"When the opportunity to do it through AAD came up, I jumped," she said. There are difficulties in the United States that have not been encountered overseas: Physicians cannot practice across state lines, they have to be credentialed to provide consults to their primary partners, and there is no reimbursement for providing the consults.
Dr. McKoy had to join the hospital staff at Cambridge Health Alliance, which owns Somerville Hospital Primary Care.
But once the referrals started, she was happy to help out. Since September, she has provided 44 consults to Somerville and 9 to another site she is paired with, Boston Health Care for the Homeless. The low caseload means it "really has not been a burden," said Dr. McKoy.
She has been eschewing the phone-based app, preferring instead to do everything over the Internet. Mostly what she sees are the basic dermatology problems encountered in daily practice: acne, dermatitis, pigmentary problems, and solitary lesions. Only one case stumped her, which led her to recommend a biopsy and an in-person consultation with a dermatologist.
Those appointments are very hard to come by for patients at Somerville, where there are no dermatologists on staff, said Dr. Erica Ross, an internist at the clinic. The majority of her patients are insured through Mass Health, the state-run plan. So only Massachusetts General Hospital will take her referrals, and the waits are months long, she said.
The consults with Dr. McKoy have been a great help, said Dr. Ross. The consults have helped her select the right treatments for her patients, and she is able to take care of almost all cases without having to refer.
It has "been phenomenal for me in terms of my own growth," said Dr. Ross. "I feel like my skills for diagnosing things have grown a lot."
Completing the telemedicine process still takes longer than writing a referral. "But I know if I write a referral, nothing is going to happen," she said.
Room for Growth? Dr. Ross and Dr. McKoy said they think the teledermatology consult model has the potential to gain in popularity, but that a number of things would have to happen.
Not everyone will be comfortable with smartphone technology, said Dr. McKoy. She is hoping for a more user-friendly app in the next iteration. She also does not think it will spread until consults are reimbursed.
The AAD and the American Telemedicine Association have been talking to the Centers for Medicare and Medicaid Services about getting paid for dermatology consults. California's Medicaid program does provide some reimbursement, as does the Indian Health Service in Alaska, said Dr. McKoy.
"It's not perfect. It's not the gold standard. But for me, it's better than nothing," she said.
The AAD is not looking to expand the program yet, in part because the society has been paying for the phone and the phone service, said Dr. Kovarik. Click Diagnostics is building apps that can run on the iPhone and Android platform, so clinicians could use their own phones. The AAD will continue to maintain the Web portal.
The AAD "feels like this is really a way to handle patients who have no access to care," she said.
CMS and Credentialing. Just recently, the CMS issued a final rule to simplify the credentialing process for hospitals and nonhospital partners providing telemedicine. In announcing the new policy in early May, Dr. Donald Berwick, CMS administrator, said, "Today’s final rule is the result of close collaboration with hospital and telemedicine care experts."
In the past, the CMS has required hospitals and critical access hospitals to go through a credentialing process for a physician providing telemedicine, even if the physician had privileges at the remote site where they were practicing. To provide telemedicine, the physicians had to be privileged at their home institution as well as the facility where they would deliver the telemedicine.
Now, a hospital that provides telemedicine to its patients can rely on the credentialing information provided by the physician’s home facility. According to the CMS, the final rule was developed to address concerns about continuing access to telemedicine.
The agency sees telemedicine as a critical way to deliver care to patients in rural or remote areas, according to the CMS statement.