Sustained reduction in no-show rate with the integration of teledermatology in a Federally Qualified Health Center.

Accessibility of direct-to-consumer teledermatology to underserved populations.

To the Editor: We read with interest the letters by Korman and Fabbro1Korman A.M. Fabbro S.K. Direct-to-consumer pharmaceutical services in dermatology: ethical implications.J Am Acad Dermatol. 2021; 85: 1067-1068https://doi.org/10.1016/j.jaad.2021.02.059Google Scholar and Ranpariya and Lipoff2Ranpariya V.K. Lipoff J.B. Direct-to-consumer teledermatology platforms may have inherent conflicts of interest.J Am Acad Dermatol. 2021; 85: e259-e260https://doi.org/10.1016/j.jaad.2021.04.102Google Scholar outlining issues related to the expansion of direct-to-consumer (DTC) teledermatology. DTC applications advertise readily accessible dermatologic care via the internet that bypasses the need for a pre-existing physician-patient relationship. As discussed, significant concerns exist, including conflict of interest, treatment by nondermatologists, and prescription of medication absent a thorough history.1Korman A.M. Fabbro S.K. Direct-to-consumer pharmaceutical services in dermatology: ethical implications.J Am Acad Dermatol. 2021; 85: 1067-1068https://doi.org/10.1016/j.jaad.2021.02.059Google Scholar,2Ranpariya V.K. Lipoff J.B. Direct-to-consumer teledermatology platforms may have inherent conflicts of interest.J Am Acad Dermatol. 2021; 85: e259-e260https://doi.org/10.1016/j.jaad.2021.04.102Google Scholar Such deficiencies are countered by the presumption that these services provide increased access to care. Here we examine if the features of popular DTC teledermatology platforms are structured to accommodate underserved populations. Google queries were performed using the key words “best telemedicine platform dermatology” and “online dermatology appointment.” Fourteen DTC websites were identified from the top hits displaying lists of teledermatology applications. Of these, 4 (28%) provided the option of a non-English language interface. Spanish was available on 2 platforms, and no Asian languages were offered on any application. All sites required email registration and used store-and-forward photography as the primary diagnostic modality. Six (43%) services accepted commercial insurance and 2 (14%) also accepted Medicaid. On many sites, the follow-up arrangement in the event of worsening or insufficient improvement was not clearly defined (Table I). A limitation of this study is that the websites evaluated do not constitute a comprehensive list of DTC teledermatology platforms but rather represent the most likely services to be encountered upon an internet search.Table IFeatures of direct-to-consumer teledermatology platforms∗Sources: https://www.verywellhealth.com/best-online-dermatologists-5095650; https://www.onlinedoctor.com/best-online-dermatologists/; https://www.byrdie.com/best-online-dermatologists-5113094; and https://www.healthline.com/health/dermatology-telemedicine-best-websitesPlatformWebsite language optionsRegistration and email requirementInsurance acceptanceFollow-up arrangementFirst DermEnglish, European Spanish, Norwegian, German, SwedishYesNoneUnknownDermatologist On CallEnglishYesNoneWithin 30 days of initial visitApostropheEnglishYesNoneUnknownSKYMDEnglishYesCommercial, Medicare, MedicaidWithin 7 days of initial visitDirectDermEnglish†According to the website, patients are to call for Spanish instructions.YesCommercial, MedicareFollow-up question acceptedTeladocEnglish, Canadian French, Canadian EnglishYesCommercial, Medicare, MedicaidVaries depending on the provideriDoc24‡Powered by First Derm.English, European Spanish, Swedish, French, ItalianYesNoneUnknownDermUtopiaEnglishYesNoneUnknownSnapMedEnglish, Norwegian, SwedishYesNoneUnknownMandelEnglishYesRegistration required to determine if the plan is acceptedYesPlushCareEnglishYesCommercial insuranceUnknownMD Live§Powered by Dermatologist On Call.EnglishYesRegistration required to determine if the plan is acceptedUnknownTibotEnglishYesFree to use artificial intelligence service, unknown insurance acceptanceNot includedOnline Skin SpecialistEnglishYesNoneWithin 7 days of initial visit∗ Sources: https://www.verywellhealth.com/best-online-dermatologists-5095650; https://www.onlinedoctor.com/best-online-dermatologists/; https://www.byrdie.com/best-online-dermatologists-5113094; and https://www.healthline.com/health/dermatology-telemedicine-best-websites† According to the website, patients are to call for Spanish instructions.‡ Powered by First Derm.§ Powered by Dermatologist On Call. Open table in a new tab One of the largest medically underserved populations in the United States is the Hispanic/Latino community, comprising over 60 million residents.3Profile Hispanic/Latino Americans. U.S. Department of Health and Human Services.https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64Date accessed: August 10, 2021Google Scholar Among this group, 28.4% report limited English proficiency, a well-understood barrier to access.3Profile Hispanic/Latino Americans. U.S. Department of Health and Human Services.https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64Date accessed: August 10, 2021Google Scholar Surprisingly, only 2 sites offered a Spanish language interface, and both were based in Europe and restricted from prescribing in the United States. In addition to language, nonnative speakers, minority groups, and low-income populations are less likely to activate and use a patient portal, suggesting that technological demands are an issue as well.4Cline A. Kim C. Berk-Krauss J. et al.Bridging the digital divide: the use of text message-enabled video in the public safety-net setting.J Am Acad Dermatol. 2021; 85: e97-e99https://doi.org/10.1016/j.jaad.2021.03.085Google Scholar All DTC sites required registration via email for privacy protection, and none mentioned the availability of any simplified or alternative methods of engagement. Underserved populations are more commonly underinsured or recipients of coverage through government programs. However, only 2 websites mentioned Medicaid acceptance. None described a sliding scale or other cost-saving measures. Additionally, the anonymity and limited-to-ambiguous follow-up associated with these services may be less useful in populations typically distinguished by a high prevalence of chronic health conditions, comorbidities, and confounding socioeconomic issues. Although a consumer profile of DTC teledermatology has yet to emerge, the analysis of an analogous DTC platform offering primary care found that users tended to be young, live in affluent urban communities and prefer to access care off-hours.5Jain T. Mehrotra A. Comparison of direct-to-consumer telemedicine visits with primary care visits.JAMA Netw Open. 2020; 3: e2028392https://doi.org/10.1001/jamanetworkopen.2020.28392Google Scholar Despite marketing a more egalitarian approach, DTC teledermatology, as currently structured, does not appear to mitigate well-known barriers to access such as language, digital literacy, and insurance acceptance. English-speaking, technologically savvy patients with less complex dermatological complaints are likely to find these services more attractive. Outcome measures such as user demographics, clinical improvement, and patient satisfaction are needed to truly understand the utility of DTC teledermatology in diverse populations. None disclosed. Direct-to-consumer pharmaceutical services in dermatology: Ethical implicationsJournal of the American Academy of DermatologyVol. 85Issue 4PreviewDear Dermatologist: Direct-to-consumer (DTC) teledermatology companies that facilitate electronic consultations between physicians and patients are expanding. DTC companies advertise on social media, promoting dermatologic treatments such as finasteride, spironolactone, and oral contraceptives. Many problems exist, such as issues with confirming patient identity, ascertaining the medical history of patients, prescription of non-evidence-based therapies, and providing inadequate counseling on the adverse effects of medications. Full-Text PDF Direct-to-consumer teledermatology platforms may have inherent conflicts of interestJournal of the American Academy of DermatologyVol. 85Issue 4PreviewTo the Editor: We read with interest Korman and Fabbro's research letter describing ethical concerns regarding direct-to-consumer (DTC) teledermatology companies identifying a financial conflict of interest that may exist for dermatologists working with these platforms.1 It is important to examine and characterize DTC teledermatology companies' structures to fully understand any potential conflicts. Full-Text PDF Reply to: “Accessibility of direct-to-consumer teledermatology to underserved populations”Journal of the American Academy of DermatologyVol. 86Issue 3PreviewTo the Editor: We appreciate the interest of Gao et al1 in our paper in which we discussed ethical issues that dermatologists may confront with the expansion of direct-to-consumer (DTC) teledermatology companies. Full-Text PDF 

http://www.jaad.org/article/S0190962221027274/pdf

Accessibility of direct-to-consumer teledermatology to underserved populations

Background Patient-to-provider teledermatology relies on a patient’s access to technology to ensure a successful visit. However, access to broadband internet and technology varies across populations in the United States—leading to the digital divide. While teledermatology has been recognized as a model to improve access, little is known about how often demographic data associated with digital inequity are captured in studies. Objective Given the expansion of teledermatology over the past decade, we sought to determine how often demographic data associated with digital inequity are reported in patient-to-provider teledermatology studies. Methods A scoping literature review search was conducted using the search term teledermatology in the following databases: PubMed, Embase, and the Cochrane Database of Systematic Reviews. All studies published between December 31, 2011, and December 31, 2021, that evaluated patient-to-provider teledermatology were eligible. Results In total, 1412 publications describing teledermatology were identified, of which 46 met the inclusion criteria. Race or ethnicity was the most frequently reported demographic characteristic (28/46, 61%). However, only 41% (19/46) of studies were representative of race or ethnicity, defined as including >20% nonwhite participants. Studies rarely reported the number of participants greater than 65 years of age (14/46, 30%), preferred language (9/46, 20%), income (6/46, 13%), highest level of education (5/46, 11%), or access to a device (4/46, 9%). Studies conducted after the onset of the COVID-19 pandemic were significantly more likely to report preferred language (9/25, 36% vs 0%; P=.002) and appeared more likely to report other demographic data associated with digital inequity, without reaching statistical significance (P>.05). Conclusions Demographic data associated with digital inequity are rarely reported in patient-to-provider teledermatology studies to date. These studies frequently lack adequate representation of racial and ethnic minorities. With increased calls for equitable representation in dermatology studies, future teledermatology studies can improve the reporting of race and ethnicity and consider demographic data associated with digital inequity as an important criterion in research design.

Demographic Data Associated With Digital Inequity Reported in Patient-to-Provider Teledermatology Studies in the United States From 2011 to 2021: Scoping Review

Telehealth has the potential to expand access or further disenfranchisement. In under-resourced settings, social and financial stressors are significant impediments to engagement with the medical system. Such challenges could be mitigated by the use of telemedicine. Conversely, telemedicine may exacerbate the exclusion of marginalized communities that have lower rates of digital literacy, Internet connectivity, and smart-device ownership. Here we discuss barriers to access and equity in teledermatology and provide actionable strategies to optimize the use of virtual medicine in vulnerable populations. 

Yasaman Mansouri

Papers

Bridging the digital divide: The use of text message-enabled video in the public safety-net setting.