Healthcare systems have undergone significant change over the past two decades, having to adapt to treating an aging population and moving away from reactive towards more preventative models of care. Dermatology has been a good example of how these larger changes are impacting the way care is being delivered.
Skin cancer is one of the most common types of cancer globally, with non-melanoma skin cancer the 5th most commonly occurring cancer in men and women, with over 1 million diagnoses worldwide in 20181. In the US alone, the annual cost of treating skin cancers is estimated at $8.1 billion2. Due to an aging population and rising rate of skin cancer and other skin conditions, some research estimates that cases will continue to grow by 18% by 20253. The good news is that when detected early, survival rates of melanoma are approximately 99%4.
This combination of increased demand and importance of early diagnosis has inevitably led to an increased need for skin examinations5. The challenge is that there is a global shortage of dermatologists and, in particular, an uneven distribution of those dermatologists across geographies6.
As the gap between increasing demand and the availability of specialists widens, health systems are increasingly looking at how they can safely shift some skin examinations into the community care setting. The typical model that you see is that of a trained Primary Care Provider (PCP) performing an examination of a suspicious lesion and, if they have concerns, referring the case onto a dermatologist for further enquiry and potential treatment. While this reduces some pressure on dermatology services, it has not been as easy as many envisioned. Skin cancer screening is a complex task and for PCPs it is very challenging identify benign from potentially malignant lesions. The result is that many unnecessary referrals still take place, one study estimated that approximately 45% of these types of referrals from community care to dermatologists are unnecessary7, and many of these services have struggled to scale to the level required for population-level impact.
So what are the challenges in delivering effective community-based skin examination programs that help get the right referrals to the right specialists?
Challenges to Community-based Dermatology Screening
As identified by the German SCREEN program8 a decade ago, you cannot simply expect non-specialists to be able to make diagnostic decisions without additional training. Being able to reliably read dermoscopy images requires understanding of typical skin structures and lesion characteristics. By providing dedicated training and ongoing certification, you empower PCP’s to better provide the first diagnosis and refer the correct patients to Dermatology specialists. Another study in the US state of Missouri9 found that after 12 months participation in a remote dermatology training program, PCP’s achieved a statistically significant increase is diagnostic accuracy.
Access to Advanced Technology
Modern dermoscopic devices enable the clinician to see lesions in greater detail and are commonly used with a large majority of dermatology practices. The development of digital dermoscopic devices has further accelerated its introduction into everyday clinical practice by enabling greater magnification, clarity and consistency of imaging and the ability to store images to enable tracking of lesion changes over time. However, adoption by PCPs has been slower due to the upfront capital investment required, concerns over IT infrastructure and the potential need for more advanced training. To overcome this, technology providers need to develop solutions that are intuitive, financially accessible, secure and meet all regulatory requirements.
Additionally, advancements in both optical technology and artificial intelligence open the door for future augmentation of clinical practice. These could be particularly useful in the community setting where learning algorithms and explainable AI, developed with specialists, may be able to provide support in areas such as lesion analytics, multi-spectral mapping and diagnostic confidence intervals. These smart algorithms hold potential for supporting PCPs with skin management decisions.
Secure and compliant referral infrastructure
For community-based providers, investments in digital infrastructure can often be challenging, as they lack the IT-expertise compared to the acute sector. Having a compliant medical device with the appropriate security protocols is key. Solutions such as cloud-based systems allow providers to rely on shared cybersecurity services to provide greater security of patient data.
Additionally, having an integrated IT infrastructure streamlines the referral process, allowing for the bi-directional secure transfer of lesion imaging, reporting and patient data across the referral network.
Teledermatology pathways and models
A number of different models have been developed around the world, customized to their individual health economic requirements. However, the core workflow of teledermatology networks is relatively consistent and shown below.
By digitising high quality dermoscopic imaging, you enable a streamlined workflow that more effectively connects community care with Dermatology specialists. This also enables more effective triage in the community, allowing the dermatologist to review diagnostic quality imaging remotely before seeing the patient.
Many healthcare providers implement variations of this model today using existing workarounds. These include methods such as WhatsApp transfer of examination images, smartphone pictures sent by email or document transfer portals such as WeTransfer. These are usually reliant on inconsistent and low-quality images from mobile devices, as well as raising serious compliance and data-privacy concerns.
A number of models have developed organically around the world, specialised to solve their unique challenges. Some of the common models and related pathways are shown below.
So what does this mean for Dermatology
There is a clear need to develop community-based teledermatology networks to more effectively manage referrals. In order to achieve this, healthcare systems need to train and provide high-quality digital dermoscopic imaging to community healthcare providers. Additionally, technology providers need to create secure and compliant IT infrastructures that allow for storage and referral of complex patient cases across the network. These measures together will help allow clinicians to make better informed decisions and facilitate an efficient and effective referral network.
About Barco Demetra
Barco Demetra® is a revolutionary skin imaging platform co-developed with leading dermatologists. It combines the best of analogue and digital skin imaging in a flexible, wireless handheld device. It allows dermatologists to take images of the skin and makes mapping, follow-up and comparison of skin images smoother and smarter. Its multispectral imaging technology provides detail on tissue composition, blood flow and pigmentation to enable clinical decision making based on a deeper level of information and understanding.
Images can be instantly and securely stored in the patient’s record in the cloud, so are readily available to any clinician with relevant access, enabling multiple stakeholders to consult referring to clinical evidence. This also means images can be viewed and compared over time and any changes easily identified. Demetra can be integrated with the local EMR, further streamlining the clinical workflow.Discover Barco Demetra
Cancer Facts and Figures 2020. American Cancer Society. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2020/cancer-facts-and-figures-2020.pdf. Accessed January 8, 2020
Acta Derm Venereol 2014; 94: 138–141, https://www.researchgate.net/publication/259387081_Referrals_by_General_Practitioners_for_Suspicious_Skin_Lesions_The_Urgency_of_Training
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