Evaluation of teledermatology in the Veterans Health Administration

Abstract

Telehealth technologies are being employed to increase access, quality of care, and cost containment. However, there are no widely accepted measures of telehealth performance and little information about long-term changes in access. The Veterans Health Administration (VHA) is advantageous for telehealth research because of the widespread implementation, organic development of multiple distinctively structured programs, and national electronic medical records. Using teledermatology, one of the earliest and most widely adopted uses, a set of recommended performance metrics are established and a select few are evaluated across the different programs. Store and forward (SF) teledermatology, taking a picture and sending it to a dermatologist for asynchronous evaluation, is the prominent method of care. In SF programs there is variation in the level of follow-up care available locally. Some locations have "surrogate dermatology providers" that are trained to do basic treatments and procedures. Based on four site visits and twenty-five interviews with stakeholders, recommendations for performance measurements were created. VHA is already in the process of executing three of the measures nationally: image quality, time to consult response, and patient satisfaction. Additionally, VHA has the data available to measure time to treatment, post-teledermatology utilization of care, travel distance, and wait-times. Finally, VHA should improve data to create future metrics regarding: cost, particularly payment for outside dermatologists; provider satisfaction; and quality of care through chart review or adverse event reporting. Using administrative databases, the metrics for which data were available were retrospectively evaluated. At a national level for 2013, entry into the care process through teledermatology is associated with faster time to treatment than entry from an in-person referral for both melanoma (teledermatology median: 62 days; in-person consult median: 70 days; p=0.002) and non-melanoma skin cancer (teledermatology median: 79 days; in-person consult median: 88 days; p<0.001). There was little consistency in the post-teledermatology care utilized across programs. Testing three programs with different resources used for local follow-up care, travel distance saved over 2013 was calculated. The program with surrogate dermatology providers had the most travel saved per patient. Implementation of teledermatology had no statistically significant impact on in-person wait times for dermatology clinics.