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PHILADELPHIA — On any given day, Dr. Carrie Kovarik's dermatology patients range from an HIV-infected girl in Malawi with a growth on her shoulder to a complex leprosy case in Brazil to a worrisome-looking mole on the neck of a woman from West Philadelphia.
Her practice is here, where she is an associate professor at the University of Pennsylvania, and she sees many of her patients not in a clinic but on her iPad. Health workers from around the world, from rural clinics to thinly-staffed urban hospitals, send her images shot with their smart phones or digital cameras, that Kovarik uses to help diagnose complicated skin conditions.
Many of the facilities she helps have no dermatologist on staff.
"Currently in Botswana there are no licensed dermatology specialists in the public sector — in the entire country," said Kovarik, 39, who first became interested in helping medically-underserved communities during medical school at Baylor College of Medicine, and early in her career when she worked in Central America and Africa with various medical programs.
Kovarik's teledermatology practice worked out so well overseas that she developed an app — called AccessDerm — modeled on her global practice. The twist is that it's now catching on back home in the U.S. where access to dermatology specialists has become increasingly problematic in recent years.
It's not the number of dermatologists that is the problem. It's their geographic distribution and who they serve.
In the U.S., she and colleagues bring teledermatology services to about 14 clinics with locations that include Washington state, California, Missouri, Texas, Virginia, Massachusetts, and Michigan.
The issue isn't that there are too few dermatologists compared with previous years. According to the American Board of Dermatology, there are more skin specialists today than there were ten years ago. Access to care, health insurance reimbursement, and changing attitudes about technology are making teledermatology an increasingly appealing practice for doctors and patients.
"It's not the number of dermatologists that is the problem,'' Koravik said."It's their geographic distribution and who they serve. For example, there are many dermatologists in Philadelphia, but not many are in the underserved areas of West or North Philly."
There are entire counties in Pennsylvania that do not have a dermatologist, she said.
Research published in the Journal of the American Academy of Dermatology in 2009 showed the typical wait time to see a dermatologist in Ohio was 4.5 weeks for new patients and 3.1 weeks for established patients. Another 2008 survey, published in the same journal, examined the U.S. dermatology workforce and said findings "suggest persistent unmet demand" in the field of dermatology.
Many dermatology practices don't accept state Medicaid because reimbursement is very low, said Dr. Roy Colven, a professor of Medicine in Dermatology at the University of Washington School of Medicine, in Seattle. A telemedicine researcher and expert, Colven said "Some dermatologists don't accept any insurance coverage at all, forcing patients to get the reimbursement from their third party payers."
The practice of using smartphones and cameras may also be growing in popularity because patients and physicians are more accepting of the technology involved, and more and more research shows it works, too. "A growing literature of study shows that teledermatology approaches the accuracy of diagnosis that face-to-face has," Colven said.
Dr. Karen McKoy, a dermatologist at the Lahey Clinic, in Burlington, Mass., and an assistant clinical professor in Dermatology at Harvard Medical School, has been practicing teledermatology for years. She said people are more tech-savvy now, so that plays a role in the field's growth, too.
"Patients are demanding the convenience of the technology,'' she said. "It works in so many other areas, why not medicine? Smart phones are changing the picture with good cameras and broad reach to everyone."
Kovarik's group now works with 10 Philadelphia-area pubilc health clinics -- some just walking distance from Kovarik's office -- but without telemedicine, the patients at those cllinics might not receive care, she said.
"Some patients feel more comfortable going to a local clinic where they are able to see healthcare providers they know better, or who speak their language, versus going to a big medical center,'' she explained.
Erasing wait time
Sayre Health Center is one such clinic. Dr. Kent Bream, an assistant professor of Clinical Family Medicine and Community Health at the University of Pennsylvania, founded Sayre eight years ago and is the medical director there. He has used teledermatology for four years now.
The wait for specialty appointments at Sayre, he said, is about three months – that is, if you can get one.
"But for a rash — a burning, itching, sore rash — you really need care right away,'' he said. "And if it's cancerous, you really don't want to wait three months.”
Bream said they've evolved from taking photos and uploading them to a computer and emailing them to Kovarik to now where Sayre clinicians just download the AccessDerm app onto their smart phones.
One Sayre patient, Trena Medford, from West Philadelphia, said she's thankful for telemedicine. Medford was suffering from a serious rash in April when she visited Dr. Katherine Mahon, a family physician at Sayre.
"The doctor whipped out her phone and said, 'Mind if I take a picture?'" said Medford, 37, whose face and arms still show scars from the rash.
She said it didn't cross her mind to call a dermatologist at nearby Penn. "I prefer to stay in my neighborhood for my medical care."
But when Dr. Mahon told Medford that a dermatologist at Penn who'd viewed her telederm photo wanted to see her as soon as possible, Medford made the four mile trip and received steroids for what turned out to be a serious allergic reaction to an antibiotic.
"That wouldn't have happened five years ago," said Sayre family physician Mahon. "To get a derm consult that fast, I would have had to have had a friend who was a dermatologist do me a favor."
Since launching a new version of the app this past January, Kovarik said AccessDerm users have performed almost 200 consults, more than they were able to log altogether in the first couple of years of the teledermatology program. The American Academy of Dermatology has helped spread the word as well.
Teledermatology will likely continue to grow in the U.S., said McKoy at Harvard. However, she cautioned, "Issues of reimbursement, confidentiality and liability remain."