Programs that deliver specialty care to underserved areas utilizing telemedicine are being launched all over the world. However a recent study published in the British Journal of Dermatolgy raises some questions about the limitations of this technology, particularly some unintended consequences that appear to have adverse patient outcomes.
The study looked at a series of dermatolgy referrals for suspicious skin lesions, gathering data on 400 patients within a VA site. What they found was that for many of those patients these visits led to important diagnoses – but not always for the lesion for which they were actually referred.
As described in a great piece in Medscape News by Dr. Laurie Barclay, who also does a great analysis of the study, the results were surprising to say the least.
The dermatologist identified 149 malignant lesions in 98 patients, but only 88 lesions (59.1%) corresponded to the index lesion. The consulting dermatologist performed a biopsy on 111 incidental lesions, of which 61 (55.0%) were additional skin cancers. Of these 61 incidental cancers, 12 (19.7%) were in patients in whom the index lesion was clinically benign and which the dermatologist did not perform a biopsy of the lesion.
So in short, 40% of the malignant lesions found by the dermatologist were the result of a complete skin exam that incidentally identified suspicious lesions. The implication here for teledermatology programs – where a dermatologist would review whatever lesions are highlighted by the referring physician – is these lesions would be missed.
Some care is better than none, so this is certainly not an argument against all telemedicine programs. For example, teledermatology programs in areas where dermatologists aren’t available would certainly be valuable. However, in areas where such teledermatology services may be utitlized as a lower-cost alternative to in-person dermatologic evaluation, this study should give us pause. It’s findings clearly suggest that these kinds of programs are not replacements for in-person evaluations and the physical exam – a notion which has implications well beyond dermatology.