. We could help dermatology providers have another option to provide care and generate income while they’re at home for medical reasons, or during maternity/paternity leave. There are a lot of opportunities out there where we can make it a win-win for providers and patients alike, we just have to take the time to design a platform appropriately from scratch with patient care and provider satisfaction as the key metrics of success rather than pure profit. The logistics of such a platform would be exponentially more challenging than fee-based direct-to-consumer care, but the impact on our society would be much higher, and in the long run, it could be financially sustainable as well!
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