HILL’S GLOBAL SYMPOSIUM 2021 | PROCEEDINGS
GETTING THE MOST OUT OF THE
TELEDERMATOLOGY CONSULTATION
Richard P. Usatine, M.D.
Professor, Dermatology and Cutaneous Surgery
Professor, Family and Community Medicine
Founding Director, Skin Clinic, University Health System
University of Texas Health San Antonio, TX, USA
HOW TO PREPARE FOR TELEDERMATOLOGY VISITS
To start doing teledermatology you need appropriate
hardware and software with a strong Internet or data
connection. The electronic health record (EHR) on
a good quality computer with a standard monitor
is the foundation. In medicine with human patients
the privacy considerations need to be HIPAA (Health
Insurance Portability and Accountability Act) compliant.
Communication for telehealth may be as simple as
a phone conversation or as complex as a discussion
through a HIPAA compliant electronic portal from the
EHR to a patient portal (e.g. Epic and MyChart).
Software options for telehealth:
• Doximity
• Zoom
• Doxe.Me
• Patient Portals in EHRs
Examples of telemedicine built into EHRs:1
• AdvancedMD
• Allscripts
• Cerner
• Epic
• Salus
• PrognoCIS
Doximity app for phone, tablet and computer: You can
use your cell phone to call patients without revealing
your private number. When their phone rings, patients
see your office number (or any number you designate)
on their CallerID. For video conferencing, just dial the
patient’s number to start a video call. They are sent a
text message from a no-reply number (not your cell
number). With a few taps the patient and provider are
connected.2
Dermatology cases in which teledermatology is most
effective:
By diagnosis:
• Acne
• Psoriasis
• Atopic dermatitis
• Fungal infections that are classic
3
• Some viral infections such as mild to moderate zoster
or herpes
• Monitoring chronic dermatology diagnoses that are
currently under control
By patient characteristics:
• 
Young adults and teenagers that are technology
proficient
• Have access to high-quality Wi-Fi connections
• Don’t need an interpreter
• Follow-up patients well-known to the provider
Dermatology cases in which teledermatology is most
challenging or least effective:
By diagnosis:
• Skin cancer and precancer such as actinic keratoses
• Skin cancer detection and total body exam
• Systemic dermatologic disease in acute presentation
• Immunobullous disease in acute presentation
• Any dermatologic condition with plans for
intralesional injections
• Rashes or any condition needing biopsies
• Conditions needing cryotherapy
• By patient characteristics:
• Any patient with limited technology literacy (often
older)
• Patients without smart phone or computer
• Patients without Wi-Fi or good phone/data
connection
• Patients not knowing how to use their smart phone
for video connections
• Patients not using email and not able to send
photographs when needed electronically
• Patients too shy for video conference
What environment is best for teledermatology?
• 
A quiet environment on both ends of the
communication
• Good lighting – avoid backlighting and dark rooms
HILL’S GLOBAL SYMPOSIUM 2021 | PROCEEDINGS
How to establish rapport with the patient using video?
• Look at the phone or camera to establish eye contact
• Place patient’s image near your camera if patient is
on the monitor
• Stay focused on patient
• Avoid distractions, disable other alerts, ringers,
alarms
• Advise patient when you are looking away at medical
record or typing notes
• Dress professionally
• Avoid eating during visit
• Understand that a patient may not want to reveal
a private area over a video connection even if they
would feel comfortable with this in the office
• Apologize if you are calling or connecting after the
appointment time and don’t assume that the patient
has nothing else to do but to wait for you
• If you are calling or connecting early make sure the
patient is ready by asking their permission to proceed
now vs calling back
• If there is no answer, leave a message that you or
someone from your office will call back so they know
that the phone number you are using is not spam or
telemarketing
• Use office staff to help facilitate these connections
when using the patient portal of an EMR. Patients
may need coaching to figure out how to use the
patient portal
Steps to increase efficiency in teledermatology:
• Use office staff to schedule the telehealth visits and
to schedule follow-ups
• Transmit prescriptions electronically including
controlled substances when necessary
• Transmit orders for labs and imaging electronically
when possible and inform patients how to get these
tests done
• Do verbal health education but consider electronic
information sheets/handouts when it is easy to send
an email or use the EMR for messaging.
How to maintain your own privacy while connecting
to patients:
• Don’t call or FaceTime from your personal cell phone
number unless you are prepared to receive messages
and phone calls from this patient in the future – in
general it is best to avoid this situation –
• Consider dialing *67 before the number, but this may
result in the patient not picking up the phone call as
it looks like telemarketing. The app Doximity works
to avoid this
• If you are using a phone-based app such as Doximity,
assign the office phone to the phone number that
they will see the call coming from
• Have an email address that you can use for patients
to send photographs when needed as these photos
are often in better focus than video images
• Don’t text from your private phone or send emails
from your private email address
4
During the physical exam, tips for best results:
• Good lighting which is often indoors rather than
outdoors where there may be glare and shadows
• Smart phone light or a flashlight can help examining
the oral cavity
• A family member or friend can help point the phone
or camera at the back or buttocks
• Foot exam means removing shoes and socks
• Palpation can be done by the patient or parent if
directions are given clearly
• Even a partial neurologic exam is possible with clear
directions
• A ruler or another common object such as a coin can
be placed near a lesion to give size
• Home dermoscopy is possible and may make sense
for patients at the highest risk of melanoma
• There is a dermoscopy loan program available
through Oregon Health Sciences University (OHSU)
Tips for working with older adults:3
• If the patient has decreased hearing, the patient may
wear a headset
• Provider should use a good microphone or wear a
headset
• Position camera for patients to be able to see and
read your lips
• Speak slowly and ask patient to teach-back to you
• Send written instructions electronically or by mail if
necessary
Pitfalls in teledermatology:
• Patients who can’t navigate the technology
• Out of focus photos
• Unhappy patients when the circumstances require an
in-person visit – the rare patient becomes unhappy
stating they wasted their time – fortunately this is
truly rare as patients are usually very grateful for the
teledermatology visit and understand that the next
step is an in-person visit
Benefits for patients:
• No travel needed
• No parking needed
• Avoiding contact with COVID-19
• No problems finding the clinic
• Less time due to no travel and no waiting room time
• While waiting for a visit, chores and work can be
performed
• Helps patients with limited mobility and limited
access to transportation
Risks for patients:
• Insurance may not cover the visit especially as the
pandemic becomes less severe
• Procedures can’t be performed, so additional visits
are then needed
HILL’S GLOBAL SYMPOSIUM 2021 | PROCEEDINGS
Benefits for providers:
• Can work from home or possibly a more relaxed office
• Less exposure to COVID-19
• Fewer no-shows - especially due to transportation
problems
• Can do charts while listening to patients without
appearing rude
• Can reach elderly and underserved patients
Risk for providers:
• Insurance may not pay for the visit, especially phone
visits
• Decreased satisfaction when procedures are needed
and cannot be performed
What can be done to make teledermatology more
effective?
• Providing avenues for patients to learn how to use
the technology needed.
• Federal and state support to overcome the digital
divide - patients with less money and resources
get help obtaining high-speed Internet and smart
phones/computers/tablets. (note that families often
need this technology for online schooling and work
at home for adults)
• Continue public and private insurance coverage for
telehealth.
Conclusions:
• There are many benefits to telehealth for patients
and providers
• There are some pitfalls regarding limited technology
literacy and limited access to the hardware and
Internet
• Private and public support to improve technology
literacy and access to the hardware and the Internet
can allow for innovations and growth of telehealth.

References 5. Clarke EL, Reichenberg JS, Ahmed AM, et al. The utility of
1. https://www.softwareadvice.com/telemedicine/#buyers-guide teledermatology in the evaluation of skin lesions. J Telemed
Telecare 2021:1357633X20987423. doi: 10.1177/1357633X20987423.
2. https://www.doximity.com/app
Epub ahead of print. PMID: 33461401.
3. Nieman CL, Oh ES. Connecting With Older Adults via Telemedicine
6. Cline A, Kim C, Deitz M, et al. Real-World Direct-to-Patient
[published online ahead of print, 2020 Aug 11]. Ann Intern Med.
Teledermatology in a Low-Income, Elderly Population. J Am
2020;10.7326/M20-1322.
Acad Dermatol 2021:S0190-9622(21)00187-0. doi: 10.1016/j.
Further reading jaad.2021.01.038. Epub ahead of print. PMID: 33476731.
1. Berman HS, Shi VY, Hsiao JL. Challenges of Teledermatology: 7. Conforti C, Lallas A, Argenziano G, et al. Impact of the COVID-19
Lessons Learned During COVID-19 Pandemic. Dermatol Online J Pandemic on Dermatology Practice Worldwide: Results of a Survey
2020;26:13030/qt7193305r. PMID: 33342172. Promoted by the International Dermoscopy Society (IDS). Dermatol
2. Hadeler EK, Beer J, Nouri K. Teledermatology: Improving Access or Pract Concept 2021;11:e2021153. doi: 10.5826/dpc.1101a153. PMID:
Widening Healthcare Disparities? J Drugs Dermatol 2020;19:1248. 33614221; PMCID: PMC787
doi: 10.36849/JDD.2020.5693. PMID: 33346507.
3. Cartron AM, Aldana PC, Khachemoune A. Pediatric teledermatology:
A review of the literature. Pediatr Dermatol 2021;38:39-44. doi:
10.1111/pde.14479. Epub 2020 Dec 9. PMID: 33295665.
4. Mizes A, Vainder C, Howerter SS, et al. Access to consultative
dermatologic care via physician-to-physician asynchronous
outpatient teledermatology. Am J Manag Care 2021 ;27:30-32. doi:
10.37765/ajmc.2021.88574. PMID: 33471459.