Teledermatologists’ management of emergency skin conditions

Traditionally, when patients presented to emergency departments or rural hospitals with a complex skin condition, the on-call dermatology registrar was consulted by telephone. More recently, clinicians have begun using store-and-forward technology to send images directly to the specialist, significantly improving their capacity to accurately diagnose and manage patients remotely. Such teledermatology services also provide valuable teaching opportunities for rural doctors and registrars. While there are numerous benefits, including improved timely access to specialist advice for rural patients and clinicians, and reduced unnecessary investigations and outpatient referrals,1 the issues related to patient privacy and confidentiality must be addressed.

Following a successful pilot study in Queensland in 2008–2009,2 the Skin Emergency Telemedicine Service was implemented at the Princess Alexandra Hospital (PAH) in Brisbane. Despite no active promotion of the service, referrals have almost doubled from 167 cases in 20123 to 318 in 2014. The disease spectrum of referred cases in 2014 was similar to 2012, with 30% diagnosed with dermatitis, 21% with infection of the skin and 15% with drug eruption. Referral sites continue to be dispersed across the state, from Brisbane to Innisfail, 1600 km away. After the cessation of outreach services to Qld towns such as Mt Isa in 2013 and closure of the Dermatology Department at Cairns Hospital in 2014, the PAH Skin Emergency Telemedicine Service has been an essential part of ensuring timely access to a dermatologist (average response time = 4 hours) for patients with acute skin conditions across Qld.

The increased use of smartphones by clinicians to capture images for telemedicine services has raised concerns about patient privacy and consent. The study by Kunde and colleagues of dermatology registrars’ (n = 11) use of digital and smartphone technology for clinical imaging reported widespread use of the technology.4 The vast majority of clinicians had stored over 100 clinical images of patients on their personal phones, and 10 of 11 surveyed clinicians reported they had texted or emailed images to colleagues. Although patient consent was obtained verbally by 10 of the responding clinicians, few reported recording consent in the patient’s medical record (n = 2).

In 2014, the Medical Indemnity Industry Association of Australia and Australian Medical Association developed the Clinical images and the use of personal mobile devices guide for medical students and doctors.5 The guide makes recommendations for the collection, use and disclosure of clinical images as well as storage and security. Clinicians using teledermatology services must familiarise themselves with the relevant guidelines, hospital policies and privacy legislation, and ensure that images and evidence of obtained consent are documented in patients’ medical records.

The addition of store-and-forward technology to the traditional referral system has enabled clinicians to access specialist advice in an efficient and timely manner, potentially improving patient care. Strategies to improve access to specialist advice should be supported, but the relevant ethical and legal issues must also be considered.