Implementing Teledermatology in Rural VISN 20: Tele-Derm Certification Program

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Implementing Teledermatology in Rural VISN
20Tele-Derm Certification Program
Lynne McFarland, MS, PhD TeleDerm Project
Director
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Of the 4 major Tele-Derm components, 2 involve
education

• Traditional store-and-forward Teledermatology
• Monitoring, oversight and quality control
• Continuing education components of basic training
  and weekly classes over 19 months
• Increasing independent scope of practice for
  primary care providers

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Objectives for lecture

1. To describe the educational component of
   TeleDerm project
2. To describe how we will assess competency for
   dermatology diagnosis treatment
3. To describe how we will assess competency for
   surgical procedures
4. To describe baseline and interim outcomes for
   educational progress

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Goals of Tele-Derm Education

• Education with expectations
• Gain competency for diagnosis treatment
• Gain competency for dermatology procedures
• Increase independent dermatology scope of
  practice at rural clinics

Improve local care to rural patients
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Continuing Education Components

1. Site Initiation
2. Structured Continuing Education
3. Skills Training
4. Diagnosis and Treatment Competency Assessment
5. Surgical Procedures Competency Assessment
6. Focused Professional Practice Evaluations

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1. Site initiation Recruitment

• Choices were made by medical center and clinic
  administrators
• One or two primary care clinicians
• Imaging tech and/or nurse
• Salary support provided by the project

Population of primary care veterans served FTE Clinician/Imaging Tech
gt12,000 1.0/1.0
6,001-12,000 0.8/0.8
3,001-6,000 0.4/0.4
1,500-3,000 0.2/0.2
lt1,500 0.1/0.1
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1. Site initiation Order Equipment

• Surgical instruments for excisions etc.
• -Procedures for cleaning, processing,
  sterilizing, delivery
• Multi-position table
• Surgical lighting
• Birtcher hyfrecator
• Heine dermatoscope
• Cry-Ac liquid nitrogen spray
• Smoke evacuator
• Cameras

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1. Site initiation Training Visit
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Initial site training Agenda

• Day 1/2
• Orientation
• The Language of Dermatology (video quiz
  review)
• Procedure manual overview
• Camera introduction (teaching clinic uploading)
• Teaching clinic (live patients)
• Day 3
• Review procedures manual
• Technicians practice uploading
• Providers practice consults
• Teaching Clinic

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2. Structured Continuing Education

• Textbooks
• Baseline survey, mid-terms and finals
• Weekly conference VISN20-wide classes
• Annual TeleDerm Conference

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2. Structured Continuing Education Textbooks
Self-assessed questions and answers to each
chapter on TeleDerm Sharepoint website
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2. Structured Continuing Education Baseline
Survey of 13 Dermatology Conditions
Dermatology Condition Knowledge Next to nothing Superficial Moderate Confident Expert Comfort Uncomfortable or refer Somewhat comfortable Comfortable Very comfortable Expert Number treated in last month?
Actinic keratosis 1 2 3 4 5 1 2 3 4 5 0 1 2-5 gt5
Basal cell carcinoma 1 2 3 4 5 1 2 3 4 5 0 1 2-5 gt5
Malignant melanoma 1 2 3 4 5 1 2 3 4 5 0 1 2-5 gt5
Moles 1 2 3 4 5 1 2 3 4 5 0 1 2-5 gt5
Etc.
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Scores from Baseline Survey on 13 Derm Conditions
Mean total 2.9
Knowledge score ranges from 1 (next-to-nothing)
to 3 (moderate) to 5 (expert)
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2. Structured Continuing Education Baseline
Survey of 11 Derm Procedures
Dermatology Procedure Knowledge Next to nothing Superficial Moderate Confident Expert Comfort doing Uncomfortable or do not do/refer Somewhat comfortable Comfortable Very comfortable Expert Number performed in last month?
Liquid Nitrogen cryotherapy 1 2 3 4 5 1 2 3 4 5 0 1 2-5 gt5
KOH wet mount 1 2 3 4 5 1 2 3 4 5 0 1 2-5 gt5
Punch Biopsy 1 2 3 4 5 1 2 3 4 5 0 1 2-5 gt5
Grams Stain 1 2 3 4 5 1 2 3 4 5 0 1 2-5 gt5
Shave Biopsy 1 2 3 4 5 1 2 3 4 5 0 1 2-5 gt5
Etc.
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Scores from Baseline Survey of 11 dermatologic
procedures
Mean total 1.8
Knowledge score ranges from 1 (next-to-nothing)
to 3 (moderate) to 5 (expert)
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2. Structured Continuing EducationBaseline
Pre-CME quiz
20 questions about basic dermatology with photos

• What makes this 1.5 cm lesion suspicious?
• a. It is asymmetrical
• b. It has irregular borders
• c. It has irregular and multiple colors
• d. It is larger than 6 mm
• e. All of the above

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Pre-CME Dermatology Quiz Scores
Mean total for 23 CBOCs 49.8 correct
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2. Structured Continuing EducationMid-term55
Intermediate Level Questions with Photos
47. What is the most likely diagnosis? a.
Pompholyx b. Pitted keratolysis c. Psoriasis d.
Candidiasis e. Tinea manuum f. Lichen simplex g.
Allergic contact dermatitis h. None of the above
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2. Structured Continuing EducationFinal
Provided Patient History, Medications,
Photo Answer to include Key Question Differentia
l Diagnosis Tests to order Most likely diagnosis
Treatment plan Follow-up plan
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2. Structured Continuing EducationWeekly
Conference Classes
Date of Class Topic Habif Chapter
July 8 The Language of Dermatology 1
July 15 Common Derm Conditions 1
July 22 Guest Lecturer --
July 29 Psoriasis-part 1 8
August 5 Psoriasis-part 2 8
later TeleDerm Case Reviews --
later CPC Reviews --
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Impact of TeleDerm Projecton Dermatology
Knowledge
Mean totals increased from 49.8 to 64.2!
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2. Structured Continuing EducationTwo types of
conference classes needed

• Providers
• Differential diagnosis
• Treatments
• Patient care plans
• MM cases-missed diagnosis or wrong treatments

Technicians Improving photo qualityHelpful
notes Labeling photos MM cases-photo quality
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Percent TeleDerm Classes Attended PCP and
TechsFirst 6 months/23 CBOCs
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2. Structured Continuing Education Annual
Training Conference

• Day 1- TeleMedicine and TeleDerm programs
• Day 2-Lectures from Dermatology experts
• Day 3-Skill Workshops

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3. Skills TrainingIntermediate and advanced
skills training with dermatology surgeon
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4. Provider Competency Assessment Diagnosis and
Treatment Skills
Youre right, Deanna! That IS a textbook case!
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5. Provider Competency AssessmentSurgical
Skills
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6. Focused Professional Practice Evaluations
(FPPE) and OPPE (increasing scope of practice)
Date completed Goal achieved or Passed Verified by Dr. Raugi/Lynne McFarland
Initial Site Training v
Pre-CME Dermatology Test v
Attendance for Weekly TeleDerm Telephone Class 50
Text-book Mid-term v
June VISN20 TeleDerm Summer Conference and Training Session v
Post-CME Dermatology Test
Dermatology Diagnosis Competency Final
Surgical Procedures Competency Final
Approved by each CBOCs Chair, Executive
Committee of the Medical Staff /Chief of Staff,
CP office
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Barriers Challenges

• Equipment tracking
• Need to increase engagement for weekly classes
• Scheduling shared classes over 3 time zones

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Future Goals Education

• Recruiting 6 new clinics
• Live Meeting Venue for Weekly VISN-wide classes
• More Intermediate to Advanced Surgical Skill
  Training
• Encourage DNA certification (Derm Nursing
  Association)
• Second Annual TeleDerm Conference in 2011

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Our main result is trained, competent,
independent healthcare teams providing
dermatology care to rural veterans!