Are Online Consultations Better Than Their In-Person Counterparts?

At YoDerm, our dermatologists use photos to diagnose and treat acne online. Patients upload photos of their skin and answer a handful of medically relevant questions. The doctor examines the pictures and information, and creates a prescription treatment plan for the patient within 24 hours.

For each follow-up consultation, patients upload new photos, update their information, and review the effectiveness of their treatment. Simple enough.

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When we started, our goal was to be “just as good.” Create a dermatology web-platform that’s “just as good” as an in-person office visit. Provide “just as good” of care, resources, follow-ups, and outcomes, and have the data to prove it. If the online experience could be “just as good,” we could differentiate to our customers with a more convenient experience at a lower cost than office visits.

After two years of trying to live up to traditional office visits, it has become clear that e-consults not only meet the standards of in-person care, they exceed them.

How could this be? How could a digital relationship transcend the effectiveness of a one-on-one in the doctor’s examination room. Surely, messaging on your smartphone couldn’t substitute the bedside manner and personal connection of an office-visit.   However, that is precisely what we have found. There are three explicit advantages teledermatology offers over traditional visits: better communication, better measurement, and better access. I’ve delved into the advantages of patient-physician communication below:

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Part 1: Better Communication.

On-demand resources:

In an office visit, the patient receives a 5-15 minute consult with the dermatologist. He/she is told the diagnosis, the treatment, instructions for the treatment, and any other helpful skincare advice. 40-80% of this information is immediately forgotten, and almost all of the “remembered” information incorrect. Consequently this void is filled by asking the pharmacist, browsing the internet, or calling the doctor’s office.

In contrast, online consultations provide patients with on-demand resources so they don’t have to “remember’ anything. Each e-consult includes a detailed analysis of the physician’s diagnosis, treatment instructions, and a specific action-plan to follow. This information is accessible 24/7 on the patient’s smartphone or computer.

Along with this instruction are condition-specific articles curated by the provider who has a personal stake in the patient’s outcome. Not opinionated bloggers or click-through incentivized properties like WebMD and About.com.

Delightful Messaging:

Online consults also offer direct and secure messaging between the patient and physician. After the consult, the patient can send a message to the dermatologist and received a prompt response to his/her particular question. So far, messaging has brought two distinct benefits to the patient.

The first is that patients don’t self-diagnose side-effects or reactions to the treatment. They instead message their doctor (possibly with photos of their condition). The derm provides either a new treatment, or more often than not, a comforting message that such effects are expected and to stick with it. From many conversations with patients, I would imagine this increases medication compliance across the board, however I have no data to support this.

This brings up the second and more general benefit to patients. With the doctor available via message, patients experience a greater sense of continuity from their provider. Patients have less guesswork and homework about their acne and treatment.

On our platform, the patients average under two sent messages per consultation. But just from these, many patients say they feel less “helpless” and more “empowered” to improve their skin. Messaging provides a delightful experience to patients that isn’t available from traditional care.

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Part 2: Better Measurement.

Every consultation on YoDerm is visually documented. Patients upload photos of their skin for the first consult. And for each follow-up, new photos are uploaded every time. These photos are a necessary component of the online diagnosis.

Aside from their obvious necessity, these images have also provided external benefits to both parties involved in the consultation. The consistent and visual documentation of each patient’s condition has added unique value that cannot be easily replicated in traditional care.

For patients:

If you’ve ever personally struggled with acne, you know that you look at your skin every single day. You check for new blemishes and wait for old ones to leave, day in and day out. With such vigilant attention, it can and is difficult to objectively assess how your condition is improving over time.

Patients treated online are able to see a side-by-side comparison in how their condition has improved. Every single consultation photo is recorded and available to the patient for such a comparison. This gives the patient immediate qualitative feedback on the efficacy of his/her treatment and improvement.

before-and-after

Instead of focusing on the minor blemishes that they are currently experiencing, patients are now gleefully surprised at their skin’s improvement from two or three months prior. We’ve found that this positive reinforcement somewhat replaces the traditional negative relationship patients have with their skin and treatment.

For doctors:

70% of dermatologists see over 100 patients every week. So when a patient comes back in for a follow-up, is it surprising that many dermatologists cannot specifically remember what the patient originally looked like? They depend on their charts and notes, which work adequately. But words and diagrams don’t compare to a few high quality close-ups of the patient’s affected area.

In an online setting, the physician can look over a patient’s previous photos to see how he/she has progressed over time. For a visual condition, like acne, this ability is advantageous to in-person care.

This can be replicated in a traditional office, by taking pictures of every patient in every consult, and then reviewing these images for each follow-up. However this benefit is captured automatically when the diagnosis is performed using images in the first place.

For optimizing care:

The patient data that we record enables significant and widespread applications. Not significant in a re-selling, big-brother marketing sense, but rather in quantitatively improving outcomes to a degree never before possible.

Upon registration, patients input the information necessary for the doctor to make a diagnose and choose an appropriate treatment plan. This includes the basics of DOB, gender, weight, etc. as well as previous treatments, allergies, and other medications and conditions. By digitally aggregating this information, we enable researchers to combine this quantitative data with the qualitative benchmarks of patient submitted images.

Each patient essentially becomes a longitudinal study on a treatment’s effectiveness.

At scale, this unbiased data can and will provide tremendous insight into true effectiveness of every medication prescribed, including the effects of combination therapies. The data will be driven down to reverse engineer an optimal treatment plan of each individual patient, taking into account his/her unique characteristics. This information won’t replace a doctor’s expertise, but rather give MD’s a powerful data-driven tool for choosing an optimal treatment.

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Part 3: Better Access

Upwards of 42% of Americans live in areas underserved by dermatologists. If you call to schedule an office appointment, you’re likely to wait over 3 weeks for an opening. These figures illustrate a system where supply misses demand by a long-shot. So what is causing this massive shortage?

Dermatology Residencies:

In order to become a dermatologist, a medical school graduate must be accepted into and complete a dermatology residency. Many factors, including the above average compensation and low risk nature dermatology, makes these residency positions highly competitive. In fact, over 29% of doctors who had dermatology as their number one choice of residency were matched with a different specialty.

The number of derm residencies is the largest contributing factor to the shortage of American dermatologists. According to the National Residency Matching Program, total dermatology residency fillings increased from 338 in 2009 to 407 in 2013, or 4.75% annually. We’re moving in the right direction, but not fast enough. Here’s why:

Assuming the same growth rate in dermatology residencies, by 2030 we’ll increase consultation supply by ~2.2M annual consults.

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However, by 2030 the population of Americans aged 65 years or older will increase from ~40MM today to ~70MM. This group is twice as likely to visit the dermatologist annually. If we use the current statistics on the likelihood each age group will visit the dermatologist annually (found here) and extrapolate this using the Census’s projected population growth we find an even greater divide between supply and demand. In 2030 Americans will need 13 million more consultations than we do now.

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The 2 million additional consultations provided by new dermatologists help, however we miss the mark by over ten million consultations. Ten million. Our current system is broken. If things remain, in 2030, our system will be bedlam.

In order to meet the challenges ahead we must accelerate the supply of dermatologists, but we also have to greatly boost the productivity of our current doctors. They must see more patients per day without sacrificing quality of care.

Asynchronous teledermatology is the answer.

Asynchronous means…not synchronous. As in not occurring simultaneously. Skype and phone calls are synchronous. Email and text messages are asynchronous. In dermatology, this translates to using images and text, as opposed to phone or video conferencing.

I will dive deeper into the efficiencies of asynchronous care in a future post. For now, just think about why emails are so much more efficient than phone calls. If someone calls you, you must stop whatever you’re doing to pick up. You have to schedule a call in advance to be free, ready, and able to share the conversation. On the other hand, someone can email you at 4 in the morning, with no notice, and you can respond when it best fits your schedule.

This analogy applies to telemedicine as well. Asynchronous care allows physicians to treat patients as it fits best in their workflow. Any excess capacity can be filled with a pending online consultation ready for diagnosis and treatment.

For conditions like acne, most patients do not need to step foot into the office. Anyone with a smartphone or computer has access to care through online consultations. With these visual, low-risk conditions being treated online, the doctor’s office now has a greater availability for patients who need a biopsy, lab test or other procedure that requires an in-person visit.

Teledermatology allows for more patients to be seen in more opportune times, in the most opportune medium.
 To conclude, we indeed set out to be “just as good.” Nevertheless, two years of performing teledermatology changed that. We’ve found significant and tangible benefits from online consultations that cannot be easily replicated within a traditional workflow.

Asynchronous teledermatology creates an improved information exchange while establishing superior measurement mechanisms. Furthermore, the efficiencies of asynchronous care will be a necessary boon to meeting the upcoming explosion in the demand of dermatological services.

The rise of teledermatology is beckoning. If you haven’t been diagnosed via “selfie” yet, you will soon.

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