ATTACHMENT A: SAMPLE CLINICAL PROCEDURES
C. Technical Analysis
Those embarking on a teledermatology program should begin their technical analysis by:
a) Identifying teledermatology equipment used by other successful programs;
b) Identifying transmission mechanisms used by other successful programs;
c) Reviewing the federal Office for the Advancement of Telehealth’s Technical Guidelines, especially as they relate to teledermatology
(http://telehealth.hrsa.gov/pubs/tech/derm.htm) [accessed on 7/10/04];
d) Exploring the Telehealth Deployment Research Testbed (TDRT)web site since it contains an evaluation of equipment used in interactive and store and forward teledermatology programs (http://tdrt.aticorp.org/) [accessed on 7/10/04]; and
e) Reviewing the American Telemedicine Association’s Teledermatology Special Interest Group web site - http://www.americantelemed.org/ICOT/icot.htm
[accessed on 7/10/04]. This link has a wealth of information regarding both live interactive and store and forward teledermatology.
After reviewing the information on the two web sites listed above and
researching what other successful programs are doing, narrow the choices of equipment and allow the dermatologists to test and participate in the final selection of that equipment.
Other Technical Considerations for ITV, S&F and Hybrid Teledermatology:
a) Determine how on-going maintenance of equipment will be provided. This includes a decision to buy spare equipment or extended service contracts. The experience of the Missouri Telehealth Network staff suggests it may be less expensive to buy spare devices when the equipment has a warranty of 2 to 3 years. That way, the spare can be placed in the field while the broken
equipment is repaired under its warranty period.
b) Determine network connectivity options and associated costs. This means exploring all the types of telecommunication services that may be available in the underserved area (e.g., ISDN, xDSL, T1, IP). If considering store and
c) Determine who will be responsible for network management from point-to-point – the distant site, originating site, the telecommunications company, or some third party.
d) Train the telehealth technical staff on proper room design. This includes understanding proper lighting (for videoconferencing and store and forward), sound and video placement for optimal telehealth presentations. For store and forward teledermatology it should also involve training the user on the
techniques needed to take and transmit digital images of the patient. A couple considerations include:
1. Lighting should be adequate enough to identify the primary lesions and their characteristics (see Chapter Fourteen for more information).
2. A medium non-reflectant blue cloth or blue screen background should be used so that there is continuity in the images taken. The color should be similar to that used for blue screens in Hollywood.
e) Clothing and jewelry must be removed sufficiently to get adequate viewing.
f) Use chaperones as needed to assist with the patient.
g) Develop agreements to determine what happens when equipment is stolen or damaged.
h) Consider the development of protocols for equipment utilization and network connectivity. The protocols should
1. Indicate how teledermatology connections between sites are to be
scheduled and which site places the call; (e.g., set block of time each week, ad hoc, scheduled into an existing clinic, distant site makes the call); and 2. Indicate how each piece of equipment works and how it interfaces with the
video system or S&F system).
i) Develop a frequently asked questions (FAQ) sheet that will help reduce the stress imposed by the Health Insurance Portability and Accountability Act. This should be done in conjunction with the distant site’s privacy and security staff.
j) Create an inventory tracking system for all equipment.
S&F Technical Considerations:
Below is a listing of technical considerations specific to S&F applications of teledermatology:
a) Images should have a minimum resolution of 1024 x768 pixels with 24 bit color.
b) All images must be properly focused.
c) Camera exposure must be set properly to allow adequate evaluation given the light reflection. In some cases a flash may be necessary.
d) For most conditions, standard protocols (see attachment D) should be used.
e) Each image set should include standard views of an involved anatomic unit:
¾ Scalp/Head (top, back, left, right)
¾ Face (e.g. front, left, right)
¾ Neck (front, back, left, right)
¾ Trunk (front, back, flank if necessary)
¾ Arms (both front, back)
¾ Legs (both front, back, left/right if needed)
¾ Groin/Buttock
¾ Hands (both front, back)
¾ Feet (both front, back)
f) In general, the images should be taken perpendicular to the plane of the lesion/rash.
g) Oblique views should be used if the lesion is subtle and difficult to evaluate its height.
h) Complementary views should be included if the condition involves certain areas:
1. Scalp- Face 2. Elbows-Knees
3. Antecubital Fossa-Popliteal Fossa 4. Hands-Feet
i) The image should be framed to show the areas involved and the areas not involved. (example: rash on hands in patient wearing long sleeve shirt, must expose the arm to show where the rash starts and stops).
j) If possible, all images must be reviewed on the computer using an image viewer prior to the patient leaving to ensure the quality of the images. If this is not possible, re-takes may be necessary in some cases.
D. Operational
Steps 1, 2 and 3 in this section are likely to take 6 or more months before the operational stage is entered. The timelines below start only after steps A-C are completed. Please remember not to embark on an operational plan until a formal telehealth agreement is in place with the originating site.
1. Start-up – The First 30 Days
a. If applicable, Universal Service Fund applications should be filed with the Rural Health Care Division (RHCD) of the Universal Service Administration Corporation (see Chapter Two). While this step can happen quickly do not order the telecommunications service until the 28-day waiting period required by the RHCD has expired, otherwise the service will not qualify for Universal Service funding.
b. Bids or comparison-shopping needs to be done to ensure best pricing of
equipment and telecommunication services. Blind bidding can produce a large variation in pricing and save a great deal of money. Locating existing bids within the institution for video conferencing equipment, cameras, etc., may also save time in the purchasing process.
c. Conduct additional site visits for finalizing the technical placement of all equipment. The technical staff should:
1. Identify the location of the telecommunications room/closet.
2. Determine the room(s) to be used for telehealth encounters in
conjunction with the administrative and clinical staff. They must ensure that wires can physically be run between the selected room(s) and the telecommunications closet.
3. Determine the general layout of the room and what changes (lighting, sound, wall color), if any, need to be made. The telehealth agreement with the site should specify which party is responsible for any room modifications and wire pulls.
d. Hold administrative and clinical meetings to discuss the logistics of scheduling, billing, reimbursement, evaluation, consent, and other administrative issues related to the program.
e. Observe in detail how in-person clinics function and detail how telehealth will best fit into that environment. Provide the staff at the underserved site with information that details the ideal real-time or store and forward encounter.
2. The 31 to 60 Day Start-up Window
a. Continue working on all of the logistical issues related to scheduling, billing, etc.
b. Order telecommunications services AFTER THE RHCD 28 DAY WINDOW CLOSES (if filing RHCD paperwork was applicable).
c. Order all equipment.
d. Order internal wire pulls for the originating site(s) (with termination jacks or plugs).
e. Room remodeling, if needed, should begin around day 31. This includes any necessary cabinetry, wall mounts, painting, etc. to be completed by the 60th day.
f. Develop or locate existing evaluation tools to pilot in the next step (see Attchment A of this Chapter). Each telehealth program will need to determine if the evaluation tools need to be academic (e.g., comparing dermatology diagnoses with telemedicine vs. traditional in-person care), financial (e.g., cost/benefit) or simply capture general utilization (e.g., patient origin, number of studies by diagnosis code, etc) data.
3. The 61 to 90 Day Start-up Window
a. Install equipment
b. Configure and connect network devices.
c. Test all equipment and network connections thoroughly for quality of service and security.
d. Begin scheduling hands-on training sessions for the staff in the underserved community (physicians, nurses, other clinical staff and administrative staff).
This includes training on hardware, software and perhaps traveling to the distant site (dermatologist site) to do some clinical and technical training with the dermatologist and his or her staff. See Attachment B for training consult managers using store and forward technologies.
e. Finalize the logistics of scheduling, billing, medical recordkeeping medical record sharing, etc.
f. Conduct mock cases to determine the smoothness of the process and to make refinements as necessary. This process should go from the referral process to the evaluation forms (if used) completed at the end of an encounter.
4. The 91st Day – Time for Patient Care
a. Begin caring for patients based on the groundwork laid during the first 90 days.
b. Refinements and adjustments to the program can be made at this point.
c. Begin collecting data per the evaluation plan developed earlier.
IV. Lessons Learned from the Field
• Dermatologists will experience a learning curve of an unknown time.
Confidence levels correlate with diagnostic accuracy. The dermatologists may want to see patients in person and via telehealth for an initial period of time until they become comfortable with their ability to render quality dermatological care.
• Originating site health care providers will also experience a learning curve of an unknown time. It takes time for the originating site health care providers, presenters and technicians to learn how to deliver teledermatology services.
Each originating site will take varying amounts of time depending upon the amount of support and time given to the telehealth service.
• Teledermatology is less difficult to implement if referral relationships with primary care providers in the community are already established. However, this may not be the case, because communities with the greatest need for
teledermatology typically lack easy access to dermatological services.
• Teledermatology services will have a greater chance of success if the dermatologists are willing to drive to the community, meet with the medical staff, and perhaps give a dermatology lecture from time to time. As in standard referral relationships, telehealth referral relationships are based on human connections and excellent service rendered over the long term.
• Primary care providers need to know to whom they are referring their patients. If in-person communications or visits are not possible, schedule a videoconference for the dermatologists to meet and greet the originating site physicians. Interactive educational programs via the network can also serve to introduce the dermatologists to the referring providers.
• The dermatologist should discuss with the originating site medical staff what level of service they are prepared to render. They may act as a consultant, as a co-manager, and sometimes as a direct caregiver for the patients. This of course depends on the clinical diagnosis and treatment plan.
Additionally, ask the primary care providers to comment on what level of service they are expecting when they write a request for consultation via the
teledermatology service.
• Keeping the originating site health care workers adept at using the equipment is an ongoing challenge. As with any telehealth service,
teledermatology works best when clinics are frequently held. Even in the best of circumstances, personnel will come and go and take their expertise with them.
Thus, be prepared for retraining users in all locations.
• Use standard operating procedures and protocols for teledermatology encounters. A standard protocol for patient presentation (ITV/Hybrid), for gathering a patient history (IVT/S&F/Hybrid), and for patient imaging
(S&F/ITV/Hybrid) should be used.
• Always take multiple images of the patient (S&F and Hybrid).
• Never take a picture at less than 6-12 inches (will vary with digital camera) from the patient (S&F and Hybrid).
• Consider turning off the flash when photographing the scalp, particularly in a patient with dark-colored hair (S&F and Hybrid). The flash will wash out the image of the underlying scalp if it is used in this case.
• If images need to be retaken at the request of the dermatologist ensure that the referring sites do not see this as an insult to their skills and abilities.
Use the retake session as a learning opportunity to improve on the process.
V. Useful References