Conducting inpatient dermatology consultations and maintaining resident education in the COVID-19 telemedicine era
Authors: Margaret I. Hammond, Timmie R. Sharma, Kevin D. Cooper, Mara G. Beveridge
Journal: Journal of the American Academy of Dermatology (2020)

To the Editor: Telemedicine is being used to provide care while minimizing coronavirus disease 2019 (COVID-19) exposure to patients and providers and preserving scarce personal protective equipment. This has led to anxiety among providers about how to accomplish this without sacrificing quality of care. The commentary by Lee et al1Lee I. Kovarik C. Tejasvi T. Pizarro M. Lipoff J.B. Telehealth: helping your patients and practice survive and thrive during the COVID-19 crisis with rapid quality implementation.J Am Acad Dermatol. 2020; 82: 1213-1214Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar summarized steps for outpatient telemedicine using existing platforms, prioritizing high-risk or urgent visits, and postponing nonessential visits. Here we aim to supplement their work by sharing our experience with inpatient teledermatology and maintaining trainee involvement in telehealth. Inpatient dermatology consult services, like other health care providers during this crisis, can take steps to conserve personal protective equipment. Telemedicine can be used to triage consults and determine who needs an in-person consultation (Fig 1). For patients who can be managed with telemedicine, a live interactive encounter supplemented by photographs is preferred. Video allows evaluation from multiple angles and maintains a "face-to-face" interaction, while photographs add greater detail. When video is not possible, adding direct audio interaction with the patient while viewing their photographs helps maintain the usual history taking and counseling. The feasibility of performing telemedicine may vary across institutions. Obtaining photographs may be a challenge. Many health systems have the ability to easily and securely send photographs between providers. Alternatively, photographs can be requested directly from the patient. For a live interactive visit, patients will need a video-compatible device. While 81% of American adults own a smartphone, including 53% of those older than 65 years,2Pew Research CenterInternet and Technology. Mobile Fact Sheet. Survey conducted Jan. 8 to Feb. 7, 2019.https://www.pewresearch.org/internet/fact-sheet/mobile/Date accessed: June 21, 2020Google Scholar many hospitals are now providing tablets to patients in isolation and have seen a resultant 50% reduction in personal protective equipment use.3Martineau P. iPads Are Crucial Health Care Tools in Combating Covid-19. Wired. April 8, 2020.https://www.wired.com/story/ipads-crucial-health-tools-combating-covid-19/Date accessed: June 21, 2020Google Scholar Health Insurance Portability and Accountability Act-compliant telehealth platforms are listed in the American Academy of Dermatology Teledermatology Toolkit.4American Academy of DermatologyTeledermatology Toolkit. Dermatologists can use telemedicine during COVID-19 outbreak.https://www.aad.org/member/practice/telederm/toolkitDate accessed: June 21, 2020Google Scholar Billing for these services is evolving as payers loosen restrictions. The Centers for Medicare and Medicaid Services have temporary waivers for initial hospital care and initial/subsequent observation codes. Restrictions on frequency of subsequent inpatient care have also been temporarily lifted.5CMS Interim Final Rule and Waivers.https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waiversDate accessed: June 21, 2020Google Scholar Hospital billing departments, the Centers for Medicare and Medicaid Services website,5CMS Interim Final Rule and Waivers.https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waiversDate accessed: June 21, 2020Google Scholar and the American Academy of Dermatology Teledermatology Toolkit4American Academy of DermatologyTeledermatology Toolkit. Dermatologists can use telemedicine during COVID-19 outbreak.https://www.aad.org/member/practice/telederm/toolkitDate accessed: June 21, 2020Google Scholar are excellent resources. The pandemic poses unique challenges in trainee education. Residents learn by being included in clinical and ethical discussions where they can contribute meaningfully. Residents can create and execute triage algorithms for telehealth or live visits with patients. To maintain resident preceptorship, we created a workflow (Table I)4American Academy of DermatologyTeledermatology Toolkit. Dermatologists can use telemedicine during COVID-19 outbreak.https://www.aad.org/member/practice/telederm/toolkitDate accessed: June 21, 2020Google Scholar that mimics an in-person encounter. In addition, video conferencing promotes faculty attendance and engagement in didactics by reducing time and travel constraints.Table ITelemedicine workflow maintaining resident preceptorshipComponent of encounterDescription of workflowInitial history and examinationThe resident initiates the video call with the patient and conducts the history taking and physical examination portion of the visit.Staffing with attendingThe resident then virtually leaves the patient encounter to discuss the case with the attending, either through the same video platform or even over a simple phone call. This allows the typical flow of resident-patient interactions, followed by attending staffing, to continue. The attending, resident, and patient then reconvene in a group call over the videoconferencing platform during which the visit is completed. The AAD's Teledermatology Toolkit provides a list of HIPAA-compliant telehealth platforms, some of which have waived their fees.4American Academy of DermatologyTeledermatology Toolkit. Dermatologists can use telemedicine during COVID-19 outbreak.https://www.aad.org/member/practice/telederm/toolkitDate accessed: June 21, 2020Google ScholarPatient counselingAs in live appointments, the attending may leave the room after completing their examination and detailing the plan of care, allowing the resident to remain in the call to perform patient education.DocumentationAfter the call, the resident completes documentation and other clinical duties such as sending prescriptions or communicating with specialists as they normally would.AAD, American Academy of Dermatology; HIPAA, Health Insurance Portability and Accountability Act. Open table in a new tab AAD, American Academy of Dermatology; HIPAA, Health Insurance Portability and Accountability Act. In summary, telemedicine can be used judiciously in the inpatient setting to meet the needs of the current health crisis. Telehealth could even be used after the pandemic to provide access to dermatology for remote hospitals. The teledermatologist could assist the primary team with their clinical decision making but still recommend transfer if needed. Residents can play a valuable role in the transition to telehealth while continuing to meet educational objectives. Preserving preceptorship and didactic education can lead to fulfillment for both resident and attending physicians alike.