Overview

A collaborative of seven Massachusetts community health centers (CHCs) implemented a remote dermatology consult system in order to triage in-person referrals more effectively, improve in-person appointment access, and reduce dermatology-associated costs.

Organization Name

Edward M Kennedy Community Health Center
Family Health Center of Worcester
Harbor Health Services
Charles River Community Health Center
Lynn Community Health Center
Manet Community Health Center
South Boston Community Health Center

Organization Type

• Community health center
• Community health system

National/Policy Context

• In 2013, $46 billion of medical spending was directed toward dermatology care.
• Patients in many communities, especially those underserved by the medical system, struggle to access timely and affordable dermatology care.

Local/Organizational Context

• While participating primary care practices could manage basic dermatologic conditions, providers felt unable to triage potentially high-risk dermatologic cases.
• Because access to dermatologists was limited for these practices, patients who were suspected to have high risk dermatologic conditions had trouble obtaining timely referrals.

Patient Population Served and Payor Information

• 44% of patients across the seven participating CHCs are enrolled in Medicaid or CHIP. 17% are uninsured.
• The project team reached individual agreements with four payors to reimburse the teledermatology service.

Funding

• The CHC collaborative received a grant in October 2015 to pilot a teledermatology service.  
• The program is currently aided by a grant from Partners HealthCare that helps pay for teledermatology consults for Medicaid patients (who otherwise were not always covered for this service).

Research + Planning

• The technology vendor and the CHCs worked together to create workflows that could be universally implemented at all participating CHCs (further detailed in the Daily Project Workflow section below).
• The CHC collaborative identified dermatology practices willing to provide remote image readings as well as practices willing to provide urgent appointments for patients who received concerning results.
• The team negotiated reimbursement rates with payors. Consulting dermatologists received $32.40 per consult from insurance reimbursement. In addition, the vendor providing the teledermatology service (3Derm Systems) received $20 per consult from the CHC collaborative as a membership fee.
• One clinic required a Wi-Fi upgrade in order to send images through the telemedicine software efficiently.

Tools or Products Developed

• 3Derm Systems: A technology partner that provides skin imaging and diagnostic services, enabling primary care providers to upload images for remote review by a dermatologist using a HIPAA-secure software interface.
• EHR-based tools: Some of the CHCs created EHR-embedded tools such as teledermatology order sets in order to facilitate the new workflows associated with the intervention.

Training

• Training sessions, mock encounter run-throughs, and demonstrations were performed for CHC staff. Medical assistants and providers received 10 minutes of training. Medical records, IT, and referral staff received 30 minutes of training.

Tech Involved

• Electronic medical record
• Telemedicine software
• Telephone

Team Members Involved

• Administrative Assistant
• MAs
• Physicians
• Program staff

Workflow Steps

• The patient is seen by a provider in clinic. The provider determines that the patient’s condition requires dermatology expertise.
• CHC staff (usually the medical assistant) confirms whether patient’s insurance will reimburse a teleconsult.
• After reimbursement is confirmed, the medical assistant or medical records staff member sends the patient’s insurance information to the vendor (3Derm systems), which manages billing for the remote dermatologists.
• The PCP places an order for teledermatology service in the patient’s chart.
• A medical assistant takes the required images and closes the EHR order for the service.
• Generally, within 3 days, the remote dermatologist reviews the images and makes a triage determination. The dermatologist enters the recommended time frame for follow-up and recommended treatments into the 3Derm system.
• A standardized consult report is generated and uploaded to the 3Derm system. CHC staff adds this report to the patient’s medical record.
• The patient’s PCP reviews the report, and CHC staff make referrals to dermatology clinics as needed.

Budget Details

Costs for the program included:

• Equipment purchases and maintenance costs
• Wi-Fi upgrades as needed
• EHR modifications
• Staff time for planning/oversight
• 3Derm subscription fee

Where We Are

• The project is still ongoing.  
• The authors estimate that a new CHC can begin implementation of the program within 5 weeks.

Outcomes

• Completed Consults: 850 consults were completed between November 2016 and May 2018.
• High Priority Results: 44 consults were considered urgent. These patients typically received in-person appointments within 1-2 weeks that otherwise would have been difficult to obtain.
• Avoided In-person Visits: Half of all consults sought resulted in the recommendation that an in-person appointment was not needed.
• Savings from Avoided Visits: An estimated $74,976 was saved via lower reimbursement rates for remote consults and reduced staff time spent making referrals.

Future Outcomes

• The team plans to examine long-term savings from identifying high-risk conditions earlier.

Benefits

• This project provided increased access to dermatology appointments for patients with urgent needs.
• It also averted the need to take time off and pay for transportation and co-pays for patients with non-serious conditions that could be managed in the primary care setting.
• The intervention resulted in costs savings that could be shared among stakeholders under a value-based payment model.

Unique Challenges

• Reimbursement agreements had to be arranged with payors individually. While four payors agreed to reimburse the service, patients covered under other plans could not receive the service.
• Insurance verification policies that were initiated to ensure reimbursement proved difficult to implement and limited some providers’ buy-in.
• Complete integration of the teledermatology consult request process with the CHCs’ EHRs proved difficult and created added work for some providers.

Sources

Paradise, Ranjani, et al. “A Teledermatology Initiative to Increase Access for Community Health Center Patients.” NEJM Catalyst, 3 Jan. 2019. https://catalyst.nejm.org/teledermatology-access-community-health/