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Service Delivery Innovation Profile

Online Visits With Dermatologists Enhance Access to Care for Patients With Minor and Serious Skin Conditions, Boost Physician Productivity


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Snapshot

Summary

Patients with skin conditions conduct virtual visits with board-certified dermatologists, submitting their medical history and information and photographs related to the condition(s) through user-friendly, secure Web-based and mobile applications. Those with minor conditions receive a diagnosis and treatment plan within 3 business days. Patients for whom the diagnosis remains unclear or who have potentially serious conditions are quickly scheduled for an inperson visit. The program has significantly enhanced access to diagnosis and treatment (including for patients with serious, potentially life-threatening skin conditions such as melanoma), increased dermatologist productivity, and generated high levels of patient satisfaction.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of patients served, physician productivity, and patient satisfaction.
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Developing Organizations

Iagnosis®
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Use By Other Organizations

Other systems are available for facilitating virtual dermatologist visits, including but not limited to Internet Dermatology Network (http://physicians.idermnet.com/), OnlineDermClinic (http://www.onlinedermclinic.com/), and Skin of Mine (https://www.skinofmine.com/).

Date First Implemented

2006
Dr. Seraly began seeing patients through virtual visits using an earlier version of the system in 2006; in 2010, Dr. Seraly and Mr. Eakin cofounded Iagnosis and began to upgrade the system significantly, under the name DermatologistOnCall®. (The Context section provides more details.)

Problem Addressed

Patients in need of skin care often wait a long time for a face-to-face appointment with a board-certified dermatologist. As a result, many patients seek other sources of care, and others live with the condition until the appointment. In some cases, waiting means that serious conditions such as cancer are not caught in a timely manner. Virtual visits can reduce wait times by safely diagnosing and treating many minor skin conditions and identifying serious cases in which immediate inperson care is required. However, few patients have access to such services.
  • Long wait times: Patients with skin conditions routinely wait weeks or even months to see a dermatologist. A 2009 study estimated average wait times of 22 days (with wide variations across clinics and regions), whereas another study estimated average wait times of 36 days.1,2 Wait times tend to be even longer (several months or more) for patients without an established relationship with a dermatologist.3 In the Pittsburgh area (where this program began), wait times in the mid-2000s averaged 4 to 6 months, with some physicians (including the developer of this program) having 8-month wait lists.
  • Causing patients to seek alternative care options or endure diagnostic and treatment delays: Faced with long waits, many patients turn to over-the-counter medications (which may or may not be appropriate and effective) or seek care from another provider, such as a primary care doctor (who typically is not board certified in dermatologic care). Each year, only about one-third of the 100 million diagnosed dermatological conditions and diseases are treated by board-certified dermatologists. In other cases, patients decide to wait for an appointment with a dermatologist and hence end up living with the condition and any related symptoms. In some instances, waiting to see the dermatologist results in dangerous delays in getting serious conditions such as skin cancer diagnosed and treated.
  • Unrealized potential of virtual visits: An estimated 80 to 85 percent of skin conditions can be safely diagnosed and treated “virtually" (such as through telemedicine or online visits), with the patient providing relevant medical information and history and submitting photographs via the Internet, telemedicine, or another technology.4 For example, a recent study found that online visits were just as effective as inperson visits for patients with acne.5 Even when diagnosis and treatment is not possible, this approach can allow dermatologists to identify potentially serious conditions and schedule an inperson appointment much earlier than they would have if the patient waited weeks or months for the initial face-to-face visit.

What They Did

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Description of the Innovative Activity

Through a service known as DermatologistOnCall®, patients with skin conditions conduct virtual visits with board-certified dermatologists, submitting their medical history and information and photographs related to the condition(s) through user-friendly, secure Web-based and mobile applications. Those with minor conditions receive a diagnosis and treatment plan within 3 business days. Patients for whom the diagnosis remains unclear or who have potentially serious conditions are quickly scheduled for an inperson visit. Key program elements are detailed below:
  • One-time prequalification, consent, and profile set-up: Using secure, Web-based applications, new patients complete a one-time process to verify their eligibility to receive services, give appropriate consent, and set up a secure account and patient profile, including providing their medical history and eliciting their personal preferences related to receiving care through the program. Once this process has been completed, returning patients skip these steps unless they need to update their medical history and preferences. The initial steps take approximately 15 minutes to complete and consist of the following:
    • Prequalification: Patients answer approximately eight questions to verify their eligibility to receive services. Among other things, these questions verify that the patient is not pregnant, lives in a State in which the program has board-certified dermatologists in its network, and agrees to pay for the services out-of-pocket and be cared for through a virtual visit. (Those who are pregnant receive instructions to schedule a face-to-face visit.)
    • Consent: After completing these questions, the patient fills out a consent form; those younger than 18 years have a parent complete this form. Patients who are incapacitated can designate a surrogate to assist them with this process and the entire visit.
    • Secure account and profile: The patient creates a secure account by setting up a login identification and password that include several levels of security. As part of this process, the patient provides demographic information; enters information about his or her medical history (e.g., diseases, conditions, allergies, drugs being taken); and indicates any care-related preferences, including choice of dermatologist (if any), pharmacy for picking up any needed prescriptions, medications (e.g., brand-name versus generics), and communication vehicles (e.g., e-mail, text) and related contact information.
  • Patient entry and submission of medical information, photographs: The system guides the patient through a set of directed questions based on well-established guidelines from the American Academy of Dermatology, similar to the questions a dermatologist would ask in a face-to-face visit. (The Other Tools and Resources section contains a link to these guidelines.) These questions are intended to gather relevant information about the skin condition(s) in question. In addition, the site provides diagrams that show various body parts, allowing the patient to click on the body part(s) where the condition exists. Finally, aided by an instructional video that shows the best way to take pictures, the patient takes and uploads at least two and no more than nine images of the skin condition(s) in question. The system has built-in applications that allow for easy, secure uploading of images to the site from most smartphones and digital cameras.
  • Patient review, submission, and payment: The patient reviews all of the information entered, makes any desired changes, and then submits the information and photographs. As part of this process, the patient pays a $69 fee via credit or debit card. (To date, insurers do not cover this service.) After completing the process, the patient receives an immediate confirmation that the information has been received and will be reviewed by a network dermatologist.
  • Transmission of information to network dermatologist: The program has a network of dermatologists who have agreed to see patients through virtual visits. If the patient chooses a particular dermatologist, notification of the case goes to that physician. If not, notification goes to a “virtual waiting room” of all dermatologists in the network qualified to care for that patient, generally those licensed in the same State and ideally located somewhere near the patient (in case a face-to-face visit becomes necessary). All qualified dermatologists receive notification that a case is ready for review, and the case gets assigned to the first one who logs in to take a new online case.
  • Dermatologist diagnosis and treatment plan: The dermatologist reviews the information and images. In rare cases, he or she may contact the patient securely through the system to request more information or new images; in this latter instance, the dermatologist will specify the type of photograph(s) needed. Aided by links to established care guidelines, the physician determines the appropriate next step, as outlined below:
    • Diagnosis and treatment plan for minor conditions within 3 days: For approximately 85 to 90 percent of patients, the dermatologist diagnoses a minor skin condition (e.g., acne) and uses built-in, condition-specific templates within the system to create and deliver a comprehensive, tailored treatment plan to the patient no more than 3 business days after—and often within 24 hours of—the initial submission. Once the treatment plan has been developed, the physician reviews and approves it and then submits the plan through the Web-based system, which in turns notifies the patient that the plan is ready via his or her preferred communication vehicle(s). The resulting user-friendly treatment plan provides the following:
      • Diagnosis: This section summarizes the diagnosis, including educational information about the condition and counseling on how to care for it or avoid getting it in the future.
      • Treatments: This section reviews any medications being prescribed, including how to take them and potential side effects (with the prescription sent electronically to the patient’s designated pharmacy). It also highlights any recommended over-the-counter treatments, including how to use them.
      • Personal message: This section allows the dermatologist to add his or her own message, thus helping to build a personal relationship with the patient.
    • Quick scheduling of face-to-face visit for potentially serious conditions: In roughly 10 to 15 percent of cases, the dermatologist (or a member of the office staff) contacts the patient to schedule a face-to-face visit for further evaluation. Most often, these patients have suspicious lesions that need to be evaluated and biopsied, or other signs of more serious (in some instances life-threatening) conditions such as melanoma or basal carcinoma. On rare occasions, the dermatologist may remain uncertain as to the diagnosis based on the information submitted online; in these cases, he or she contacts the patient to explain that uncertainty and request a face-to-face visit. In these latter instances, the patient receives a refund of the fee for the virtual visit.
  • Followup communications for 30 days: As part of the fee, the patient can communicate via secure messaging with the dermatologist for up to 30 days. These followup communications are often used to determine if the prescribed treatment is working (and to make changes if not) or to see if unexpected side effects or other problems have arisen. In most cases, patients initiate these communications, although physicians can do so as well at their discretion.

Context of the Innovation

Founded in 2010, Iagnosis® provides proprietary, Web-based telemedicine and telehealth services and products to facilitate the diagnosis and treatment of skin disease. The company’s flagship product is DermatologistOnCall, the impetus for which came from Mark Seraly, MD. A practicing dermatologist in the Pittsburgh area, Dr. Seraly found himself with an 8-month waiting list for patients, even higher than the typical 4- to 6-month wait for other dermatologists in the local area. Patients sometimes became so desperate to see a dermatologist that they would approach Dr. Seraly on the street or at local events to ask him to look at their skin. Working 7 days a week and still not able to get through his backlog of patients, Dr. Seraly decided to explore the potential of online visits, which he thought could be particularly helpful for those with minor skin conditions and hence would free up capacity for face-to-face visits for those with more serious problems.

Did It Work?

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Results

The program has significantly enhanced access to diagnosis and treatment (including for patients with serious, potentially life-threatening skin conditions such as melanoma), increased dermatologist productivity, and generated high levels of patient satisfaction.
  • Enhanced access to care: To date, more than 5,000 patients have been treated through the system, primarily by Dr. Seraly through an earlier, less sophisticated version. (See the Planning and Development Process section for more details.) Without access to this program, most of these patients would have either waited weeks or months for a face-to-face dermatologist appointment, sought care from a primary care doctor or another provider with less training in dermatology, or gone without care altogether.
  • Earlier diagnosis and treatment of serious conditions: In roughly 10 to 15 percent of cases, the online visit identifies something that warrants an in-office diagnostic or therapeutic procedure, such as treating an inflamed cyst or biopsying a suspicious lesion. For these patients, the online system leads to earlier diagnosis and treatment than would have occurred otherwise, in some cases resulting in lives being saved through early detection of a potentially deadly condition. (See the Back Story section for an example of a patient whose life may have been saved by the system.)
  • More productive physicians: Physicians can review roughly 8 to 12 virtual cases per hour (and up to 20 if all cases are for minor conditions such as acne), much more than the 4 to 6 patients per hour they typically see through face-to-face appointments. In addition, they can fit the reviews of online cases into natural downtime, such as at the end of the day (after the last face-to-face appointment) or when patients cancel or unexpectedly do not show up for face-to-face visits. Physicians who make virtual visits a meaningful part of their practice can, over time, transition most minor skin conditions to the online approach, thus freeing up scarce face-to-face capacity for patients with more serious conditions that truly require an inperson visit.
  • High patient satisfaction: Approximately 96 percent of patients who have used the online system would highly recommend it to a family member or friend. In particular, patients express appreciation for quick access to care from a board-certified dermatologist (rather than waiting months for an appointment with one or seeing a less qualified provider) and the convenience of not having to take time off of work or pull their children out of school to travel to and from the appointment.

Evidence Rating (What is this?)

Suggestive: The evidence consists of post-implementation data on the number of patients served, physician productivity, and patient satisfaction.

How They Did It

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Planning and Development Process

The program has evolved and expanded over time, beginning as a rudimentary system used by one physician and later expanding to become a separate company with a network of dermatologists serving patients; key steps include the following:
  • Developing initial, rudimentary platform: In 2006, Dr. Seraly developed his own telemedicine system to allow patients to initiate online visits 24 hours a day, 7 days a week through a Web-based application that met Health Insurance Portability and Accountability Act (HIPAA) requirements. To develop this system, Dr. Seraly pieced together various HIPAA-compliant consumer tools that allow for secure e-mail and uploading of photographs to a server. For the next several years, he offered this system to his patients, diagnosing and treating many of them in this manner. During this time, the system went through several rounds of minor modifications.
  • Forming separate business venture: Over time, Dr. Seraly began to recognize that online visits were a service that dermatologists throughout the country could offer to enhance patient access to care. Recognizing the potential to scale this approach, Dr. Seraly and Larry Eakin cofounded the company in 2010, with the goal of developing proprietary, Web-based and mobile applications related to skin care diagnosis and treatment.
  • Upgrading the system significantly: Because the rudimentary system designed by Dr. Seraly was not scalable, the newly formed company invested in a significant upgrade to the system, with the idea of creating a scalable enterprise. This upgrade included integration with an electronic health record and investments in cloud technologies, e-prescribing, and other user-friendly Web-based and mobile applications to make the system as simple as possible for patients and dermatologists. This process included the investment of significant time and money (including use of outside consultants) to develop and test the security of the system and ensure its compliance with HIPAA and Health Information Technology for Economic and Clinical Health Act (HITECH) requirements. Throughout the process, the partners relied on advice and guidance from roughly 20 experts who tested the system on a regular basis. The new, upgraded service debuted in late 2012, with mobile applications launched in August 2013.
  • Recruiting and signing on network dermatologists: As an ongoing process, the sales team meets with board-certified dermatologists about joining the network. During these meetings, the sales team emphasizes the potential benefits of participating, including greater productivity and billings and the ability to serve patients more quickly and free up scarce capacity for those who really need inperson care. They also stress that the system is merely a conduit to allow them to see their patients virtually, with no changes to their clinical autonomy. As of August 2013, a growing number of board-certified dermatologists have signed on and offer online visits through the system to patients mainly in and around Pittsburgh. The company is rapidly expanding its reach across Pennsylvania, currently focusing on the Philadelphia region. It expects to expand into neighboring states, and then other states across the country. Participating dermatologists sign a service line agreement in which they commit to various requirements, including meeting the 3-day turnaround time and seeing patients with more serious conditions as quickly as possible.
  • Expanding to other geographic areas: The company is in various stages of obtaining legal and regulatory approval in a number of states outside of Pennsylvania.
  • Marketing partnership with insurer: The company has partnered with Highmark, a large insurer, which has agreed to take steps to create greater awareness of the service among its 4.9 million members in Pennsylvania, West Virginia, and Delaware.

Resources Used and Skills Needed

  • Staffing: The program requires no new staff, as dermatologists diagnose and treat patients online as part of their regular job responsibilities; as noted earlier, the program allows dermatologists to see more patients per hour than they could via face-to-face visits.
  • Costs: The company has invested significant funds to create, upgrade, and maintain the system; data on these costs are not available.
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Funding Sources

U.S. Department of Health and Human Services
As noted, patients pay $69 per visit, with this money going to the dermatologist who handles the case. At present, insurers do not cover services offered through the program, but program developers are hopeful that some will do so in the future. Participating dermatologists pay a weekly licensing fee for access to the virtual platform that enables the online visits, including tools to facilitate diagnosis, treatment (including electronic prescribing), secure messaging, billing, collections, and other functions.

In 2010, Iagnosis applied for and was awarded a Qualifying Therapeutic Discovery Project tax credit from the Internal Revenue Service and the Department of Health and Human Services (which reviews applications for the credit). More information on this credit is available at: http://www.grants.nih.gov/grants/funding/QTDP_PIM/index.htm. Going forward, the company hopes to sign agreements with outside investors to support expansion of the program.end fs

Tools and Other Resources

More information on this program is available at: www.dermatologistoncall.com.

The American Academy of Dermatology guidelines that are integrated into the system are available at: http://www.aad.org/education/clinical-guidelines.

Adoption Considerations

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Getting Started with This Innovation

  • Design or choose system that is fully integrated, easy to use: The success of this program depends in large part on offering an easy-to-use system to dermatologists and patients. To that end, choose or design a system that mimics a face-to-face visit. This sort of system typically requires a fully integrated electronic health record and systems for secure messaging, electronic prescribing, billing and payment, and other functions. All functions should be as user friendly as possible, incorporating templates and applications that make it easy for patients to enter accurate and complete information (including submitting photographs) and for dermatologists to diagnose and treat patients.
  • Emphasize potential benefits, maintenance of autonomy to dermatologists: At present, most dermatologists have more patients than they can handle and so their concerns focus more on lifestyle issues than finances. Consequently, they are most likely to be attracted to the system’s potential to enhance their productivity and reduce patient backlogs. In addition, when meeting with dermatologists, emphasize that using the online system will not result in any loss of clinical autonomy, which is another issue likely to affect dermatologists' willingness to participate.

Sustaining This Innovation

  • Advocate on regulatory and legal issues: Telemedicine and other forms of virtual care remain subject to various legal and regulatory restrictions related to licensing and other areas, and these laws and regulations have generally not kept up with the rapid technological changes that have allowed for such care. Consequently, program leaders need to meet regularly with relevant stakeholders (e.g., public officials, legislators, regulators) and otherwise advocate for change. As part of this effort, leaders should share information documenting the lengthy wait times that most patients currently face to see a dermatologist and explain how virtual visits can not only enhance access to care, but reduce costs and save lives through earlier diagnosis and treatment of serious skin conditions.
  • Lobby payers for reimbursement: As noted, few if any payers currently cover virtual visits with dermatologists. To secure such coverage, share data with the leaders of health plans, insurers, and other public and private payers that demonstrate the program’s potential to enhance access, reduce costs, and save lives.
  • Monitor adherence to service line agreements: The program’s success depends on providing patients with timely diagnosis and treatment, within the guaranteed turnaround time. To that end, make sure that participating dermatologists adhere to these requirements.

Use By Other Organizations

Other systems are available for facilitating virtual dermatologist visits, including but not limited to Internet Dermatology Network (http://physicians.idermnet.com/), OnlineDermClinic (http://www.onlinedermclinic.com/), and Skin of Mine (https://www.skinofmine.com/).

More Information

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Contact the Innovator

Mark P. Seraly, MD
Chief Executive Officer, Chief Medical Officer, and Founder
Iagnosis
222 East McMurray Road
McMurray, PA 15317
(724) 969-2500
E-mail: mseraly@iagnosis.com

Lawrence Eakin
Chief Strategy Officer and Co-Founder
Iagnosis
222 East McMurray Road
McMurray, PA 15317
(412) 216-0892
E-mail: leakin@iagnosis.com

Innovator Disclosures

Dr. Seraly and Mr. Eakin are majority owners of Iagnosis, which in turn wholly owns DermatologistOnCall.

References/Related Articles

Toland B. Washington, Pa. company’s online service puts dermatologists on call, cuts down on waiting times. Pittsburgh Post-Gazette. 2012 Dec 1. Available at: http://old.post-gazette.com/pg/12336/1280982-28.stm.

Uhlenhake E, Brodell R, Mostow E. The dermatology work force: a focus on urban versus rural wait times. J Am Acad Dermatol. 2009 Jul; 61(1):17-22. [PubMed]

Nixon A. McMurray company’s medical website expands access to doctors. Pittsburgh Tribune-Review. 2012 Dec 1.

Mamula KB. Iagnosis® raises $4 million. Pittsburgh Business Times. 2013 Jan 16.

Highmark. Highmark teams up with Pittsburgh-based company to expand access to dermatology services. News Release. 2012 Nov 30.

Smit D. Pop City puts Iagnosis’s online dermatology service to the test. (We’re cancer free.) Pop City. 2012 Nov 28. Available at: http://www.popcitymedia.com/innovationnews/iagnosis11282012.aspx.

Nixon A. Highmark opens innovation center at Grove City College to develop health care business. TribLive. 2012 Dec 1.

PR Newswire. Iagnosis, Inc., launches mobile application for DermatologistOnCall. 2013 Aug 5. Available at: http://www.marketwatch.com/story/iagnosis-inc-launches-mobile-application-for-dermatologistoncall-2013-08-05.

Footnotes

1 Toland B. Washington, Pa. company’s online service puts dermatologists on call, cuts down on waiting times. Pittsburgh Post-Gazette. 2012 Dec 1. Available at: http://old.post-gazette.com/pg/12336/1280982-28.stm.
2 Uhlenhake E, Brodell R, Mostow E. The dermatology work force: a focus on urban versus rural wait times. J Am Acad Dermatol. 2009;61(1):17-22. [PubMed]
3 Nixon A. McMurray company’s medical website expands access to doctors. Pittsburgh Tribune-Review. 2012 Dec 1.
4 Mamula KB. Iagnosis® raises $4 million. Pittsburgh Business Times. 2013 Jan 16.
5 Watson AJ, Bergman H, Williams CM, et al. A randomized trial to evaluate the efficacy of online follow-up visits in the management of acne. Arch Dermatol. 2010;146:406-11. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: November 06, 2013.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 06, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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