COVID-19 pandemic ushering in the era of teledermatology

Sir,

Since it was first reported in December 2019 in China, COVID-19 caused by the novel Corona virus SARS-CoV-2, has spread rapidly throughout the world. It was declared a pandemic by the WHO on March 11, 2020.¹ In a bid to control the spread of this highly contagious infection, countries have declared ‘lock-downs’ with emphasis on social distancing. The out-patient services of many hospitals and clinics have been shut-down, with only emergency services being run. Health-care policies changed quickly to prioritize the care of COVID patients, and rightly so. In such a scenario, the care of non-COVID patients understandably took a backseat. However, as it becomes increasingly likely that such curtailments will be extended, it is important that the health-care needs of our non-COVID patients are not ignored.

Telemedicine, which can provide a potential solution to this problem, is currently almost non-existent in India. In a country like ours, where medical professionals are largely concentrated in cities and urban areas (doctor-population ratio of 0.68/1000 Indian population, with 77.4% of health workers located in urban areas), perhaps telemedicine consultation should have become the norm long back.² Its utility has already been demonstrated in pre-COVID settings, and can be particularly advantageous during disasters and public health emergencies in rendering medical services at remote locations.³ COVID-19 pandemic also provides an opportunity to revive telemedicine. Dermatology, as a visual branch of medicine, is particularly suited to telemedicine (teledermatology).

Teledermatology services can be delivered through either real-time (RT) video consultation or as asynchronous store-and-forward (SAF) modality. In the former, the patient and dermatologist can interact through video and/or audio chat. On the other hand, in the latter, patient usually sends the image and clinical information to the dermatologist, who could reply as per convenience. While RT consultations have the advantage of allowing direct conversations between the patient and doctor (akin to face-to-face consultation), it is more time consuming, and the experience is dependent on the video/image quality, which may be variable. SAF consultations, which have a better image quality (static images), may be preferable for dermatologists. Earlier, one would require a dedicated videoconferencing set-up, available only in large hospitals, to deliver these services. Now with the advent of easy-to-use applications such as WhatsApp, Skype and Facetime, all one needs is a smartphone for a successful telemedicine consult. Patients can use these smartphone applications to make a video call to their doctors to seek medical advice. Patients can also use WhatsApp messaging service to easily send their clinical images, prior medical details and laboratory investigations to the dermatologist, who can then evaluate them and provide medical advice. The department of dermatology and venereology, All India Institute of Medical Sciences, New Delhi, is providing teleconsultation to patients since early April 2020. We contact the patients telephonically on the day of their appointment, and provide medical advice after examining the pictures of their skin lesions and previous medical records that we request the patients to send to us. Currently, we are offering teledermatology services only to our follow-up patients, as a full assessment is not required and prior relevant medical history is easily retrievable. This makes titrating the previous treatment and dose adjustments relatively easy. Providing teleconsult to a new patient can be trickier. However, follow-up patients can also have new complaints or a medical emergency which may require detailed patient examination. In such a case where a tele-advice is not possible, the patient is asked to visit a local doctor.

The medico-legal aspects of telemedicine are evolving. However, it is imperative that professional ethics observed during regular patient consults be followed for teleconsultation as well, with an emphasis on patient consent, data privacy and patient confidentiality. Recently, Ministry of Health and Family Welfare (MoHFW), in collaboration with NITI Aayog and Board of Governors (BoG), Medical Council of India (MCI), released “Telemedicine practice guidelines” for registered medical practitioners.⁴ The recommendations include that telemedicine consultations be charged the same fees as in-person consultations. Further, medical practitioners practicing telemedicine will have to complete a mandatory online course within three years of release of these guidelines.⁴

Patient satisfaction with teleconsultation also merits consideration. Though it lacks a ‘hands on’ evaluation, patients find real-time teledermatology consultations similar to in-person consultations. On the other hand, store-and-forward teledermatology does not provide a sense of personal interaction with the physician. ⁵ Patients’ lack of comfort in telecommunication due to technologic illiteracy and lack of access to such facilities, especially in our country, can be another deterrent. A telemedicine model where patient visits their local doctor who then discusses the case with the specialist (known as secondary teledermatology), may be better.³ Several skin conditions can be managed by a general physician who is adequately supervised by a qualified dermatologist. This could save the patient frequent long distance visits to the dermatologist, while maintaining patient-doctor interactions. Though not feasible during the current pandemic, such a model could be the way forward in future. It has the potential to decongest the tertiary care centres which are overcrowded with patients not needing advanced medical care.

Hopefully we, both doctors as well as patients, will gain confidence with the increasing use of teledermatology, which will make us more comfortable in the times to come. It is important that we do not view telemedicine as only a stop-gap measure. There is little doubt that telemedicine is here to stay and will be useful even after COVID-19. This pandemic provides us an opportunity to set the telemedicine ball rolling.