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To the Editor: In response to COVID-19 restrictions, we developed a hybrid photo- and video-based (“store-and-video evaluation” or “SAVe”) electronic health record Epic-integrated workflow (Fig 1) to rapidly transition a large multispecialty group from a completely office-based dermatology practice to one that can support virtual care. The SAVe approach addresses challenges associated with asynchronous/“store-and-forward” workflows (no real-time assessment, absence of patient-provider interaction, and unclear reimbursement strategies) and synchronous/“live interactive” workflows (logistical/execution challenges and poor image quality).
This retrospective descriptive study conducted from 3/16/2020 to 8/31/2020 analyzed 74,411 dermatology cases (20.8% digital and 79.2% in-person; Fig 2) encountered by 89 providers to care for 46,024 patients. SAVe was the predominant digital encounter type (88.8%), followed by telephone/message encounters. At the initial pandemic peak (April 2020), SAVe encounters increased to 71.5% of all encounters (from 0% prior to 3/16/2020) and was sustained at 11.5% upon full-clinic reopening (June-August). Extrapolation of the 9.5% steady-state SAVe utilization (July-August) represents 21,385/year teledermatology consultations versus 263/year teledermatology consultations (range: 20-20,000) reported across United States programs.
As 81% (n = 25) providers wanted to continue SAVe indefinitely, we speculate that the drop in virtual care from the peak utilization was because of postponed full-body skin examinations and familiarity with traditional clinic visits once COVID-19 safety protocols were in place.
The implementation of SAVe increased access to dermatologic care. The wait time for referrals was shorter for SAVe (mean = 14.3 days) than for in-person (26.8 days, P < .0001) encounters. Despite significant staff reduction, the in-person referral wait times during the study period were shorter as compared with those in the 2019 timeframe (26.8 vs 56.4 days, P ≤ .0001), possibly because SAVe encounters made more in-person appointments available.
During COVID-19, SAVe allowed for flexibility to match the needs of providers (with increased responsibilities as parents, spouses, and caretakers), patients (with fears of leaving the house), and clinics (with low personal protective equipment and strict spacing guidelines). One region's safety protocols allowed only 3 of 12 available providers to be on site, but SAVe enabled 9 additional providers to provide virtual care remotely. Since only 4.3% of SAVe required immediate (≤7 days) in-person follow up and >80% of SAVe visits were performed from home, clinic capacity was increased for required in-person evaluations/procedures.
Among patient demographics (Supplementary Table 1 available via Mendeley at https://data.mendeley.com/datasets/mjt7fk9ps7/1), the most striking difference was in age. Patients aged ≤30 years were more likely to use SAVe than those aged >65 years (P < .0001). This could be attributed to differences in ease with technology or chief complaints.
Compared with in-person diagnoses, diagnoses performed via SAVe were more likely to be of rash (30% vs 24%, P < .001) and acne (17% vs 3%, P < .001, Supplementary Fig 1 available via Mendeley at https://data.mendeley.com/datasets/mjt7fk9ps7/1), which may be more amenable to virtual care. The most common in-person diagnostic category was growth (27% vs 10%, P < .001), which is more likely triaged to in-person evaluation.
SAVe was designed by and created for dermatologists to provide a secure and integrated teledermatology model to complement in-person workflows to preserve access and quality of care.
Conflicts of interest
The authors thank Kathryn Martires, MD, and Kiana Aguilar, CMA.
Telehealth: helping your patients and practice survive and thrive during the COVID-19 crisis with rapid quality implementation.
Funding sources: This article was funded in part by the Center for Health System Research at Sutter Health .
IRB approval status: Ethical approval for this study was waived by the Sutter Institutional Review Board because it is a report of an experience with a new clinical tool implemented by the integrated healthcare system. Analyses for this study were covered under Sutter IRB determination of quality improvement and approval of healthcare utilization research (IRB protocol # 1592336).