Claudia Hernandez, M.D.

Access is emerging as a key issue in improving dermatology care. Some patients simply can't get to a dermatologist regardless of need.

"We have done all of these quality improvements and changes in the way we practice medicine, but without equity in access, it is all for nothing," said Claudia Hernandez, M.D., assistant professor of dermatology at the University of Illinois College of Medicine, Chicago. "There are still many parts of the United States where health outcomes are pretty much on par with Third World countries."

New methods expand care to vulnerable populations
The supply of dermatologists isn't likely to increase dramatically, but the profession is developing a variety of methods to make dermatologic care easier to access. When patients can't get to a dermatologist, technology can help get a dermatologist to the patient. Dr. Hernandez directed the Aug. 5 forum, "Using Technology to Improve Dermatology Access," to explore tools and trends that are helping dermatologists expand their reach to vulnerable populations.

"A vulnerable population is anyone who can't safely or comfortably access medical care," she said. "There is a tendency to think of it in terms of ethnic group disparities, but we have many vulnerable populations. We have people who are physically disabled. We have rural populations, the elderly, children — who all need help."

One of the largest vulnerable populations is the working poor, people who earn too much to qualify for Medicaid but earn too little to afford health coverage or health care.

"There are a lot of people falling through the cracks," said Amit Pandya, M.D., professor of dermatology at University of Texas Southwestern Medical Center, Dallas. "It is estimated that there are at least 250,000 people just in Dallas who are above the poverty line but make way too little to afford insurance. When they need care, they often can't even afford the sliding scales charged by public hospitals and clinics."

Volunteering improves access
One solution for improving access is to volunteer at free and low-cost health clinics. Dr. Pandya is one of three UT dermatologists and a growing number of residents and medical students who provide services at the Agape Clinic. The group sees about 60 dermatology patients a month. Project Access Dallas, administered by the county medical society, coordinates free care provided by about 2,000 physicians, 16 hospitals, and a network of laboratories and clinics.

Newest technology for patient access is virtual
The Academy has expanded volunteering into teledermatology. Inspired by virtual consults with primary care providers in Africa, the Academy launched its own teledermatology pilot to provide free consults for 26 community health centers and free clinics from Boston to San Diego.

"When I saw that we could provide care for people in Botswana, it seemed like we ought to be able to do the same thing for people in North Philadelphia and Oakland," said William James, M.D., professor and vice chair of dermatology at the University of Pennsylvania Health System, Philadelphia. "Volunteer dermatologists receive basic information from primary care providers, either through mobile devices or a web-based program. We view the information and photographs of the patient, then provide diagnostic and therapeutic recommendations back to the primary care doctor."

The program began with a Philadelphia-area pilot in 2009 that provided about 100 consults, Dr. James said. The Academy launched a nationwide pilot in August 2010 and has done about 400 consults. The project is currently upgrading its technology system for faster access to easier communication across different mobile and web-based devices. The clinic roster could be expanded by late 2012.

"We, as an Academy, are trying to improve the skin health of disadvantaged Americans," Dr. James said. "We are hoping to provide a model that other groups may want to emulate so the patient's whole health, not just their skin health, can be improved."

More groups making use of new, virtual technology
The Academy isn't the sole source for teledermatology. A group of academic physicians has developed a visual diagnostic decision support system called VisualDx. Dermatologists at the University of California, Los Angeles, are combining VisualDx and teledermatology to help primary care physicians diagnose and treat patients at safety net clinics.

"The waitlist to get a dermatology appointment is up to 12 months in our county clinics," said Noah Craft, M.D., Ph.D., associate professor, dermatology and adult infectious diseases at Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Los Angeles. "Primary care physicians use VisualDx to help manage patients when a dermatologist is hard to get to. We use it as a kind of continuing education piece as well as in teledermatology consults and as a standalone solution when the dermatologist is hard to get to."

Testing the power of cell phones
Other dermatologists are working directly with patients. April Armstrong, M.D., assistant professor of dermatology and director of teledermatology at the University of California, Davis, Health System, Sacramento, is testing text-message reminders to improve medication and self-examination adherence.

"In terms of underserved populations, cell phones are a powerful tool to affect behavior," Dr. Armstrong said. "Most people have cell phones and carry them pretty much everywhere. If people are even somewhat motivated to change their health behavior, we can deliver purposeful messages that are appealing, but not intrusive, to encourage them to practice healthy behaviors."

Early tests with daily sunscreen use showed that daily text messaging more than doubled adherence, she reported. A follow-up study using text messaging to encourage self-examination for atypical moles is in the planning stages.

Another study showed significant improvement in eczema symptom scores for patients using web-based education videos compared to patients using traditional pamphlets. Video-based informed consent also showed greater understanding of procedures and risks compared to in-person explanations.

New uses for social media
Jeffrey Banabio, M.D., Kaiser Permanente dermatologist and clinical assistant professor of medicine at the University of California, San Diego, is exploring ways to use social media, such as Twitter and Facebook, to improve patient access. Social media isn't just a tool, he said, it's a fundamental shift in medicine.

"Physicians have all the knowledge, physicians have all the tools," Dr. Benabio said. "To get advice or treatment, the patient has to access the physician. Social media disrupts that model. Knowledge that was once sequestered among physicians is now widely available on the Internet. Social media gives patients things that physicians can't provide, like a support network, a community. That is a very powerful way to improve compliance in the chronic diseases we see in dermatology."