Dermatology: Patient Safety Strategies for Telehealth

Susan Shepard, MSN, CPHRM, Senior Director, Patient Safety and Risk Management Education, The Doctors Company

When performing teledermatology examinations, these strategies can help reduce risks and keep your patients safe.

Remote Exam Limitations

Many types of dermatologic conditions lend themselves to the use of remote visual examination for diagnosis and management.¹ Certain conditions and patient circumstances—such as the location or type of lesion, unfamiliarity with or unavailability of remote technologies, or patient communication barriers—may, however, necessitate an in-person examination. It is important to know when to see your patient in the office setting—and that you can always request to see the patient in person.

Prepare the Patient

Educate your patient about remote exam techniques for dermatology. When asking patients to take photos or videos of their skin, provide them with instructions for using a cell phone to capture the images. The patient should provide the images prior to the telehealth visit. It is also a good idea to send the patient a preparation sheet that includes guidance about taking photos or videos. For example, instruct the patient to:

• Use natural light, face the window, and do not take photos or video with the light coming in from behind.
• Take photos or videos from multiple angles, close up, and from a distance.
• Use a ruler or another small object (e.g., a dime) next to the spot to help demonstrate size.

Your instructions should also include how to submit the photos and/or videos and the correct image size or format. It is helpful to have the patient include symptoms, such as itching, burning, pain, or changes in size, shape, or color.

If the examination will include a part of the patient’s body that is sensitive (i.e., the patient has to disrobe), you may want to have a chaperone available. It is essential that the patient does not record the visit. If you decide to record the visit, you must disclose it to the patient before the exam begins—particularly if the patient will need to disrobe.

As with an in-person office visit, obtain adequate diagnostic-quality images and the data necessary for making a diagnosis, differential diagnosis, workup (if appropriate), and treatment plan. Ensure you have the appropriate lighting when conducting the online exam, particularly with mucosal lesions.

Patient Relations

Be aware of who else may be in the room when talking with a patient. Assure the patient that the conversation with the clinician is confidential. To mitigate your own liability, prioritize privacy when determining where you will conduct the patient visit and what your patient will see around you. You and the patient should both be in private locations. Advise the patient of the risks of connecting from public places.

To help patients feel they are seeing you in a professional setting, wear your ID badge and usual office attire. Introduce yourself and use two identifiers to ensure that the patient you are seeing is the patient you are scheduled to see.

If a technical glitch occurs, call the patient to determine next steps. Telephone triage is better than a missed appointment that could lead to a delayed diagnosis. Calling the patient with updates to the plan eases the patient’s frustration and can mitigate clinician liability.

If, for any reason, your patient refuses to come in for further evaluation, clearly explain the potential risks of not performing an in-person examination. If the patient still refuses, document the refusal of care, and ask the patient to sign a refusal to consent form with a staff member as a witness. This can mitigate liability in case of an adverse event. See our sample form Refusal to Consent to Treatment, Medication, or Testing.

Additional Strategies

• Train your staff on the telehealth workflow.
• Educate each patient prior to the visit about what to expect and what will be expected of them.
• Consider scheduling a short visit for a technology check to ensure that the technology will work, answer questions, and obtain consent for the telemedicine visit.
• Document the visit, including the modality used, telehealth consent, and discussion regarding recording. Incorporate photos or videos, if appropriate.
• Verify consent for telemedicine with the patient at each subsequent visit.
• See in person the patients and conditions you need to see in person.

We offer additional resources to help you implement telehealth safely. For assistance, contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.

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