More than 200 mobile applications dealing with dermatology are now available, dealing with issues ranging from rosacea to skin cancer, according to VA researchers. How safe and useful are they, and how soon will the technology be incorporated into VA telehealth services?
By Stephen Spotswood
DENVER — The last few years have seen a precipitous rise in the number of mobile phone applications designed to assist with the treatment of skin conditions.
A recent study conducted by VA researchers catalogued more than 200 dermatology-specific apps. The explosion in patient-controlled technology does not necessarily translate to better care or better efficiency in the exam room, however, according to VA experts.1
While apps providing patient information can be supportive of the doctor-patient relationship, such as Bayer HealthCare Pharmaceuticals’ Rosacea App, others that provide diagnosis or medical advice raise questions about accuracy and security, VA experts pointed out.
Teledermatology using the telehealth cart at the Lawrence County Community-Based Outpatient Clinic (CBOC). The Butler, PA, VAMC offers a variety of telehealth services at its main facility and satellite locations. Photo from Butler VAMC.
Robert Dellavalle, MD, PhD, MSPH, chief of dermatology at the Denver VAMC and senior author of the VA study, said that, with the applications going beyond only patient information, “This is an area of buyer beware because there are no regulations and no guarantees that these apps are providing accurate medical information.”
For example, recent research found that mole-diagnosing apps misidentified as many as 30% of melanomas.2
The Food and Drug Administration has opted not to regulate the majority of mobile medical apps, determining that few pose any immediate risks to consumers. That means that the designers of applications — except those that act like medical instruments and perform ultrasounds and other procedures — are not required to prove their product improves patient care prior to releasing them into the marketplace.
“Even though these apps are doing cool things, nobody’s watching to make sure they work the way they’re supposed to,” Dellavalle told U.S. Medicine
. “And the FDA is not regulating them the way they would a device or a drug.”
While mobile applications have a variety of purposes, including monitoring psoriasis, connecting patients with support groups, dispensing sunscreen advice, providing dermatology education and informing patients about medications, those that diagnosis conditions such as melanoma are the greatest concern, according to the VA study.
The self-surveillance/diagnosis apps also vary widely in capabilities, with some allowing patients to document lesions, upload and receive dermatologist or algorithm-based feedback about the malignancy potential of lesions, follow diagnosis algorithms and log personal treatment regimens, study authors pointed out.
One even allows users to photograph a mole and monitor its changes over time to help determine if it is malignant, according to the report.
“We found a lot of apps, but if we were to do this study again, we’d probably find twice as many,” Dellaville noted. He added that some regulations are needed “to make sure they’re doing what they’re claiming to be doing, especially when they’re doing diagnoses.”
On the Drawing Board
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At the VA, meanwhile, the growth in teledermatology has yet to include much in the way of mobile apps, although a concept for one is on the drawing boards.
“There’s some evidence appearing in the literature about the use of it, but in terms of it entering routine practice, there are concerns about it,” said Adam Darkins, MD, MPHM, FRCS, VA’s telehealth chief.
One concern is the ability of veterans and other patients to take high-quality images. In VA’s teledermatology program, images forwarded to the dermatologist are very clear, not only because the camera is sensitive but also because the imagist has been trained.
Another concern is security. Mobile applications designed by third-party vendors have little to no data security regulations. After several electronic data leaks over the last decade, VA has made patient data security a high priority.
The biggest concern that makes the use of patient-controlled mobile apps untenable for VA, at least for now, is how they might affect workflow.
“Patients in teledermatology are screened in primary care first,” Darkins explained. “If images are sent in, it’s very important that the images are managed, processed, tracked and audited. Images are linked and patients identified.”
With patient-controlled apps, images are coming “straight out of the blue,” Darkins said.
“Most dermatologists are pretty busy in terms of how they manage workflow,” he said. “But the threshold for sending images is way, way down. Imagine 10 times the number of images [being sent to the dermatologist]. How is that workload credited for recognition? How would it get paid for? We’ve started doing some of the thinking about this but haven’t gotten any answers yet.”
Empowering Frontline Providers
More Than 45,000 VA Patients Used Teledermatology Services Last Year
WASHINGTON — While it is not clear when or how VA will incorporate mobile technology into its dermatology care delivery, the agency has a strong track record for use of technology to help patients.For example, VA has been at the forefront of the telemedicine surge of the past 15 years and has included teledermatology as part of its service to veterans since 1997.
In fiscal year 2013 approximately 45,000 patients received teledermatology care through VA — a 249% growth in the last two years.
Most of that care is done through various store-and-forward models. Veterans visit their usual source of VA care, photographs are taken of whatever skin conditions are being treated and images are forwarded electronically to dermatologists at other sites to examine the image and send their diagnoses back to clinicians at the initial sites of care.
While the technique seems relatively simple, it took several years for the program to expand and for VA physicians to buy in to the process.
“Up until three or four years ago, we did a fair amount of teledermatology, but they were small programs,” explained Adam Darkins, MD, MPHM, FRCS, VA’s telehealth chief. “They lasted as long as the dermatologist there was keen to do them. Across the board, there has been some reticence in teledermatology. There were concerns about making diagnoses and the logistics of it.”
About three years ago, VA began to systemize how teledermatology worked. At the site where the veteran is receiving care, someone specializing in dermatology — either the physician or a nurse practitioner — is trained to take images of skin conditions with a digital camera and to send that image off. Sometimes there is a professional there dedicated solely to receiving the patient, taking images and forwarding the images to the dermatologist.
“We’re working with the community [to] standardize the technology and work it into the workflow,” Darkins explained. “It’s all really organized, not just between two sites but multiple sites.”
The exponential increase in the power of simple digital cameras also has helped with physician buy-in. Increased clarity in the image results in more confidence by the dermatologist in their diagnosis.
This isn’t to say that VA is ruling out using mobile applications or recommending them to patients altogether. Some applications are designed around the maintenance of chronic conditions and are focused more on providing information to the patient rather than providing a link from patient to physician.
For example, Bayer Healthcare’s Rosacea Concierge is set up around a variety of multimedia assets that provide tutorials from dermatologists, nutritionists and aestheticians to provide recommendations on living daily with the chronic condition.
VA already makes regular use of information-based applications, though most are on the physician side.
“The question with enabling dermatological care of chronic conditions is really one of who we are choosing to empower to improve care delivery,” explained Neil Evans, clinical director of VA’s mobile health program. “The first step a big healthcare organization like VA has to take is really empowering the frontline primary care teams. If you equip frontline providers with better tools to understand dermatological conditions, you’re going to lead to better patient care.”
VA has had great success with its use of VisualDX — a clinical support system that helps clinicians recognize and diagnose visually presenting conditions. VA has a national contract for VisualDX, including it on every desktop in VA. Any VA provider can download the mobile version.
Last year in the VA system, four million images were viewed on VisualDX — 31% of those through mobile devices.
“The vast majority [of users] are frontline providers,” Evans explained. “They’re not just using it to reinforce their own diagnostic suspicions but using it as a patient education tool. They can reassure a patient that this dermatological lesion is what they say it is.”
VisualDX is often used in the teledermatology process, with dermatologists including a link to VisualDX along with their diagnosis. The primary care provider can use it to teach themselves and the patient about the condition.
VA is just starting the process of creating its own teledermatology application, Darkins said. Details on what it would include and its timeline for development are sparse, because discussions have only recently begun.
Whatever the future holds, it is unlikely that use of mobile technology in treating dermatological conditions will slow in growth, especially as the newest generation of veterans is arriving having grown up embracing the potential of mobile applications.
“We have a patient population that’s come to expect technology as part of their care,” Evans said. “And we have a cadre of interested technicians and staff members implementing these virtual care solutions in a way that doesn’t lose the heart of healthcare. Technology in healthcare does not replace meaningful relationships.”
In the long run, Dellavalle predicted, the rise in medical apps, in general, and dermatology, in particular, could help expand care into rural and underserved populations and help mitigate the shortage of dermatologists nationwide.
“There is a huge expansion of medical apps across all disciplines now. This will require some caution by users but it also opens up new opportunities,” he said. “I think most apps are generally safe right now, but I would not rely solely on them.”
Brewer AC, Endly DC, Henley J, Amir M, Sampson BP, Moreau JF, Dellavalle RP. Mobile applications in dermatology. JAMA Dermatol
. 2013 Nov;149(11):1300-4. doi: 10.1001/jamadermatol.2013.5517. PubMed PMID: 24067948.
Wolf JA, Ferris LK. Diagnostic inaccuracy of smartphone applications for melanoma detection-reply. JAMA Dermatol
. 2013 Jul;149(7):885. doi: 10.1001/jamadermatol.2013.4337. PubMed PMID: 23864095.
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