Like It or Not, Teledermatology Is Here to Stay

When the COVID-19 pandemic hit and clinicians turned to telemedicine video chats as a substitute, David J. Goldberg, MD, JD, recalls the challenges of dealing with clunky internet connections and well-meaning patients who struggled to use the technology.

“You’d get them on and you’re having this conversation and they’re sitting in their kitchen and you say, ‘show me—with your phone—that spot on your leg,’” Goldberg, clinical professor of dermatology at the Icahn School of Medicine at Mount Sinai, New York, said at the annual Maui Derm Hawaii conference. “ Then the next thing you see is a chandelier hanging from the ceiling.”

While he no longer uses a lot of teledermatology in his practice, he said, “it is here to stay and it’s getting more popular. Today it’s very easy to communicate through high resolution video chats between mobile phones anywhere in the world.”

He went on to explain that using teledermatology as a triage tool improves access to care for patients in underserved areas, those with rare diagnoses, homebound individuals, and physicians who want to take calls from home “to make their lives a little easier.”

A 2018 study examining the outcomes of adults with psoriasis who were randomized to receive care in person or via teledermatology found no significant difference in treatment outcomes after 12 months. However, Goldberg raised the question, “Is the diagnosis as accurate with teledermatology as it is when we face the patient in person?” He acknowledged that teledermatology has been shown in published studies to be a useful screening tool for melanoma and that it can have a favorable impact on initial prognosis, despite his reservations. “The problem is that correlation is between a correct diagnosis and the quality of the photograph,” he said. “These studies are done in a vacuum.”

Then there are social effects of teledermatology, he continued, such as the impact on the patient-physician relationship: “when they’re not in front of you to shake their hand, when you can’t touch their skin,” he said. “It also raises issues of support rather than replacing quality medical treatment and certainly issues of informed consent and confidentiality.”

Other potential limiting factors of teledermatology include physician fees for a HIPAA compliant server and the fact that the practice may not be covered by the patient’s insurance.

From a legal standpoint, most states require physicians to limit their teledermatology practice to the states where they are licensed. “So, if one practices teledermatology over state lines, a medical license is required in that state,” said Goldberg, who has offices in New York and New Jersey and, therefore, can practice teledermatology in both states.

Still, legal issues can arise. He cited the example of a patient in rural Louisiana who sought expertise from a California-based specialist about a pigmented lesion. The specialist in California instructed his staff to download the patient’s images, biopsies, and other medical records to assist in the diagnosis and treatment plan. The specialist discovered that the patient was pregnant and notified his staff. “In California, that patient’s right to confidentiality has been breached,” Goldberg said. “In Louisiana, the patient has no such right. We have two different state issues here. Which state’s confidentiality law should apply? There’s no answer to this. You don’t get answers in the law often until there is a lawsuit over that issue.”

According to Goldberg, clinicians who choose to practice teledermatology can minimize liability risks by publishing broad disclaimers on their telemedicine sites and by limiting the practice to their own patients. “Don’t practice teledermatology on patients you’ve never seen before,” he advised. “That’s the easiest way to stay out of trouble.”

He reported having no relevant disclosures.