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How telemedicine can cut referrals

GP Dr Barbara Compitus explains how a digital camera and an enthusiastic consultant reduced dermatology referrals by 62%

GP Dr Barbara Compitus explains how a digital camera and an enthusiastic consultant reduced dermatology referrals by 62%

A pilot scheme in which an in-house clinic used teledermatology to send electronic images of skin conditions for consultant advice had a dramatic effect on referrals in our practice, reducing them by 62%. The pilot also offered patients a better, faster service, closer to home.

I saw patients for one hour a week at the in-house clinic. Patients' images, data and case histories were then sent by e-referral to a consultant dermatologist at the hospital, who gave advice and guidance on diagnosis, treatment and management.

Getting started

41228572I have had an interest in dermatology for some time, working as a clinical assistant at Southmead Hospital and studying for the Cardiff Diploma in Practical Dermatology.

My GP partners at the Southville Surgery supported my interest and we set up the in-house clinic to find out how well teledermatology would work on a practical level and test whether it would provide a faster and more cost-effective service to our patients. I had already been holding an in-house dermatology clinic for four months before teledermatology was introduced.

We wanted to find out whether sending digital images to seek a consultant opinion would provide accurate, swift diagnosis or confirmation of diagnosis, and advice on management and treatment.

A successful practice engagement bid to South Bristol PBC consortium gave us funding for the scheme. The pilot cost £3,120, which covered two hours of GP time per week for three months, project preparation work, assessment, audit and final report. The consortium supported this use of resources because dermatology had been identified as a key driver for referrals.

Next steps


We used guidelines from the British Teledermatology Society in setting up the service – see The practice bought a digital camera, a dermatoscope and conversion rings to enable the camera to be attached to the dermatoscope. Any decent quality digital camera with high resolution used for home photography is suitable. I used an 8 megapixel model, which cost about £250. However, this would not be suitable for small lesions. The equipment for suspected cancer lesions that do not come under the two-week rule, such as basal cell carcinomas, costs in excess of £3,000.

A dermatoscope and a dermatology diploma are optional extras. The key point is that additional dermatology skills or spending thousands of pounds on technology are not necessary to make teledermatology work in a GP practice.

Instead of typing referral letters, I signed up for an account to transfer patient data, images and history electronically. Locally e-referrals and pathology reports can be sent through Avon Web, an NHS web portal. We use a standard photo package that came with the computer – we did not need to buy new software.



The clinic ran for one hour-long session a week, and a further hour was allocated for uploading images, preparing emails, reviewing replies and acting on advice.

We designed a patient information leaflet and a consent form to enable patients to give written agreement for their clinical photos to be sent electronically through a secure system and giving us permission to use the images for teaching.

Consultant dermatologist Dr David DeBerker, of University of Bristol NHS Trust, agreed to accept electronic referrals including images, patient data and case histories, and offer advice and guidance on diagnosis, treatment and management. We chose e-referral because we believed it offered greater security than email and provided an audit trail.

Dr DeBerker did not take a fee for his work – he supported the trial because he was interested in both testing how well teledermatology would work and in reducing avoidable referrals.

At a practical level, it was important to ensure we had adequate lighting for photography, and took and sent more than one image, with at least one wide view and one close-up.

All children were excluded from the pilot, as were patients who required an urgent referral to secondary care, such as those with lesions that suggested malignant melanoma or squamous cell carcinoma.

My partners referred patients to the clinic and it was advertised on our practice website and in patient leaflets. Patients were enthusiastic as they wanted to be diagnosed as quickly as possible. Having a GP say ‘it could be 16 weeks before you are seen at hospital' only increases anxiety.

We explained to patients that within seven working days of them having their teledermatology assessment, the GP would do one of the following:

• Send a letter detailing the diagnosis and any treatment advice

• Send a letter or telephone to ask them to attend the surgery

• Refer them directly to the hospital dermatology clinic.

Results

Waiting times were reduced from an average of 16 weeks to outpatient appointment at Bristol Royal Infirmary, Southmead or Frenchay hospitals to seven days for an appointment at the in-house dermatology clinic.

Dr DeBerker responded to all e-referral advice requests the same day. Patients were contacted within a week, although we could also see them sooner if there were clinical reasons or the patient was anxious.

Patients were extremely positive about the service. They appreciated not having to wait for outpatient appointments and being able to stay within the surgery yet have the reassurance of an expert opinion. No patient refused to take part in the pilot and none requested a referral to outpatients.

Referrals to outpatients were dramatically reduced between the interim figures, when we were running the in-house clinic without teledermatology, and the end result with teledermatology:

• baseline – 26 referrals to secondary care dermatology over one year

• interim period – in-house dermatology clinic – 21 referrals over four months (extrapolate to 12 months = 63)

• teledermatology clinic – six referrals over three months (extrapolate to 12 months = 24).

The number of patients seen at the in-house clinic increased by 27% during the course of the pilot, reflecting a better take-up and meaning the clinic can run closer to full capacity.

41228571Before the pilot, 35 referrals were made from our practice to secondary care over a 12-month period, 26 of which would fulfil the criteria for being seen in the in-house clinic.

We ran the in-house clinic without teledermatology for four months. Out of 36 patients seen at the clinic, only nine were referred on to secondary care.

During the three-month pilot, 37 patients were seen at the clinic. Only two were referred on to secondary care, one to dermatology and one to immunology. The teledermatology service was particularly helpful in diverting the patient to immunology as it avoided a wait to be seen in dermatology outpatients and a further wait for an appointment with the immunology clinic.

We estimate teledermatology could save up to £6,000 a year in our practice alone by avoiding referrals, based on a first outpatient referral tariff charge of £150. However, if the scheme were to become permanent we would need to include the cost of the consultant advice that was provided free during the pilot.

Patients also received a better service. For example, one had phymatous rosacea that was not responding to treatment. A same-day response to the e-referral gave advice on laser treatment and camouflage options and indicated that topical therapies were of limited use in such cases.

Outcomes

The pilot proved that teledermatology works, offering a better, faster, more local service to patients and reducing referrals. All members of the practice team were happy to refer to me and appreciated the speed of response.

There were no problems encountered during the process of sending referrals and having advice returned.

Any concerns about the technology were shown to be unfounded. The quality of images was suitable for the consultant to be able to offer advice and the response times were excellent.

The service was popular with patients, who welcomed the opportunity to be seen quickly in their own practice rather than waiting for weeks and having to go to hospital outpatients. No patients were unhappy with the outcome achieved with our service.

The success of the scheme depends on taking a good history and explaining the service clearly to patients. Teledermatology is not just about the technology, it is a diagnostic tool and it is important to be clear about why you are using it.

Next Steps

Bristol NHS and the South Bristol PBC consortium are both interested in tackling dermatology referrals. We have identified dermatology as the third highest category of referrals in the south Bristol area. The PCT is now exploring the possibility of setting up a formal scheme, using this kind of technology to reduce avoidable referrals and offer care closer to home.

I have discussed our teledermatology project and the lessons we have learned with PCT managers working on service redesign, and although this is at the early stages, there seems to be a lot of enthusiasm. One possibility being considered is to develop the scheme with a tariff price for consultant advice. With PBC support we would envisage linking this in to practices for consortium-wide use of teledermatology. The aim would be to use local resources more cost-effectively and set up alternative patient care pathways.

The PBC consortium is supportive and keen for each of its board members to work with local practices to develop better care pathways. It is also looking to fund GPs to take the Cardiff diploma as a step towards GPSI in dermatology status. The aim would be to develop cluster consortium resources to provide primary care-led community dermatology clinics.

I hope in the future we will develop a more formal scheme so patients can be seen in their own GP surgery for diagnosis, treatment and management. However, we need to identify the training resources and funding required to do that.

Unfortunately the pilot project ended because no more resources were available to continue funding it, so I now see patients in my routine surgeries. We would have liked to maintain the service but South Bristol's health economy has a huge overspend on our historical budgets so money is tight. Partly as a result of this, there has been a great deal of apathy in Bristol about PBC as people fear that any resources it frees up will be diverted to the overspend rather than invested in developing new primary care services.

Our perceived overspend is the biggest challenge we face as practice-based commissioners. For example, the Southville Surgery has the second-lowest referral rates in the South Bristol consortium but we are the most overspent on our historical budget, which makes no sense.

As for teledermatology itself, it appears to be such a simple idea that it is often overlooked. In carrying out a literature search for the project I found only a small number of schemes in operation. It deserves wider application – it is a simple idea that could make a significant difference in terms of offering improved and more cost-effective services.

Dr Barbara Compitus is a GP at Southville Surgery, Bristol and a board member of South Bristol PBC consortium

Conditions seen 60-second summary Dr Barbara Compitus: teledermatology can work without spending thousands on technology Dr Barbara Compitus: teledermatology can work without spending thousands on technology

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