Teledermatology making a difference in Waikato region
Telehealth is about using technology to enable new ways of providing health care when patients and care providers cannot be in the same place.
Waikato DHB dermatologist, Amanda Oakley, has been interested in using technology to provide teledermatology services since 1995.
“Consultations using technology started to gain momentum in the 1990s. In the US, teledermatology was an early telehealth adopter and it proved to be very effective. I was introduced to the concept in 1995 by Professor Richard Wootton, who is the current head of research at the Norwegian Centre for Integrated Care and Telemedicine. We joined the UK Multicentre Teledermatology Trials and demonstrated safety and efficacy of video conference consultations for dermatological diagnoses.”
Amanda says for telehealth to be effective, it needs to fill a gap that is currently not being met or not as well as it could be.
“New Zealand has very few specialist dermatologists and most people have some type of skin disease. An estimated one in six (15%) of all visits to the GP involves a skin problem. Access to dermatologists can be difficult. New Zealand has a very high rate of skin cancer, requiring expert diagnosis and treatment. The potentially dangerous skin cancer, melanoma, is particularly difficult to diagnose. Several DHBs don’t employ a dermatologist for skin lesion management. Dermatologists can reduce rates of unnecessary surgery, reducing costs and complications, and diagnosis can be made remotely using high quality dermatoscopic imaging.”
“Unfortunately skin cancer statistics are going to get worse due to increasing numbers of elderly people. Ageing skin is prone to skin cancer because of prior sunburns and everyday sun exposure and reduction in immunity. People are now more aware of the need to protect their skin from the sun than in the past, but for many the damage has already been done. We are also seeing skin cancers arising due to immune suppressive drugs.” says Amanda.
With Waikato DHB as a main sponsor, and on behalf of the New Zealand Dermatological Society, Amanda set up a dermatology website called DermNetNZ in 1995. “It became clear that consumers and health professionals needed reliable and accessible health information about skin conditions and their treatment.” DermNet NZ is now owned and managed by the DermNet New Zealand Trust.
Originally, Amanda set up the plain language site for patients but “it quickly became clear that our most loyal users are clinicians.” Over 50,000 people from all over the world visit www.DermNetNZ.org daily.
With increasing popularity of emails, GPs started sending clinical photos to Amanda and her fellow dermatologists, asking for advice about their patients with skin complaints. “This form of communication has disadvantages, including variable quality of information, insecurity, lack of archiving or follow-up, and intrusion into daily life even when on holiday. It’s also not reimbursed at either end. ”
Waikato District Health Board has also identified that people living in rural areas may not always have the access to specialist or primary health care:
- It takes longer and costs more for people to travel to hospitals and other health services.
- Attracting and retaining doctors and other health staff in rural areas can be more difficult.
- People in some rural areas can be poorer and more likely to face some health issues.
The Waikato DHB has a strong focus on connecting secondary and primary health care. Developments in technology, such as teledermatology, are providing opportunities to link rural facilities and rural health professionals with their colleagues in secondary and tertiary hospitals.
“Teledermatology improves access to specialist services. We can make accurate diagnoses and plan treatment just as effectively as face to face and in some cases more effectively. Teledermoscopy, a teledermatology service depending on dermoscopy—an instrument that magnifies and clarifies skin surface structures—reduces the cost and increases the sensitivity and specificity of melanoma diagnosis.”
"There are several options. In earlier years, some patients with skin diseases have consulted a dermatologist by video conference, reducing the need for face-to-face clinics at rural hospitals. This service has been particularly valuable in the follow-up and monitoring of patients with chronic inflammatory skin conditions on complex second-line medications. Video conferencing is not suitable for skin lesion diagnosis. We now use Waikato Hospital’s video conferencing equipment during a weekly academic and multidisciplinary meeting to enable participation by Taranaki Base Hospital’s new specialist dermatologist," says Amanda.
Waikato’s Virtual Lesion Clinic (VLC) is a teledermoscopy service that reduces the waiting time for patients with lesions suspicious of skin cancer to get an opinion from a specialist, and eliminates the need for 75% of referred patients to travel to the base hospital for treatment.
MoleMap New Zealand provides the imaging technology and software to support the VLCs. There are three models operating in the Waikato area.
- A MoleMap nurse provides the VLC service at a MoleMap clinic at Anglesea Clinic in Hamilton.
- Another MoleMap nurse provides the VLC at the public hospital in Thames.
- A hospital clinic nurse provides the VLC at the public hospital in Te Kuiti and covers patients from Taumarunui and surrounding areas as well.
The specially trained nurse records the patient documentation and takes several images of the lesions concerning the referring GP, including regional, close-up and dermoscopic views. Data is transferred securely to the MoleMap database, and downloaded for diagnosis by the dermatologist at a convenient time. The history and images for about 40 lesions in 20 patients are assessed each week in the Dermatology meeting room. This forum offers a unique opportunity to link patient care to specialist teaching in dermoscopy and is eagerly attended by medical and nursing staff keen to enhance their diagnostic skills.
The minority of patients who prove to have skin cancers can be brought to outpatient clinics for consultation or booked directly for surgery in a timely fashion. Each is referred to the specialist service most appropriate to their needs, with close collaboration between dermatology and plastic surgery departments. The GPs receive a report via HealthLink, with a copy to the patient.
Amanda says the virtual lesion clinics are a very efficient way to deliver skin cancer diagnostic service. We can provide a rapid lesion diagnostic service for the GPs, and significantly reduce unnecessary excisions of benign lesions. At the same time, we have freed up outpatient clinic time to see patients with inflammatory dermatoses. “Several GPs have also commented that they find the illustrated reports useful for their learning.”
MoleMap NZ provides the staff training and the technology. This has three components:
- The cameras to photograph the lesions
- The software to display the images and historical information
- The teledermatology platform, a cloud based service
Adrian Bowling, the CEO of MoleMap, says the virtual lesion clinics are a very efficient way to deliver dermatology services when there are not enough dermatologists.
“At the virtual lesion clinic, the image or images taken of lesions also provide a baseline record so follow-up photos can be taken later. “The image of the lesion is localised or mapped on a corresponding virtual model to make lesion identification easy at future appointments. At follow-up consultations, a health provider can select a lesion to re-image and compare directly with historical images, to easily identify changes.
“Follow-up images will document if the lesion remains stable or changes over time.”
Amanda says that skin cancers change over weeks to months, in size, shape, colour and structure, whereas the majority of benign skin lesions do not change at all. “Observing change in a minimally atypical lesion is one of the reasons we might decide to remove a lesion for pathological examination. Melanoma can be diagnosed at the earliest possible stage, when clinically it may appear the same as a harmless mole or freckle”.
“The patient’s usual health provider can also generate and save a patient report that includes lesion images, notes and location, which can then be imported into a patient’s electronic health record. So this process is greatly improves the patient’s individual dermatology health information,” says Amanda.
Having good visuals documentation is a MoleMap priority. Adrian says, "Taking high quality photographs that are useful for dermatologists requires the right camera, so that the lesion image is as clear as possible. Our camera, which is sold internationally, creates high contrast and gives better definition of the subsurface structures of pigmented skin lesions, allowing for more accurate diagnosis of melanoma."
Nicky Humphris has been the Te Kuiti virtual lesion clinic nurse for the last 3 years. She says her out-of-work passion in photography has been extremely useful. “It really helps that I am familiar with a wide range of cameras and know how to use lighting to get the best possible images. The camera is very easy to use. The tricky thing is that skin lesions are not often on a flat surface. The hardest places to photograph are the corner of the eye, the sides of the nose and in the folds of ears.”
Nicky says that the virtual lesion clinic gives nurses more skills and responsibilities. “It is a very useful and interesting work and it is making a real difference."
"The benefits for Te Kuiti patients, and patients in surrounding areas, are huge. No longer do they have to travel to Waikato Hospital for every appointment. “says Nicky.
About Waikato region
Waikato DHB serves a population of 373,220 (9.5 percent of New Zealand's population) and covers 21,220 square kilometres. It stretches from northern Coromandel to close to Mt Ruapehu in the south and from Raglan on the west coast to Waihi on the east. The district covered by Waikato DHB includes extensive rural areas, rural communities and small towns. In fact 60 per cent of Waikato’s population lives outside the main city of Hamilton. Waikato Region is the fourth largest region in the country in area and population size.
13.5 per cent of this country's Māori population live in Waikato Region. Its Māori population ranks second in size out of the 16 NZ regions.
Factors that help make Virtual Lesion Clinics successful
To have the virtual lesion clinic working well, Amanda Oakley says the following factors are essential:
- Having enthusiastic, well trained, nursing staff running the clinics
- Having high quality and appropriate equipment
- Having reliable data imaging and archiving software and secure networks
- Having the support of medical, nursing and administrative staff and management
- Being innovative and striving for improvement in processes
“The virtual lesion clinics reduce the need for dermatologists to travel to outreach areas and provide easy access for patients to be seen locally. They help primary care to access quicker diagnosis and treatment for their patients.” Amanda Oakley
Waikato GPs teledermatology web support
Amanda Oakley has also set up a web-based network via a charitable telemedicine organization, Collegium Telemedicus. This allows Waikato GPs to access informal advice from a dermatologist. The GP uploads their own photographs and patient information, and one of Waikato’s dermatologists provides advice, usually within hours of the request. Of 380 referrals over the last year or so, about one third were benign and malignant skin lesions.