1. health and fitness

SPECIAL FOCUS ISSUE
04.2015
A Publication of the American Academy of Dermatology Association
Navigating Practice, Policy, and Patient Care
www.aad.org
TELEDERMATOLOGY
Ready for prime time?
+
07 Coding
12 Research
14 Legal Issues
16 Practice Management
44 Academy News
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in this issue
from the editor
VOL. 25 NO. 4 | APRIL 2015
DEAR READERS,
For those born in April,
the diamond is the birthstone.
PRESIDENT
PHYSICIAN EDITOR
Mark Lebwohl, MD
Abby Van Voorhees, MD
EXECUTIVE DIRECTOR
PHYSICIAN REVIEWER
Elaine Weiss, JD
Barbara Mathes, MD
PUBLISHER
Lara Lowery
EDITOR
Katie Domanowski
T
he name is believed to derive from the Greek word adamas which
means invincible. This stone has been an important symbol for millennia. In ancient medicine it was thought to have healing powers.
People were encouraged to heat this stone and sleep with it to draw
out various toxins in order to regain health. I like the idea that it was
thought to be invincible. Of late, though, the appearance of diamonds
has morphed. No longer just clear and crystal-like, all sorts of colors are
now seen — blues, browns, yellows, pinks. And so it has become more
versatile, appealing to those who favor a different look. I wonder where
all these colored stones were before? Were they simply discarded as not worthy? Were they
just not sellable and therefore overlooked? It makes me wonder what junk I have that one day
will become the next treasure. It also makes me think of telemedicine, a part of dermatology
that has been around awhile but is only now gathering steam.
This month the focus of Dermatology World is on teledermatology. Health care is changing
in many ways, and this is certainly one of the big ones for us. Our features review the history
of teledermatology and the prescient views of some of our own. Carrie Kovarik understood
its potential in serving those without care in Africa; Bill James saw its potential in serving the
underserved here at home via AccessDerm; Karen Edison and April Armstrong saw its role
in rural areas; the military saw its role in serving those in battle. They were not the only ones;
others were critical too. These early views demonstrated the potential of teledermatology. We
now see that it can allow for greater access to care in some settings and can offer flexibility for
those without access to a dermatologist. The lack of proper coding, legal supports, and insurance coverage have limited its use up to now, but a “climate change” is occurring with many of
these barriers coming down state by state. Even CMS is showing signs of moving the needle
on this. You will want to read each of our features which focus on different aspects of this
ground shift. We have also created a how-to video for those of you who want to get going; visit
www.aad.org/dw/monthly/april to watch it.
The traditional office visit is akin to that diamond — it is a lovely way to interact with patients. However, like the diamond, which has figured out how to appeal to those wanting color,
I predict our interactions with patients will broaden too. Teledermatology may be one tool that
will allow us to reach and care for more folks with skin disease. And I don’t know about you,
but that is why I became a dermatologist. Trust that you feel the same.
Enjoy your reading.
MANAGING EDITOR
Richard Nelson, MS
ASSISTANT MANAGING EDITOR
Victoria Houghton, MPA
DESIGN MANAGER
Ed Wantuch
EDITORIAL DESIGNER
Theresa Oloier
DESIGN TEAM
Nicole Torling
ADVERTISING SPECIALIST
Carrie Parratt
CONTRIBUTING WRITERS
Diane Donofrio Angelucci
Ruth Carol
Rachna Chaudhari
Hayley Goldbach
Susan Jackson
Clifford Lober, MD, JD
Alexander Miller, MD
Victoria Pasko
EDITORIAL ADVISORS
Lakshi Aldredge, MSN, ANP-BC
Annie Chiu, MD
Jeffrey Dover, MD
Rosalie Elenitsas, MD
John Harris, MD, PhD
Chad Hivnor, MD
Sylvia Hsu, MD
Risa Jampel, MD
Michel McDonald, MD
Christen Mowad, MD
Robert Sidbury, MD
Oliver Wisco, DO
Printed in U.S.A. Copyright © 2015 by the
American Academy of Dermatology Association
930 E. Woodfield Rd. Schaumburg, IL 60173-4729
Phone: (847) 330-0230 Fax: (847) 330-0050
MISSION STATEMENT: Dermatology World is
published monthly by the American Academy
of Dermatology Association. Through insightful
analysis of the trends that affect them, it provides
members with a trusted, inside source for
balanced news and information about managing
their practice, understanding legislative and
regulatory issues, and incorporating clinical and
research developments into patient care.
Dermatology World® (ISSN 10602445) is
published monthly by the American Academy
of Dermatology and AAD Association, 930 E.
Woodfield Rd., Schaumburg, IL 60173-4729.
Subscription price $48.00 per year included in
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ADVERTISING: For display advertising information
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2 DERMATOLOGY WORLD // April 2015
ABBY S. VAN VOORHEES, MD, PHYSICIAN EDITOR
www.aad.org/dw
HOT
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IN
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DERM12015CA
04.2015
A Publication of the American Academy of Dermatology Association
Navigating Practice, Policy, and Patient Care
features
www.aad.org
depts
02
FROM THE EDITOR
07
CRACKING THE CODE
“There’s
going to be a
convenience
factor that’s
going to drive
teledermatology
in a way that
you can’t match.”
How do changes in a
practice’s personnel
impact E/M coding?
10
ROUNDS
Pharmacy compounding.
12
ACTA ERUDITORUM
SPECIAL FOCUS ISSUE
18
THE FULL PICTURE
Experts detail the benefits and limitations
of teledermatology
BY VICTORIA HOUGHTON
4 DERMATOLOGY WORLD // April 2015
ANSWERS IN PRACTICE
42
DELIVERING ON THE PROMISE
2011 Ozzie Silver Award,
Best Redesign:
Association/Non-profit.
2014 Eddie Honorable
Mention, Association/
Non-profit video
16
Successfully integrating telederm into your practice
30
2013 HOW InHOWse
Design Award –
Cover/Feature Design
LEGALLY SPEAKING
How do you deal with an
employee you suspect of
embezzlement?
24
BY HAYLEY GOLDBACH
2011, 2012, 2013, and 2014
Graphic Design USA Award –
Cover/Feature Design.
2014 Graphic Design USA
American Web Design Award
14
Cybersecurity: Are you at
risk of being hacked?
STEPS TO TELEDERMATOLOGY
2014 AM&P Excel Bronze
Award, Design Excellence
Why does sun damage to
DNA continue hours after
exposure?
How dermatologists have found uses for
telemedicine — around the world and at home,
from rural areas to prisons to down the hall
BY DIANE DONOFRIO ANGELUCCI
FROM THE PRESIDENT
44
ACADEMY UPDATE
Election candidates,
more.
48
FACTS AT YOUR
FINGERTIPS
All eyes on dermatology.
36
READY FOR TAKEOFF?
Slow progress on teledermatology reimbursement
could accelerate
BY RUTH CAROL
www.aad.org/dw
cracking the code
coding tips
BY ALEXANDER MILLER, MD
How do changes in
a practice’s personnel
impact E/M coding?
ALEXANDER MILLER, MD, addresses important coding and documentation questions each month in Cracking the Code.
Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the
AMA-CPT® Advisory Committee.
ntuitively, one will have formed a concept as to who constitutes a new patient, who is empowered to evaluate the patient and bill individually for that evaluation, and how medical records should support the level of billing. However, what criteria should one follow?
The Current Procedural Terminology (CPT) and Medicare provide specific guidance.
A new patient is one who has not received any services from a physician or qualified non-physician practitioner — or, in a multispecialty group practice setting, from any physician of the same specialty and subspecialty — for the preceding three years. The corollary is
that if the patient has received services by any of the above individuals for the preceding three years, that patient is defined as an established patient. Note that whether the presenting problem is new or ongoing has no bearing upon the new patient/established patient decision making. The essence is whether the patient is new to the physician/qualified non-physician practitioner, and whether the patient
had been previously evaluated by a group practice physician of the same exact specialty/subspecialty within the preceding three years.
Who are the individuals empowered to individually provide evaluation and management services? They are state-licensed professionals practicing within their scope of practice and fulfilling the practice and license requirements as set forth by their individual
state’s laws:
• Physicians (MD, DO)
• Nurse practitioners
• Certified nurse midwives
• Physician assistants
The level of the evaluation and management service provided is determined by three principal features: history, examination, and
medical decision making. For a detailed review of the criteria utilized for determining levels of service provided, see the Medicare
Learning Network document “Evaluation and Management Services Guide” at www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/Downloads/eval_mgmt_serv_guide-ICN006764.pdf.
I
Example 1: A patient is assigned to see you in your multispecialty group practice for an evaluation of a diffuse rash that may be allergic in nature. She has already been evaluated by an allergist in the group two weeks prior, but is new to you, the dermatologist. You do
an appropriate evaluation and, as she is a new patient to you, you bill CPT 99203 for the new patient evaluation.
Answer: Correct. Although the patient was previously evaluated and treated by a physician in the group practice, you may bill for a new patient E/M code, as the patient is new to you and you are of a different specialty/subspecialty than the allergist. Commercial insurers may handle
the billing in their own proprietary manners, distinct from Medicare. Be aware of your individual private payer’s handling of such claims.
Example 2: You are in dermatology group practice. A patient new to you comes in for an evaluation of an established problem. She
was last evaluated two years ago by a dermatologist who has since left the practice. As the patient is new to you, you bill for an appropriate level of E/M new patient service, CPT 99202.
DERMATOLOGY WORLD // April 2015
7
cracking the code continued
coding tips
Answer: Incorrect. The patient received care from a same-specialty physician in the group practice within the preceding three years. The group
practice identifier and the less-than-three-year time interval between visits determine the new versus established patient status. The fact that the
previous practitioner has left the practice has no bearing upon the visit type determination.
Example 3: After several years working in a group practice you decide to leave the practice to join another group miles away. A patient
whom you had cared for in the first group trails after you and sees you for a new problem evaluation 2 ½ years after you had last cared
for him/her in the preceding group practice. The patient fills out new patient information, including a new patient history and review of
systems, and is entered into the new group practice’s records. As the patient is new to your group practice, you bill CPT 99203 for the
level of E/M provided.
Answer: Incorrect. The definition regarding new versus established patient status does not mention practice setting as a determinant for new
versus established patient status. Rather, an established patient is one who “has received professional services from the physician/qualified health
care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group
practice, within the past three years.” (CPT 2015) In this case, although the physician has moved to an unaffiliated, separate group practice, he/she
had cared for the patient within the preceding three years. Consequently, although the practice location had changed, the patient is not considered
new to the treating physician, and the office visit must be billed as an established patient E/M: CPT 99212-99215. Furthermore, the absence or
availability of the patient’s medical records from the previous practice does not influence the new versus established patient decision making.
Example 4: You, the dermatologist, are in a multispecialty group practice. A Medicare patient whom you had evaluated in the preceding three years comes in to be evaluated in your absence with a new problem and is seen by a nurse practitioner (NP) who works with
another dermatologist in the large practice. As the patient is new to the nurse practitioner, the visit is billed under the NP’s identifier as a
new patient E/M (CPT 99201-99205) and the practice is reimbursed at 85 percent of the Medicare fee schedule.
Answer: Incorrect. The nurse practitioner is considered to be an extension of the specialty/subspecialty of the physician with whom the NP works.
In this case, the NP works with another dermatologist in the practice. Therefore, as the patient had been seen by a dermatologist in the practice
in the preceding three years, the visit is considered to be an established patient visit. The CPT supports such an interpretation: “When advanced
practice nurses and physician assistants are working with physicians, they are considered as working in the exact same specialty and exact same
subspecialties as the physician.”
Example 5: Your dermatology practice is covering for an outside dermatology practitioner during his/her absence. A patient who was
last seen one year ago by the absent dermatologist is referred from the absent practitioner’s office for evaluation of a new problem. You
have the patient fill out a new patient data form, treat the patient, and bill for a new patient visit, CPT 99203.
Answer: Incorrect. Although you have never before seen this patient, the encounter is treated as it would be if the patient were seen in the covered
dermatologist’s office. Since the patient last saw the absent dermatologist within the preceding three years, you must bill for an established patient visit.
Example 6: You are a Mohs surgeon. A patient new to you is referred by one of your group practice’s general dermatology colleagues. You
evaluate the patient, determine an appropriate need for Mohs surgery, and schedule the patient for surgery. Although your Mohs surgery
subspecialty is distinct from the referring physician’s general dermatology specialty you bill an established patient visit, CPT 99213.
Answer: Correct. Although the patient is new to the Mohs surgeon, he/she is not new to the practice, which is defined by the group practice NPI
and Tax ID number. Medicare will adjudicate your claim submission based on your primary specialty taxonomy code, NPI, and Tax ID number.
Subspecialty categories of practice that have different taxonomy codes under the NPI, such as general dermatology and Mohs surgery, do not clearly
determine primary subspecialty status. In order to be able to bill for this scenario as a new patient encounter, your primary specialty must be listed
as Micrographic surgery — taxonomy code 207ND0101X — in the Medicare database to distinguish the difference in expertise that allows for you
to bill the new patient encounter code. Commercial payers, on the other hand, do not have the capability of identifying primary and/or subspecialty
taxonomy codes. In this case, the encounter will be adjudicated based on the group practice NPI and Tax ID number, hence an established patient
code would be appropriate. dw
8 DERMATOLOGY WORLD // April 2015
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rounds
news in brief
State compounding
bills advance while FDA
gradually implements Drug
Quality and Security Act
STATE NEWS ROUNDUP
n the fall of 2013, Congress passed the Drug Quality and
Security Act (DQSA) in response to the dozens of deaths
and hundreds of infections that occurred across the U.S. as
a result of contaminated injectable steroids produced by the
New England Compounding Center. The law allows the FDA to
regulate and monitor the use and development of compounded
drugs. However, the FDA has interpreted the law to not allow
for in-office or anticipatory use of compounded products in
physician offices. The AADA is concerned that this interpretation will restrict patient access to commonly used dermatologic non-sterile compounded products, and jeopardize public
health, as limited or delayed access to these necessary treatments could result in increased patient morbidity and health
care expenses.
The AADA maintains that drugs, specifically non-sterile drugs, prepared for office use from traditional compounding pharmacies,
should continue to be regulated by the individual states. Numerous states have taken up legislation on their own while the FDA gradually
implements the DQSA. The AADA continues to monitor state activity on in-office use and other provisions affecting patient safety and
access.
HB 1737 in Virginia would allow for the outsourcing of compound drugs at both in-state and out-of-state facilities. Further, it would allow pharmacists to compound drugs in advance of prescriptions based on a routine, regularly observed prescribing pattern. The legislation
passed the House and has been referred to a committee in the Senate.
Maryland HB 181 would repeal certain in-office-use provisions of the Maryland Pharmacy Act — legislation that passed in 2013 that
would have made it impossible for many dermatologists to provide necessary compounded medications to their patients in a timely manner. The bill specifically repeals multiple requirements for obtaining a sterile compounding permit. This bill passed the Maryland Senate
without objection.
Nebraska LB 37 would adopt the comprehensive Prescription Drug Safety Act that, among other provisions, allows pharmacists to compound drugs in advance of prescriptions based on an established routine between the practitioner, patient, and pharmacist, or for office
use only. The bill is under final review in the Nebraska unicameral legislature.
HB 3161 in South Carolina would revise established compounding practices to include more patient protections. The bill would also
authorize physicians who administer compounded medications in an office setting to order and purchase those medications directly from
the compounding pharmacy. Additionally, the bill would allow the physician to store the medications in their office for future use but not
for resale, and to administer those medications according to their usual physician/patient/pharmacy practice relationship. The legislation
would not require a prescription for an individual patient for each administration of the drug. – VICTORIA PASKO
I
10 DERMATOLOGY WORLD // April 2015
www.aad.org/dw
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acta eruditorum
Why does sun
damage to DNA
continue hours
after exposure?
IN THIS MONTH’S ACTA ERUDITORUM COLUMN,
Physician Editor Abby S. Van Voorhees, MD, talks with
Douglas Brash, PhD, about his recent Science article,
“Chemiexcitation of melanin derivatives induces DNA
photoproducts long after UV exposure.”
Q&A
DR. VAN VOORHEES: What do we know
about the mutations that are seen in suninduced melanomas? What is the UV
signature?
DR. BRASH: Melanomas on sun-exposed
skin have acquired mutations in many
genes. Most of these mutations are
“UV signature” mutations — cytosine
mutating to a thymine at a location where
cytosine’s neighbor was a thymine or
another cytosine. The only carcinogen that
makes this kind of mutation frequently is
ultraviolet light, implicating sunlight as the
mutagen.
Ultraviolet light also makes less
specific mutations, with about a quarter of
its mutations being indistinguishable from
those made by other carcinogens. So if we
see UV signature mutations in a tumor,
then many of the other mutations must
have been caused by UV too. For example,
the famous BRAF mutation in melanoma
is not a UV signature mutation but it
might yet have been caused by UV; we just
can’t tell.
DR. VAN VOORHEES: Tell us about CPDs.
What cell are they derived from? What
about the timing of when they are formed?
The cell of origin? Are they created by
exposure to both UVB and UVA? Is there a
genetic disorder that closely correlates?
DR. BRASH: When two neighboring
pyrimidine bases (that is, cytosine or
thymine) absorb a UV photon, their double
bonds rearrange within a picosecond and
join the two bases together. The resulting
cyclobutane pyrimidine dimer (CPD) puts
a bend in the DNA that makes it difficult
for the cell to copy its DNA correctly.
When a person goes to the beach, many
CPDs are created in every cell of the skin.
Fortunately, a DNA repair system called
excision repair removes most of the CPDs
and replaces them with normal DNA.
12 DERMATOLOGY WORLD // April 2015
www.aad.org/dw
research in practice
Xeroderma pigmentosum patients lack
one or another of the genes required
for excision repair, so children with XP
have a 10,000-fold greater incidence
of skin cancer. UVB is much better
than UVA at making CPDs in purified
DNA, but UVA penetrates deeper into
the skin and there is 20 times more
UVA in sunlight.
DR. VAN VOORHEES: Are some CPDs
more important in causing this
genetically altered signature?
DR. BRASH: The most frequent CPD is
the one that joins two thymines, a “TT
CPD.” It causes cell death. But the UV
signature mutations are caused by the
less frequent TC and CT CPDs.
DR. VAN VOORHEES: Explain to us what
you learned about how this occurs
scientifically in melanin-containing
cells.
DR. BRASH: In cells containing
melanin, the events described above
still happen, although about half as
often because the melanin acts as
a shield by absorbing much of the
UV. As we expected, CPDs could be
measured as soon as the UVA or UVB
lamp was turned off. The surprise was
that, when melanin was present, CPDs
continued to be made for another three
to four hours — ultimately as many or
more than were created initially by the
standard route.
What happens turned out to be
a three-part story. First, UV activates
two enzymes; one normally makes an
oxygen free radical, superoxide; the
other makes a nitrogen free radical,
nitric oxide, that is widely used in the
cell as a signaling molecule. This is the
slow step that can continue for several
hours. These reactive molecules
combine to make peroxynitrite, a very
strong oxidizing agent that initiates
a chemical reaction that ultimately
excites an electron in a fragment of
melanin. Most chemical reactions in
the cell instead increase a molecule’s
vibrational energy so that it can react
with other molecules. The electron
reaches a high energy usually only
possible after ultraviolet radiation
exposure. If DNA happens to be
nearby, this energy is transferred to
the DNA in the dark, creating the
same CPD that sunlight causes in
daylight. Chemically induced electron
excitation is called “chemiexcitation”
and was previously encountered only
in bioluminescent lower organisms
such as jellyfish and fireflies.
Why would nature do this? There
seems to be a balance between
“melanin is good” and “melanin is bad,”
with dark eumelanin having a better
ratio than yellow pheomelanin. There
might be a perfect sunlight absorber
out there, but melanin is the best that
evolution came up with. It is better than
no melanin at all, particularly at young
ages because evolution does not care
about cancers that arise after the childbearing years. The imperfect melanin
strategy does serve to spread the CPDs
out over time, which may be better than
occurring all at once during the sun
exposure and possibly overwhelming
the DNA repair system.
skin cancer, so melanin has a net
benefit. It is less clear to me what the
melanoma incidence is in albinos.
Published studies may not have
examined enough albino and matched
pigmented individuals to detect a
difference unless it were an increase
and were greater than seen for nonmelanoma skin cancer.
DR. VAN VOORHEES: What is the
implication of this work to the
practicing dermatologist? Is melanin
both protective and potentially
carcinogenetic? Does this work
suggest possible future treatments to
prevent melanomas?
DR. BRASH: While this may have
been evolution’s best solution, it
doesn’t have to be ours. The delayed
pathway should be interceptable at
several points: preventing enzyme
activation, scavenging free radicals and
peroxynitrite, and diverting the energy
from the excited electron into heat
before it can transfer to DNA. dw
DR. BRASH is professor of therapeutic radiology
and dermatology at Yale School of Medicine. His
article appeared in the February 20, 2015 issue
of Science. Vol. 347 no. 6224 pp. 842-847
DOI: 10.1126/science.1256022.
DR. VAN VOORHEES: What about
in albino skin — how does this
mechanism apply in this situation?
DR. BRASH: Albino individuals
have a higher frequency of actinic
keratoses and non-melanoma
DERMATOLOGY WORLD // April 2015
13
legally speaking
BY CLIFFORD WARREN LOBER, MD, JD
How do you deal
with an employee
you suspect of
embezzlement?
EVERY MONTH, DERMATOLOGY WORLD covers legal issues in “Legally
Speaking.” Clifford Warren Lober, MD, JD, presents legal dilemmas in
dermatology every other month. He is a dermatologist in practice in
Florida and a partner in the law firm Lober, Brown, and Lober.
I
t’s a bright, sunny afternoon and Bryan,
who has just returned from lunch, is
interrupted by his receptionist who tells
him Lonnie is on the telephone. Lonnie
is evidently quite upset and believes that
his office manager is stealing money from
the practice. Bryan picks up the telephone
and begins the conversation.
Bryan: Hello, Lonnie! How are you?
Lonnie: I’m really upset, Bryan. I think
that my office manager, Sara, who has
been with me for over 15 years, has been
stealing money from my practice! I
thought that she was a great employee,
since she has always been the first one to
arrive in the office in the morning, the last
to leave in the afternoon, and only rarely
takes vacation or sick leave. At the end of
every day she takes all of the checks and
cash we receive and deposits them in the
bank. Sara checks the credit card and bank
statements when they arrive every month.
She’s really efficient!
Bryan: Why do you think she is stealing
money?
Lonnie: After several patients complained
that they received bills from my office that
they had already paid and after receiving
a notice from the IRS for non-payment of
taxes, I asked our front desk receptionist
to keep a record of the amount of money
she gave Sara to deposit every day. When I
checked with the bank, only part of it was
actually deposited.
Bryan: If your suspicion is correct, Sara
may be guilty of embezzlement.
Lonnie: Isn’t that simply stealing?
Bryan: That depends upon state law.
In some states, criminal statutes treat
embezzlement as theft. Usually, however,
embezzlement is a distinct crime in which
several factors have to be present. First, the
14 DERMATOLOGY WORLD // April 2015
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legal issues
property must have belonged to someone
other than the accused. In this case, the
money clearly belonged to you or your practice, not Sara. Secondly, the accused usually
must at some point have been in lawful
possession of the property. Since Sara is
your office manager and charged with handling the money received, she was certainly
in lawful possession of your money when
your receptionist gave it to her to deposit.
Lonnie: Why is it so important that she
was in lawful possession of the money?
Bryan: Because if you accuse someone
of embezzlement who was not in lawful
possession of the money at some point
in time, you may be accusing them of the
wrong crime.
Lonnie: Are there any other requirements
for someone to be accused of embezzlement?
Bryan: Yes. Many states require that the accused be in a position of trust. In this case,
your office manager has a fiduciary duty
to safeguard the practice’s money. Finally,
the accused usually must have intended to
defraud the lawful owner.
Lonnie: How can you prove what Sara
intended to do? Can’t she simply say she
intended to put the money back?
Bryan: Although she may say anything she
wants, that defense usually does not hold
up in court. Are you aware of any significant changes in Sara’s life? For example,
are you aware of a financial or health crisis
in her family? Is anyone in her family addicted to drugs, alcohol, or gambling? Significant changes in an employee’s personal
circumstances may be associated with an
increased likelihood of embezzlement.
Lonnie: No, Bryan. I am not aware of any
such circumstances. Incidentally, what is
the punishment for embezzlement?
KEY POINTS:
1 To prove the crime of embezzlement, it usually must be proven the
property in question initially belonged to someone other than the accused,
that the accused at some point in time had been in lawful possession of the
property and in a position of trust, and that the accused had the intent to
convert the property to his/her benefit.
2 Indications of possible embezzlement include overly dedicated employees
who always arrive first in the morning, leave last in the afternoon,
and rarely take vacation or sick leave, who have sole oversight of
office finances, and those who have a significant change in personal
circumstances (such as a major illness or addiction in the family).
3 Penalties for embezzlement, which usually depend upon the amount and
type of property converted, usually involve restitution as well as fines or
imprisonment.
4 To avoid embezzlement, personally examine all bank and credit card
statements. No single person in your office other than you should have
exclusive daily oversight or control of the practice’s finances. If you have a
signature stamp, get rid of it and insist on signing all checks over a nominal
value yourself.
5 If you are suspicious that your practice has been embezzled, contact your
attorney.
Bryan: Depending upon the value of the
property or money taken, embezzlement
may be a misdemeanor or a felony. Penalties usually involve making restitution to
the victims as well as fines and possible
imprisonment. Several states impose
additional or harsher penalties for the
embezzlement of particular items, such as
firearms. They may also do so when certain classes of victims, such as the disabled
or elderly, are involved.
Lonnie: What should I do now?
Bryan: Effective immediately, you must
look at all bank and credit card statements
yourself. Your receptionist should tell you
every day the amount of money that is to
be deposited and it should correlate with
your bank receipts. You should revoke
Sara’s access to the practice’s deposits
and bank accounts and have new account
numbers generated. If you have a sig-
nature stamp, get rid of it and insist on
signing all checks over a minimal value
yourself. I will contact your CPA and initiate an audit of the practice. You need to
place Sara on paid leave immediately. If
the audit confirms that she has embezzled
the practice, you will need to terminate her
employment.
Lonnie: Thanks, Bryan!
If you have any suggestions for topics to be
discussed in this column, please e-mail them
to me at loberc@gmail.com. See the February 2013 issue of Dermatology World for
disclaimers. dw
DERMATOLOGY WORLD // April 2015
15
answers in practice
BY RACHNA CHAUDHARI
Cybersecurity:
Are you at risk
of being hacked?
EACH MONTH, DERMATOLOGY WORLD tackles issues “in practice”
for dermatologists. This month Rachna Chaudhari, the Academy’s
practice management manager, offers tips on an area she
commonly receives questions about from members.
16 DERMATOLOGY WORLD // April 2015
A
s electronic security breaches become common headlines in today’s news, dermatologists should be especially aware if they have
electronic health records (EHRs) in their
practice. North Korean hackers may not be as interested in your practice’s medical records as they are
in Sony’s internal emails, but other nefarious hacking entities have already struck dermatology offices.
A dermatology practice in North Carolina was hit
with a malware attack by a hacker in 2012, but it did
not become aware of the infraction until September
2014. In that amount of time, the hackers gained
access to patient information including names,
Social Security numbers, and billing information,
among other identifiers. A small surgery practice
(non-dermatology) in Illinois was hacked in 2012;
they were informed that they would not gain access
to their servers until they paid a ransom to the
hackers. They refused and lost access to all of their
medical records.
Hacking patients’ medical records may not be
the only way your practice faces a potential privacy
breach. The Health Insurance Portability and Accountability Act (HIPAA) requires that practices
institute internal security controls to effectively prevent breaches from occurring and that they implement notification policies in case of a breach. The
Department of Health and Human Services (HHS)
publishes information about breaches that occur on
its website, and reports have found that 23 percent
of these breaches were due to hacking while 68 percent were due to devices or files being lost or stolen.
In fact, a dermatology practice in Massachusetts
faced one such scenario and had to pay a $150,000
fine to HHS for losing an unencrypted thumb drive
which contained patient medical records (for more
information, see the Jan. 31, 2014 issue of Member
to Member at www.aad.org/members/publications/
member-to-member).
What can a small private dermatology practice do
to prevent a breach from occurring and mitigate the
damage if one does? First, determine if your EHR is
cloud-based or server-based. Having a cloud-based
EHR has many advantages; however, you could be
more susceptible to online hackers through this
system. You should confirm with your vendor how
they prevent malware attacks and what you can do
to lessen any breaches to your system. If you have
a server-based EHR, ensure you have the proper
physical safeguards in place, such as encrypting
www.aad.org/dw
management insights
analysis, fix any underlying problems and
implement policies to address them. For
example, ensure employees are not using
their personal email accounts to send protected health information (PHI); instead,
they should be sending this information
through the EHR’s secure HIPAA-compliant electronic exchange.
Other simple steps you can take to
ensure data security in your office include
installing antivirus software, applying
security patches and security updates to any
programs connected to the Internet, and
installing proper firewalls to your system.
Your EHR vendor can help you determine
which firewalls need to be in place. Also,
look into installing software that can disable
access to PHI on any devices that are taken
out of the office by staff. This would guar-
VISIA®
back-up files and locking rooms that have
access to the server. Additionally, regardless
of the type of system you have, make sure
your wireless Internet is protected through
a strong password that cannot be easily
breached. Your system should be encrypted
to the latest standards.
Another important step you should take
in preventing the loss of PHI is administering a security risk analysis on your
system. Both HIPAA and the meaningful
use program require that you perform this
on an annual basis, and it would serve your
practice well to perform this on a more
consistent basis. The Office of the National
Coordinator for Health IT has a helpful
toolkit explaining this analysis at www.healthit.gov/providers-professionals/securityrisk-assessment. Once you complete your
®
IntelliStudio®
VEOS®
Reveal®
HAND-HELD 3D CAMERA
antee that your patients’ PHI would not be
accessible if the devices were lost or stolen.
If you have taken these steps to secure
your PHI, but you find yourself in a situation where your data has been hacked,
what should you do? At a minimum, you
must report the breach to your patients
and to HHS at www.hhs.gov/ocr/privacy/
hipaa/administrative/breachnotificationrule/brinstruction.html. If the breach
affected more than 500 patients, you must
also post a notice in major print or broadcast media within 60 days. You can also
expect a response from HHS in the form
of a HIPAA audit. It will be extremely
important that you maintain documentation of all your safeguards and security risk
analyses if you face such an audit. dw
innovative
3D imaging
www.canfieldscientific.com
info@canfieldsci.com | +1.973.276.0336
DERMATOLOGY WORLD // April 2015
17
THE FULL
PICTURE
Experts detail the benefits and limitations
of teledermatology
18 DERM
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www
w.aad.o
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BY VICTORIA HOUGHTON, ASSISTANT MANAGING EDITOR
ary Maloney, MD, chief of the division of dermatology at the
University of Massachusetts, remembers the first time she
did a teledermatology consult. “I received a picture of a huge
spot that had turned black. I took one look at it and thought it was a
melanoma so I got the patient in,” Dr. Maloney said. “It ended up being
a nice big seborrheic keratosis — completely benign.” In hindsight, Dr.
Maloney realized that the image that was sent to her was taken too
close-range and there was no side-lighting to determine if the spot was
raised. At the time, this experience left a bad taste in her mouth. “I got
put off from telemedicine thinking that I wasn’t going to be able to make
good diagnoses.”
M
At first blush, telemedicine appears to be an uncomplicated practice.
An image of a patient’s ailment or concern is sent to a dermatologist
via the patient or a referring physician, or a patient is seen through a
video conferencing system. The dermatologist offers a diagnosis and,
when applicable, a treatment plan. However, as more dermatologists
dip their toes in telemedicine, some of the practice’s drawbacks
are becoming more evident. Yet, despite her first encounter with
teledermatology, Dr. Maloney’s impression of telemedicine has
improved and she still accepts images from her existing patients. >>
DERMATOLOGY
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19
THE FULL
PICTURE
“I have changed my mind in that if you get good
pictures, you get good thoughts that go with them,”
Dr. Maloney said. Nonetheless, “There are still some
problems with it that I have found. It’s a little bit of a
mixed bag.” Like Dr. Maloney, many dermatologists
are finding that successful implementation of
teledermatology is dependent on many factors. As
such, while the telemedicine movement appears to
be moving full steam ahead, physicians are weighing
the drawbacks of this type of care against the potential
benefits that it can yield.
ACCESS TO CARE
One of the original and current motivations behind
the use of teledermatology is granting patients access
to dermatologic services who otherwise couldn’t visit a
board-certified dermatologist in person. The Academy
launched its volunteer teledermatology program,
AccessDerm, in 2009 in an effort to provide care to
underserved populations in the United States. Through
AccessDerm, participating primary care physicians
can submit images for consultation to volunteer
dermatologists licensed in their state through a secure
Web platform — also known as store-and-forward
telemedicine. Julie Lin, MD, assistant professor of
medicine at the University of Vermont Medical Center,
started utilizing AccessDerm in hopes that its use
would improve patient access. “We started it as a way to
provide access to dermatologic care because we are the
only academic medical center in the state of Vermont.”
According to Dr. Lin, there are 20 dermatologists in the
entire state and 13 of those are in the Burlington area
where the medical center is located.
Beyond Vermont, access concerns span the
nation, and as a result AccessDerm — which is
available in 20 states — is looking to expand. Some
of Dr. Maloney’s patients travel up to two hours to
receive her care. But it’s not just pure mileage that
creates these access barriers. Patients in large urban
areas can endure the same access problems as those
in remote areas of the country. “In New York City
it could take an hour and a half to get to an office.
This could be the same time as it takes in South
Dakota,” Dr. Maloney said. “There’s good rationale for
telemedicine wherever we are.”
Access issues can also arise from the lack
of adequate health coverage. April Armstrong,
MD, MPH, chair of the American Telemedicine
Association’s Teledermatology Special Interest Group,
can attest to this. “I’ve seen situations where there are
dermatologists in a community but they will not take a
certain type of insurance. Even though the patients are
in certain proximity, they don’t have access. These are
the precise communities where people can’t afford to
take time off and travel long distances. Telemedicine is
one of the few ways they can get access.”
20 DERMATOLOGY WORLD // April 2015
CARE MANAGEMENT AND COORDINATION
On the other hand, telemedicine may also prove
beneficial for the patients who do have adequate
health insurance and can take the time to travel to a
physician’s office. Because telemedicine allows the
physician to triage patients who need to be seen in
person — and those who don’t —those who should
be seen in person will experience shorter wait times.
“My hope is it will diminish the number of visits for
benign lesions and therefore allow increased access
for other people,” Dr. Maloney said. Karen Edison,
MD, deputy chair of the Academy’s Telemedicine
Task Force, adds, “We all know in dermatology that if
a patient can have access to your expertise early in the
disease process, they do better. If patients don’t have
access to our expertise, they may be misdiagnosed
several times.”
In addition to improving diagnosis times,
telemedicine is often considered an efficient method
for caring for wounds in patients who have had
serious treatments. As a surgeon, Dr. Maloney
often gets follow-up images with questions such
as, “is this the way it’s supposed to look?” and “is it
infected?” “It’s also very helpful for middle-of-thenight consultations if a patient is having a problem.
All of that is helpful and it’s good that we can offer
that.” Dr. Maloney also finds that telemedicine allows
her to work more seamlessly with her dermatology
peers. Often Dr. Maloney’s patients will go back to
their referring dermatologist to remove the sutures
from the procedures she performed. “It’s easy for the
referring dermatologist to snap a picture and say ‘is it
okay to take the stiches out? What do you think?’” Dr.
Maloney said. “They can also snap a picture in three
months and say, ‘do you think that scar is as good as it
can get?’”
In the same vein, Dr. Edison adds that
telemedicine offers the opportunity to work more
closely with colleagues in other specialties. “It’s a
benefit to our primary care colleagues because when
they have a question about a dermatology issue
with their patients, they want to know what’s going
on at the point of care. It doesn’t help them much
educationally to get a letter six weeks later,” Dr. Edison
said. “If we can begin to be available to our colleagues
at the point of care, I think our value to them will go
up exponentially.” As such, telemedicine could help
physicians interested in providing more consults in the
hospital setting while alleviating the perception that
dermatologists are not typically available or interested
in serving in hospitals. “Hospital consultations have
become difficult for many practicing dermatologists
— in terms of transportation and the time it takes
to find the patient and find out the information on
that patient. You may live in an urban area with five
hospitals and five different EHRs,” Dr. Edison said.
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“This has really hurt us because we’ve been seen as
unwilling to see patients who need to be seen in the
hospital. I believe that teledermatology can work for
hospital consults.” In an effort to demonstrate this, the
AAD offers a pilot program, Inpatient TeleDerm, that
provides dermatologists with a platform for offering
hospital consults. Contact Kristina Finney for more
information at kfinney@aad.org.
FLEXIBILITY
Hospital consults aside, dermatologists are grappling
with full patient loads of their own. Coupled with
increasing administrative burdens from required
health care programs — such as EHR meaningful
use, quality measure attestation, and Maintenance of
Certification requirements — physicians’ schedules
are stretched. However, some argue that telemedicine
can ease the time constraints of the day, allowing
for a greater work-life balance. “I can see cases from
anywhere at any time,” Dr. Armstrong said. “So it
affords a lot of flexibility in terms of work hours and
schedule.” Bob Durst, MD, chair of the Academy’s
Advisory Board, adds, “It’s difficult to raise a family
and work, but with teledermatology you could have
your kids at home and when you put them down for
a nap you could do a couple of hours of telemedicine.
There’s going to be a convenience factor that’s going
to drive teledermatology in a way that you can’t
match.”
Ultimately, however, Dr. Armstrong believes that
telemedicine offers the new, tech-savvy patient a form
of flexible health care delivery that is more comfortable
for them to utilize. “Our health care consumers are
changing. There are newer patients in the pool who do
everything online. If we look at patients in their teens,
20s and 30s and beyond, many of them do everything
online — shop, bank. They’re comfortable with the
technology.”
Kaiser recognized this trend and has been offering
the telehealth option to its beneficiaries for several
years, where patients and primary care providers
can send secure email images of their conditions
to a specialist. According to Jeffrey Benabio, MD,
physician director of healthcare transformation
at Kaiser Permanente, teledermatology not only
improves patient access and wait times, it allows
the patient to be seen on their turf and their terms.
“Teledermatology improves access to care and enables
physicians to diagnose patients more efficiently, so
patients can get the care they need more quickly,” Dr.
WEIGHING UP
Telemedicine is quickly evolving into a budding option for delivery of health care.
While many consumers are sold on its benefits, some physicians may still be weighing
the advantages and limitations of utilizing teledermatology in their practices. Experts
boil down the pros and cons of telemedicine to the following:
POSITIVE
+ Increased access for patients who
cannot travel/have inadequate
insurance
+ Improved wait times for
in-person visits
+ Efficiency in care management and
coordination among physicians
+ Improved physician work-life balance
+ Better customer service for patients
increasingly utilizing technology
NEGATIVE
- Reduced efficiency due to unreliable
technology
- Potential for HIPAA violations,
documentation issues
- Inappropriate for many patients –
especially high-risk or health illiterate
- Limitations with physician diagnosing
capabilities – psychological, vision,
smell, touch
- Potential shift in practice and value
of dermatology
DERMATOLOGY WORLD // April 2015
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Benabio said. “It’s also an easy and convenient option
to provide care when and where a patient wants it.”
GLITCHES
Regardless of many patients’ preference to conduct
their personal activities online, experts don’t deny
the inevitable difficulties associated with the use of
technology. “With live interactive teledermatology,
there can be issues with dropped connections which
can be problematic because you are in a consultation
with a patient that depends on a secure connection,”
Dr. Armstrong said. “The other aspect is storeand-forward teledermatology which is dependent
on the image quality. Depending on the resolution
of equipment as well as the bandwidth of the
connection, some of the images can be blurry.”
Indeed, in its position statement on
teledermatology, available online at www.aad.org/
Forms/Policies/ps.aspx, the American Academy of
Dermatology recommends that all images have a
minimum of 800 x 600 pixel (480,000) resolution.
Additionally, for live, video conference consultations,
the connection speed should be above 384 kbps so
the images are not blurry. “Our phones have just
about the same computing capability as the Mercury
spacecraft did, which gives us tons of resolution with
pictures, and we shouldn’t discount the pictures that
people take with an iPad or iPhone. They really are
quite brilliant and a tremendous asset,” Dr. Maloney
said. However, “The colors may not come through
like you want them to. Something could look redder
or less red depending on the quality of the picture.
If the camera is held too close and there’s a brilliant
flash, it could wash out all the color.”
Technology notwithstanding, participants in
telehealth will note that not every patient or referring
physician is a trained photographer or videographer.
“For me, people who are used to taking medical
pictures do a much better job,” Dr. Maloney said.
“The pictures can be brilliant and very helpful and
can help in deciding how to manage a tumor as well
as deciding whether there’s a complication. The
pictures the patients take are not as useful.” Dr.
Edison agrees. “The photos have to be of high quality
so people have to be trained to take them in a highquality way.”
LEGAL IMPLICATIONS
All told, just as it is with in-person consultations, the
utilization of telemedicine does not come without
significant liability considerations. “There’s a huge
risk. The greater risk is when we take the pictures
and lose our phone. We need to be careful to clean
it off our phone,” Dr. Maloney said. “We’re also best
served if we keep them off our personal computers.
So if it’s stolen we don’t have to worry that we had
22 DERMATOLOGY WORLD // April 2015
that photo on there. Of course, we have to have
secure places to keep our photos, so they do need
to go in the medical record.” As for in-person visits,
failure to ensure HIPAA compliance with images
transferred via technology could result in civil and
criminal penalties. Failure to keep that image for
documentation purposes could result in issues filing
insurance claims.
Rob Portman, health care attorney with Powers
Pyles Sutter & Verville and general counsel for the
American Academy of Dermatology/Association,
also notes that there’s a critical distinction between
a formal and informal telemedicine consultation.
“There’s telemedicine that’s done through hospitals
and certified equipment, and then there’s sharing
pictures over your iPhone. Make sure you’re using
equipment that meets industry standards and
be very cautious of providing telemedicine in an
informal way,” Portman said. “It’s risky to give
medical advice without being able to clearly see the
patient; dermatologists should make sure they’re
using equipment that meets quality and HIPAA
standards and that they have a good photo to review.
Dermatologists should also be wary of treating
new patients via teledermatology unless referred
by another physician who can provide sufficient
history to make a diagnoses.” Read more from
Portman about the legal implications associated
with telemedicine, in Dermatology World’s January
2015 Legally Speaking column at www.aad.org/dw/
monthly/2015/january/dealing-with-patient-images.
THE MISSING PIECES
Even if the photographer takes a secure, high-quality
image of the issues at hand, and the technology
is in perfect working order, physicians remain
concerned that teledermatology — particularly storeand-forward — has the potential to omit critical
information about a patient. “Everyone has a couple
of concerns when they start to do this,” said Alexa
Kimball, MD, MPH, professor of dermatology at
Harvard Medical School and medical director for
the Massachusetts General Physicians Organization.
“One is: am I going to miss something because I
can’t do a full-body skin exam? The second is: am I
getting good enough information if I’m not directly
having an interaction with the patient? The better
information you have, the better you’re going to be.”
Fortunately, Dr. Armstrong indicates that a
number of studies have determined that clinical
outcomes are no different between patients who
are receiving teledermatology care and those who
receive face-to-face care (J Am Acad Dermatol,
67(4):576-581; JAMA Dermatol. doi:10.1001/
jamadermatol.2014.2299). However, Dr. Armstrong
recognizes that with teledermatology, in order to
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maintain the same outcomes as in-person visits,
the physician will often have to look for more than
just what is presented by the patient. For example,
if a patient has a rash on one hand it could be hand
dermatitis or superficial fungal infection. However,
the dermatologist won’t know what it is unless they
have the picture of the opposite hand and the feet.
“If they had that picture and that hand is clear, the
likelihood that it is dermatitis is low,” Dr. Armstrong
said. She adds, “If the patient takes a picture of the
soles of the feet and they’re scaly, you can make a
confident diagnosis that it’s a superficial infection of
the hand lesion — one hand, two feet syndrome. You
wouldn’t be able to make the diagnosis if you didn’t
also simultaneously have the image of contralateral
hands as well as the bilateral soles.”
Carl Johnson, MD, a member of the Academy’s
Ad Hoc Task Force on Patient Advocacy and
Private Payers, maintains that there are intangible
symptoms that may be missed when a physician
relies solely on images for a diagnosis. “We need
face-to-face visits because in a photo you can’t really
have the basis of understanding of what’s going
on with the patient in terms of mood and other
psychological aspects.” Dr. Durst adds, “Often 20
percent of what is communicated is by words and
80 percent is non-verbal. A lot of times you pick up
whether the patient is going to be compliant. You
can tell if someone is fearful of something. You
need to recognize that.” Additionally, Dr. Edison
maintains that telemedicine simply won’t work for
certain patients. “There are some things that you
really need to see a patient for, like very high-risk
skin cancer patients — those who have very busy
skin, have had two melanomas, and they’re covered
with atypical nevi. Those patients are probably better
seen in person,” Dr. Edison said. Additionally,
“There are a lot of patients who have low health
literacy, so sometimes in those situations it’s better
to see the patient in person so you can make sure
that understanding is complete.”
And while telemedicine seems a natural fit
for dermatology — as a specialty recognized for
its reliance on visual analysis — physicians agree
that the practice involves senses beyond sight. “In
actuality, the dermatologist is looking for more than
just what they’re showed,” Dr. Johnson said. “In
dermatology, a big component of evaluating a patient
is feeling the lesion. For cancer patients, we’re
looking for other lesions and sometimes they have
to be felt in terms of thickening, where the skin does
not have a normal feeling.” Also, according to Dr.
Johnson, often physicians can smell if something is
infected. All told, “You can’t transmit everything you
want to unless you are face to face,” Dr. Durst said.
“You don’t know what you don’t know.”
REDEFINING THE SPECIALTY AND DERMATOLOGIC CARE
While some experts believe that these care-related
limitations could prevent telemedicine from
becoming the primary method of health care
delivery, some contend that the increased interest in
telemedicine could significantly change the practice
of dermatology and the value of its care. In terms
of how dermatologists conduct their businesses,
Dr. Durst theorizes that an increased use of
telemedicine could cause a drop in the number of
brick-and-mortar practices. “You may have an office
that you have to support and people who work there
who expect to work 40 hours a week to pay their
bills,” Dr. Durst said. “With teledermatology you
will probably have a lot less need for help. We could
probably very nicely work at home with a special
room set up with the right equipment and practice.
You won’t have staff or an office to pay for.”
Experts also argue that telemedicine will invite
other health care providers to flood the market
and in effect devalue the importance of seeing
a specialist. “Every time a physician assistant,
nurse practitioner, or family physician uses
telemedicine, they’re going to increase their ability
to make decisions in dermatology and it could
profoundly affect when patients need to go to the
dermatologist,” Dr. Durst said. This potential scope
creep appears to be spreading to the commercial
world. “We already have the commercial interest
online — primarily for acne treatments. They’re
selling them for $30 a visit, which is less than many
people’s copays,” Dr. Johnson said. “That’s going
to devalue teledermatology.” Right now, he said,
“Insurance companies are paying for it many times
at a rate of face-to-face visits.” But he says the goal
of the insurers will be to save money; it will be up to
dermatologists to defend their ability to provide the
best care for each individual patient.
According to Dr. Benabio, however, the need for
in-person visits will remain. “I think telemedicine
will become more widely used within the health
care industry,” Dr. Benabio said. Regardless, “It is
also important to remember that telemedicine is
a complement to traditional care delivery. Using
telehealth services is not for everyone. Some patients
want to come in and see a dermatologist in person,
and that should always be an option. Finally, any
physician using telemedicine should act responsibly
and request that a patient come in to the office
when necessary.” Dr. Armstrong agrees and while
she recognizes the inherent benefits of in-person
care, she believes that telemedicine is here to stay.
“There’s always going to be a role for face-to-face
care and I don’t think telemedicine will eclipse that
anytime soon. But teledermatology will not likely go
away.” dw
DERMATOLOGY WORLD // April 2015
23
STEPS
TO
TELEDERMATOLOGY
AM I LIA
IABL
BLE?
?
HOW
OW DO I PRO
ROTE
TECT
TE
CT PAT
PATIE
IENT
NT PRI
RIVA
VACY
VA
CY?
CY
?
HOW DOES PA
PAY
AYMENT WORK?
WHAT TYPE IS RIGHT FOR ME?
24 DERMATOLOGY WORLD // April 2015
2015
www.aad.org/dw
Successfully integrating
telederm into your practice
BY HAYLEY GOLDBACH, CONTRIBUTING WRITER
s computers and the Internet have helped us with everything
from tracking flu trends to finding love, many have looked
toward technology to improve health care. Telemedicine, and
teledermatology in particular, is one use of technology that allows
patients to “visit” with physicians electronically. This notion is not
new or even particularly revolutionary. Indeed, physicians have
been using remote images of skin since cameras were first able to
capture images of disease.
A
But many are left wondering why teledermatology hasn’t yet
changed the reality of practicing dermatology. Obstacles such as
privacy concerns, outdated laws, difficulty obtaining reimbursement,
and lack of uniform technology all pose barriers to introducing
teledermatology. However, physicians who have found ways to
incorporate telederm into their practices have by and large been
satisfied with what it can accomplish for them and their patients.
Physicians who are thinking about incorporating teledermatology
into their practice should consider a few questions. >>
DERMATOLOGY WORLD /// April 2015
25
STEPS
TO
TELEDERMATOLOGY
WHAT TYPE OF TELEDERMATOLOGY IS RIGHT FOR YOU?
HOW DOES PAYMENT WORK?
Like any decision, it helps to do your background
research. Physicians should figure out what type of
teledermatology would benefit them and their patients.
Live-interactive teledermatology allows a
physician to ask questions, see different angles of the
skin, or even have the patient or a remote practitioner
perform basic diagnostic maneuvers. However, this
requires sufficient bandwidth to accommodate a
live-stream, and slightly more specialized equipment
on the part of the patient and physician. Therefore,
most docs who choose to practice this type of
teledermatology often have patients go to specially
equipped centers such as primary care offices that are
designed to accommodate this set up.
Store-and-forward teledermatology is when a
physician is sent an image of a rash or lesion, to evaluate
in his or her own time, and send comments back.
Even within these types of teledermatology
there are also decisions to be made. Some
Payment for teledermatology services is not
straightforward as there are many ways to practice
telederm. Given this complexity, many physicians
choose not to charge for their teledermatology
services. Ivy Lee, MD, a private practitioner in
Southern California and chair of the AAD’s
Telemedicine Task Force, frequently has existing
patients send her images and views this service as
a courtesy. “I don’t bill. I have patients who travel a
lot,” she explains. “It gives them a communication
line to me — it allows them to reach me outside of
the office setting. I feel comfortable knowing that my
patients can reach me if they need me.”
Many physicians also practice pro bono
teledermatology as a way to care for underserved
patients. Dr. Lee uses AccessDerm, the AAD’s
volunteer teledermatology platform for outpatient
provider-to-provider consults, to help underserved
patients.
Obtaining
reimbursement for
teledermatology can
be slightly tricky
It’s a part of meaningful use to engage with patients.
and reimbursement
varies by insurance
You can use teledermatology as a way to do that.
provider and state.
“This is where
the nebulousness
comes in,” says April
physicians see brand-new, self-referred patients
Armstrong, MD, MPH, the chair of the Dermatology
using technology (though the AAD’s position
Special Interest Group in the American Telemedicine
statement on teledermatology does not endorse this
Association. “Reimbursement policy varies state
approach for direct-to-patient store-and-forward
by state — especially for private insurance.”
teledermatology). These patients are often in rural
Because of this she recommends doing state- and
areas or are otherwise unable to make the journey
insurance-specific research. And don’t count out
to see a dermatologist. Other dermatologists use
reimbursement by government-sponsored insurance:
teledermatology for follow-up care, to monitor
many do reimburse for teledermatology but again,
treatment, or otherwise to stay connected to existing
policies vary by state. A good launching point is the
patients — all uses that can fall within the scope of
American Telemedicine Association’s state report
the position statement’s recommendations. (Read
card. (For more details, see the article “Ready for
the full position statement at www.aad.org/Forms/
takeoff” on p. 36.)
Policies/ps.aspx.)
Some doctors are moving forward despite these
Dermatologists can also choose to act as
difficulties, however. Mark Seraly, MD, founder
consultants to other providers. As physicians who
of DermatologistOnCall and chief medical officer
work in academic or inpatient settings already
of its parent company, Iagnosis, has wrestled with
know, dermatologists are often “curbsided” by other
this issue. “Up until recently there has not been
physicians and asked to give an opinion about a skin
a payment model in place for direct-to-patient
issue. Teledermatology allows this process to be
telederm,” he explained. Therefore, his company
formalized and allows dermatologists to train and
charged a flat $59 out-of-pocket fee for its services.
interact with a wider range of other practitioners.
But this year there was a change as a major insurance
Utilization of a program like the AAD Inpatient
company, Highmark, made store-and-forward
TeleDerm pilot allows for an ER or other hospital
teledermatology a covered benefit for three states.
provider to send images to consulting dermatologists
He is confident that this is indicative of a trend. “I
via a secure Web portal to allow for provider-topredict that many other insurers will now follow as
provider feedback.
consumers are really demanding access.”
26 DERMATOLOGY WORLD // April 2015
www.aad.org/dw
AM I LIABLE?
As always, physicians need to be aware that
giving medical guidance — whether in person
or electronically — potentially opens them up to
liability. It’s important to note that not all medical
malpractice insurers include teledermatology in
their coverage. “Most of them do not cover it,” said
Haines Ely, MD, clinical professor of dermatology
at the University of California Davis, who practices
store-and-forward teledermatology through UC
Davis, the Veteran’s Administration, and the
Department of Corrections, “but most insurance
companies can recommend someone to underwrite
you.” And physicians may be pleasantly surprised
by the exceptions. Dr. Lee contacted her liability
carrier and notified them that she was including
teledermatology services in her private practice. They
told her that it was included in her existing coverage.
But it is important for physicians, even those offering
teledermatology on a volunteer basis, to explicitly
inform their carrier that they intend to incorporate
teledermatology into their practice and ensure they
have proper insurance coverage. Even working with
an established teledermatology company or platform
does not necessarily mean you are covered. Dr.
Seraly’s company recommends that all physicians
who use his company’s teledermatology software
contact their insurer to see if they are covered. If they
are not, the company offers a supplemental “slot
policy malpractice” coverage that covers them for
teledermatology visits.
HOW CAN I PROTECT MY PATIENTS’ PRIVACY?
One of the biggest concerns with the use of
technology in medicine is the risk of violating a
patient’s privacy.
Are doctors even allowed to talk to patients
over email? HIPAA rules do permit physicians to
communicate electronically with their patients as
long as they use “reasonable safeguards” when doing
so. According to the U.S. Department of Health and
Human Services website, “while the Privacy Rule
does not prohibit the use of unencrypted email for
treatment-related communications between health
care providers and patients, other safeguards should
be applied to reasonably protect privacy, such as
limiting the amount or type of information disclosed
through the unencrypted email.”
There are certain behaviors that make electronic
patient communication especially risky. Using a
personal mobile device to communicate and store
patient information is especially troubling. Some
physicians receive images via text message but
depending on the technology used, these images
are often stored in a “cloud” and can be accessed if
the doctor’s phone or account is breached. Small
portable electronic devices or even laptops are also
frequently stolen, leaving thieves access to patient
photos and data. Platforms that require a secure login
(AccessDerm, for instance) are safer from such issues.
If physicians are going to communicate with
patients electronically, Dr. Ely suggests drawing up
a contract with your patient stipulating that they
consent to communicate via email and understand
the risks posed by this type of arrangement.
Consulting a lawyer would be helpful in creating
a legally valid consent form and, as stated above,
physician should also ensure that they are covered
under their malpractice insurer.
A safer bet is to use a secure system. Many
electronic health records systems are equipped with
“patient-facing” systems — so-called “patient portals”
— that allow physicians to communicate with their
providers in a secure manner. Many are also able
to handle photos. This is how Dr. Lee chooses to
communicate with her patients: “I checked with my
EHR. Any legitimate [EHR-created] patient portal
should have privacy and security — I didn’t want to
reinvent the wheel, I wanted to use technology that
already exists.” And she explains that there is an
added perk to using this type of system — engaging
with patients electronically can meet meaningful use
requirements.
THINK OUTSIDE THE BOX
There are ways to get involved with teledermatology
that don’t always involve direct-to-patient contact.
Many companies have sprung up that market
telemedicine to patients and recruit and pay
dermatologists to look at skin images. Dr. Lee works
with one such company, Direct Dermatology. She
feels that this job fits her goals and affords her an
opportunity to broaden the scope of her practice
beyond the brick and mortar walls of her office in
Pasadena, California. “When I moved to private
practice, I missed my opportunity to see a more
diverse patient population but [working for Direct
Dermatology]…allows me to see underserved
patients, work with their primary care providers, and
see more patients in a flexible manner.” She also
said that teledermatology allowed her to recreate the
team atmosphere that she had missed while working
in private practice. “I also get to work with my
colleagues in internal medicine, pediatrics, OB-GYN,
surgeons — it’s been really fun to have that more
well-rounded experience.”
Dr. Ely is also able to care for a unique population
— prisoners — thanks to teledermatology. The
company he works for, Telemed2u, has a contract
with the California Department of Corrections
DERMATOLOGY WORLD // April 2015
27
STEPS
TO
TELEDERMATOLOGY
and handles all the scheduling and billing while
he sees his incarcerated patients “real-time” using
a webcam. He says that the opportunities to get
involved are myriad — he also participates in storeand-forward teledermatology through the Veteran’s
Administration.
Dr. Lee cautions that it is important to do
research into a company before signing on the
dotted line. She recommends that physicians find
out about the founders and ethos of the company
and also ask about the nuts and bolts: how do the
recommendations of dermatologists get conveyed to
patients? Is there adequate follow-up? What happens
if patients need further specialty care?
To get involved in providing care for underserved
patients, the AAD offers AccessDerm (www.aad.
org/members/volunteer-and-mentor-opportunities/
accessderm-teledermatology-program) where AAD
dermatologists provide teledermatology consults for
primary care providers. This is a store-and-forward
model and participating dermatologists can review
telemedicine-practice-guidelines/practice-guidelinesfor-teledermatology#.VKsIWLvLjWY). While
the current guidelines were written in 2007, Dr.
Armstrong promised that they are due to be updated
in the next few months.
Most of the special skills associated with
teledermatology involve coaching patients or primary
care providers about how to take quality images. Dr.
Ely said that he often has trouble when patients go to
clinics to get images taken — in some cases he has
even gotten images unrelated to the chief complaint.
And he stresses that it’s important to get quality
images. “You should be presented with multiple
different pictures and if you don’t like them, ask for
more.”
The ATA has a free teledermatology photography
guide (http://canfieldsci.3dcartstores.com/
Photography-Guide-for-Teledermatology_p_30.html)
that can be distributed to patients or other referral
sources. It demonstrates which poses are most
appropriate to showcase lesions on specific parts of
the body.
Dr. Armstrong
recommends that
physicians ask
If you think about it, you’re actually
patients or other
doing teledermatology when
providers to capture
you’re tested on the boards.
images using cameras
equipped with auto
image quality sensors.
But ultimately,
cases in their own time by using the AccessDerm
most providers are surprised by how facile most
platform, which is accessible via Web, mobile Web,
patients are with technology. Dr. Lee reported that
or using apps for the iPad, iPhone, or Android
her older patients are often the most excited about
devices.
teledermatology and are able to capture high-quality
images with a bit of coaching.
MASTERING THE LEARNING CURVE
The good news is that most dermatologists are
already good at diagnosing skin conditions using
pictures. “If you think about it,” Dr. Armstrong said,
“you’re actually doing teledermatology when you’re
tested on the boards.” Given this training, she doesn’t
think that special training is always necessary. “As
long as the images are clear and the dermatologists
get adequate history then they are well on their way.”
The AAD and the American Telemedicine
Association (ATA) both offer resources to help
dermatologists get started. The AAD’s position
statement on teledermatology, available online
at www.aad.org/Forms/Policies/ps.aspx, offers
guidance for both live interactive and store-andforward telederm. Another good starting point, Dr.
Armstrong said, is the ATA’s practice guidelines
for teledermatology (www.americantelemed.
org/resources/telemedicine-practice-guidelines/
28 DERMATOLOGY WORLD // April 2015
TELEDERMATOLOGY MOVING FORWARD
Practitioners interested in teledermatology will be
on the forefront of what many consider to be an
important part of the future of medicine. And just
as technology continues to improve the quality of
life, it also poses unique and interesting challenges.
For support, visit the AAD website at www.aad.
org/members/practice-and-advocacy-resourcecenter/practice-arrangements-and-operations/
teledermatology. AAD members can also consider
consulting with other dermatologists in their area
who are also using teledermatology; the AAD now
offers members the opportunity to list that they
partake in telemedicine in their AAD profiles and
this information is searchable within the member
directory at www.aad.org/find-a-member. dw
www.aad.org/dw
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DELIVERING ON
the
PROMISE
How dermatologists have found uses for telemedicine —
around the world and at home, from rural areas to
prisons to down the hall
30 DERMATOLOGY WORLD // April 2015
www.aad.org/dw
BY DIANE DONOFRIO ANGELUCCI, CONTRIBUTING WRITER
dvances in teledermatology enable dermatologists
to remotely diagnose skin conditions and potentially
recommend treatments for patients halfway around the
globe, as well as those closer to home.
A
The technology, experts say, exists to make either store-andforward or live interactive teledermatology workable. In the
vignettes that follow, they share their experiences regarding
how far this technology has come in various arenas and their
vision for the future. >>
DERMATOLOGY WORLD // April 2015
31
DELIVERING ON
the
PROMISE
EXTENDING CARE TO UNDERSERVED POPULATIONS
Carrie Kovarik, MD, associate professor of
dermatology, dermatopathology, and infectious
diseases at the University of Pennsylvania, began
working with the Baylor International Pediatric AIDS
Initiative in 2006, when she was a fellow. The program
provided patient care, treatment, and education on
pediatric AIDS care throughout Africa.
“These clinicians were doing a great job taking care of
the human immunodeficiency virus (HIV), but at the same
time half of their patients were coming in with complex
skin conditions that they weren’t sure how to manage,” Dr.
Kovarik said.
She traveled to Baylor sites in Uganda, Malawi, Lesotho,
Swaziland, and Botswana to lecture to clinicians and train
them on telemedicine, using an Internet-based Web portal
that she and a colleague from Uganda developed.
However, computers were often scarce and connectivity
slow. “We had to build the Internet site to accommodate
dial-up Internet and make sure that it was very easy to
navigate,” she said.
Eventually, the cellular network flourished in Africa.
“Everyone has a cell phone now, from the very, very low-
income rural people to everyone in the metropolitan areas,”
she said.
Smartphones allow clinicians to send photos to
specialists within or outside their country and retrieve
medical information. “Being able to access information and
access people who can help them, it just makes the world
so much smaller, and people learn so much,” she said.
Dr. Kovarik and her colleagues worked with the
Ministry of Health in Botswana on a mobile-based, countrywide telemedicine network for about four years. “We’re
now working to integrate it into their health care system
and use it as a model for other countries,” she said.
In addition, clinicians in Botswana can place biopsy
slides on a telepathology scope, and Dr. Kovarik can read
them in her office if they need assistance with a case. “I
can actually change the objective and move the scope here
robotically. I’ve read probably 500 cases over the last five
years,” she said.
Dr. Kovarik and her Penn colleagues also set up a
consult service with a hospital in Ethiopia, which obtained
a slide scanner and Internet service, enabling them to send
virtual slide consults. It also will help pathologists in Africa
who need pathology consults in other specialties.
EMBRACING THE BENEFITS OF TELEDERMATOLOGY FOR U.S. POPULATIONS
Observing the inroads in overseas teledermatology, William
James, MD, vice chair and director of the residency training
program at Penn, recognized the technology’s potential in
underserved populations in the U.S. “There were a lot of
people who either couldn’t afford care or couldn’t access
it for a variety of reasons,” said Dr. James, who served as
president of the American Academy of Dermatology (AAD)
from 2010 to 2011.
As president-elect, Dr. James worked with the AAD to
explore free health care clinics, including free consultations
from dermatologists. He and his colleagues began a pilot
program at two Philadelphia clinics. “We were able to provide
the same kind of service that we could to overseas people in
need, and the Academy was very supportive,” he said.
Early in Dr. James’ presidency, the Academy kicked off
AccessDerm, its volunteer teledermatology program for
underserved populations, on a nationwide basis. “Part of
our expansion at Penn was to include all of the clinics here
in town,” he said. In this program, dermatology faculty
members and supervised medical residents volunteer for
teledermatology consults. “It lets residents participate in
volunteer efforts and also provides us with the opportunity
as supervising faculty members to see in real time how our
residents would answer a consult,” he said. “We provide
them feedback that allows learning as well as patient care.”
32 DERMATOLOGY WORLD // April 2015
AccessDerm, which is now available in 20
states, has provided nearly 1,500 free dermatology
consults. Based on photos and patient histories
sent by primary care physicians using assorted
mobile devices, dermatologists engage in a providerto-provider consultative dialogue which allows them to
recommend a diagnosis and potential treatments for the
primary care physician to consider. Teledermatology may
be used to triage patients with both lesions and rashes.
To gauge results of teledermatology care at UPenn, Dr.
James and his colleagues examined more than 100 cases
in a pilot study comparing in-person and telemedicine
dermatologists. “We figured out that 95 percent of the time
we could provide the primary care doctor with a plan and a
diagnosis, but in the other 5 percent of cases, we needed to
see the patient,” Dr. James said.
“We have a large number of dermatologists who are ready
and willing to provide such service,” he said. “The Academy
staff has been instrumental in marrying up primary care
doctors and volunteer dermatologists and providing quite a bit
of education.” Primary care physicians who are interested may
access information online about using the system.
“It’s all working well,” Dr. James said. “It’s expanding
across the country, and I think it’s providing a great service
to our patients.”
www.aad.org/dw
TELEDERMATOLOGY IN THE MILITARY
Teledermatology began to emerge in the
military approximately two decades ago. During
the Bosnian War, clinicians in Bosnia sent digital
images of skin conditions via FTP, said Hon Pak, MD,
chief medical officer at Longview International Technology
Solutions, Inc., who was a medical resident at Walter Reed
Army Medical Center at the time. Prior to teledermatology,
retrieved images were printed and taken to the dermatology
clinic to be read.
With the Internet boom, Dr. Pak began developing the
concept of a store-and-forward teledermatology consult. He
and his colleagues designed the software and deployed it to
the military using grant funding.
“With the military being in every time zone, we don’t
have enough dermatologists to be everywhere the soldiers
are,” said Dr. Pak, who is retired from the U.S. Army.
Teledermatology provides time and distance advantages
when conditions such as leishmaniasis or anthrax require
rapid diagnosis and management recommendations from
trained dermatologists.
Store-and-forward teledermatology typically is used in
these cases. “Even though it’s not real time and you don’t
have the immediate answer, still it’s done within 12 hours,
certainly in 95 to 98 percent of cases,” said Col. Chad
Hivnor, MD, who is serving in the U.S. Air Force Reserves.
Teledermatology also reduces transport risks. “Every
time you transport someone to a larger hospital you’re
always putting them at risk from the transportation
standpoint,” Dr. Hivnor said.
The email-based overseas program has expanded
to other missions, including Ebola support in Africa.
In the last decade, the Army has performed 4,908
teledermatology consults with its email-based store-andforward program, said Charles Lappan, project manager,
OTSG Telemedicine Teleconsultation Programs, and
project manager, Telehealth Southern Regional Medical
Command, Fort Sam Houston, Texas.
Although military teledermatology began out of
necessity overseas, it eventually transitioned to remote sites
in the continental United States, Dr. Hivnor said.
Store-and-forward teledermatology and
videoconferencing are also being used in remote locations,
such as Japan, Lappan said.
In addition, teledermatology is expanding to additional
agencies. “The Veterans Administration now has a
significant number of telederms. It’s actually incorporated
into the electronic health records,” Dr. Pak said. VA clinics
that do not have dermatologists on-site can refer cases via
store-and-forward teledermatology.
Reimbursement for telemedicine has increased, but there
is still room for improvement, Dr. Pak said. “If there was
one thing that I think would increase adoption it would be
the Centers for Medicare and Medicaid Services providing a
mechanism to reimburse store-and-forward teledermatology,”
Dr. Pak said. The military may have had an advantage as
an early pioneer because it didn’t have to struggle with
reimbursement issues private practices do, Dr. Pak said.
Dr. Pak emphasized that teledermatology must
become an integral part of dermatology — rather than a
separate modality. To support such an integrated vision,
“the electronic health record vendors would have to be
interoperable and ‘tele-enabled,’ which means that it must
support intra- and interfacility consultations with images,”
he said.
TELEDERMATOLOGY IN THE PRISON SYSTEM
Because of difficulties in transporting inmates to outside
medical facilities, teledermatology offers valuable
advantages in the prison system. In 2014, the Federal
Bureau of Prisons completed 750 teledermatology
consultations.
The Federal Bureau of Prisons reported that its
teledermatology program saves the prison system money
and speeds the time to consult. The teledermatology
program also improves patients’ access to care and
continuity of care.
Teledermatology is used easily for diagnosis
in this type of setting, said Karen Edison, MD,
chair of the department of dermatology at the
University of Missouri, Columbia, and medical
director of the Missouri Telehealth Network, who has
provided teledermatology services to a Missouri hospital
that admits maximum-security and intermediate-security
clients.
“It’s just when biopsies or procedures have to be done
that patients need to travel and be seen in person,” she said.
DERMATOLOGY WORLD // April 2015
33
DELIVERING ON
the
PROMISE
EXPANDING POSSIBILITIES
The medical community is recognizing the
potential of teledermatology for all patients.
The Missouri Telehealth Network performs live
interactive teledermatology clinics with rural/underserved
areas using modern videoconferencing technologies, Dr.
Edison said.
Using a specially designed app, clinic health providers
can photograph a patient’s skin with an electronic tablet
and transmit the photos to her tablet. “I actually see
their skin disease before I ever talk to them over the
videoconferencing,” Dr. Edison said.
“We’re also just starting to do e-visits via email and
video visits through our health system’s patient portal, so
we’re using this primarily for follow-up appointments or
follow-up interactions with patients we’ve seen in person,
but we see this expanding in the future,” Dr. Edison said.
It is important that telemedicine
is part of integrated care
and does not become part of
anonymous, disconnected care.
Teletriage is a useful application of store-and-forward
teledermatology. For example, teletriage may be used
to potentially decrease cellulitis admissions, as recent
studies indicate that many people admitted to the hospital
for cellulitis don’t actually have it (JAMA Dermatol
2014;150:1056-1061). If a teledermatology consult is
performed and stasis dermatitis is determined to be
the culprit, the dermatologist may be able to prescribe
treatment and save thousands of dollars per admission.
In military telemedicine, clinicians have also been able
to place their hands in gloves providing tactile feedback,
allowing them to feel the skin remotely. “It’s been cost
prohibitive up to now, but I could see in the future where
the price point on that kind of technology would come
down where we could actually put our hand in a glove and
actually feel the patient’s skin,” Dr. Edison said.
34 DERMATOLOGY WORLD // April 2015
“That would be helpful, however, it’s not essential,”
she said. “I’ve been doing telemedicine over 20 years
and I’ve studied whether we make the same diagnosis
and recommend the same treatments in my own patient
population, and many others have done so as well. I think
the bulk of the evidence shows we make the same diagnosis
and recommend the same treatments using either live
interactive or store-and-forward teledermatology.”
However, Dr. Edison, an early champion of
teledermatology, has concerns about the explosion of
online offerings. “I believe in telemedicine and I support
teledermatology where it improves quality and access,” she
said. However, she said, it is important that telemedicine
is part of integrated care and it does not become part
of anonymous, disconnected care. “Because many of
our patients have multiple diseases and are on multiple
medications, it is really important to have a meaningful
working knowledge of what is going on with the patient
and also to communicate with their primary care team,
so that if you prescribe them medicine, their primary care
team knows what you did,” Dr. Edison said. Indeed, the
Academy’s position statement on teledermatology says,
“The provision of teledermatology services should include
care coordination with the patient’s existing primary care
physician or medical home, and existing dermatologist if
one exists.” (Read the full position statement at www.aad.
org/Forms/Policies/ps.aspx.)
Follow-up and communication with the primary care
team will be important as medicine moves toward patientcentered medical homes, accountable care organizations,
and other health system innovations, Dr. Edison said.
Dr. Edison envisions dermatologists would even be able
to take turns being on call to be immediately available to
provide input to primary care physicians at the point of care.
“We’re a long way from that, but I think that would go a
long way to increasing the awareness of our value in those
integrated, multidisciplinary health care settings,” she said.
With the evolution of payment systems and the
electronic health environment, teledermatology may also be
helpful in urban centers, where dermatologists may need
to visit several hospitals for inpatient consults, Dr. Edison
said. dw
www.aad.org/dw
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READY FOR
TAKEOFF?
Slow progress on teledermatology
reimbursement could accelerate
36 DERMATOLOGY WORLD // April 2015
www.aad.org/dw
BY RUTH CAROL, CONTRIBUTING WRITER
R
eimbursement is not the only challenge for telemedicine
adoption, but it is one of the greatest. Whether looking at
the state or federal level, payment and coverage remain
patchy and sparse. All of that could change rapidly, though, as
both Medicaid and Medicare policies are increasingly favoring
reimbursement for a growing number of telemedicine services.
Furthermore, increasing numbers of private payers are covering
telemedicine, prompting what could be a reversal from the normal
route by which reimbursement rates are developed through the
RUC/Medicare process and leaving CMS to follow suit.
Reimbursement poses the greatest challenge to the adoption
of telemedicine services, according to the 2014 Telemedicine
Survey conducted by Foley & Lardner LLP, a Milwaukee-based
law firm. Approximately half of the 57 executives from a variety
of health care organization types and sizes nationwide polled last
fall identified difficulties seeking and receiving reimbursement for
such services. >>
DERMATOLOGY WORLD
WO
/// April 2015
37
READY FOR
TAKEOFF?
While 90 percent of respondents reported that their
organizations have already begun developing or
implementing a telemedicine program, 41 percent said
their organizations do not receive any reimbursement
for these services. Twenty percent of executives reported
receiving lower rates from managed care companies
for telemedicine than in-person visits. Medicare’s thin
coverage practices for telemedicine were the biggest
reimbursement concern for 21 percent of respondents
while 18 percent said they were most uneasy about state
laws failing to mandate that commercial companies pay
for such services.
That is the same message Brenda Dintiman, MD,
a dermatologist from Fairfax, Virginia who testified as
a small practitioner on behalf of the AAD, delivered
before the House Small Business Subcommittee on
years, a single widely accepted standard is lacking.
Reimbursement is neither consistent across payers
nor across states to allow for proper patient access,
Dr. Dintiman noted during her testimony. While
Virginia law addresses coverage for telehealth
services, this does not guarantee access with all
private insurance, she said. Similarly, Missouri has
a parity law, but many insurance plans, including
self-insured companies, don’t fall under it, explained
Rachel Mutrux, director of the Missouri Telehealth
Network. When she surveyed several insurers in the
state, she found that each one had its own policy for
what is covered and how.
Among private payers covering telemedicine services
in certain states are Aetna, Blue Cross Blue Shield,
Cigna, and WellPoint. The latest to join in is Highmark
Commercial Insurance,
a Blue Cross Blue
Shield-affiliated carrier
in Pittsburgh, which
Reimbursement is neither consistent
began covering Webacross payers nor across states.
based visits — including
teledermatology offered
by DermatologistOnCall
— for its 5.2 million
Health and Technology in July 2014. “Without assured
members across Pennsylvania, West Virginia, and
reimbursement,” she said, “providers and patients are
Delaware as of Jan. 1. “It’s the first opportunity where
unlikely to utilize telehealth.”
a store-and-forward teledermatology encounter is a
covered benefit,” noted Mark Seraly, MD, founder of
STATE COVERAGE RAMPS UP
DermatologistOnCall and chief medical officer of its
If the number of bills being introduced is any
parent company, Iagnosis.
indication, states are definitely ramping up their
Medicaid programs in 47 states currently offer some
telemedicine adoption efforts. During the 2014
type of coverage for telemedicine services; however,
legislative session, 36 states and the District of
no two states are alike. At this time, only 10 states
Columbia introduced telemedicine-related legislation.
cover store-and-forward telemedicine under Medicaid
In 2015, more than a dozen states have introduced
(see sidebar). But states are slowly embracing newer
legislation. New York Governor Andrew Cuomo
technology applications. Bills being introduced in
recently signed a bill into law that expands the
Colorado, Missouri, and Texas call for coverage of
availability of telehealth services and requires insurers
store-and-forward telemedicine, Dr. Redbord noted.
to cover them at the same rate as in-person visits.
Twenty-three states and the District of Columbia do not
Many of the state bills address different aspects of
specify a patient setting or patient location as a condition
reimbursement for both Medicaid and private payers.
for payment, reports the American Telemedicine
Proposals in Missouri and Texas address Medicaid
Association (ATA). While 21 states recognize the home
programs whereas legislation calls for the creation of
as an originating site, 13 states recognize schools and/
parity laws in Colorado and North Dakota. Connecticut
or school-based health centers as an originating site.
and New Jersey are also expected to introduce parity
Fifteen states and the District of Columbia do not specify
bills this session, noted Kelley Pagliai Redbord, MD,
the type of provider allowed to provide telemedicine as
chair of the Academy’s State Policy Committee,
a payment condition. Instead of focusing exclusively
which reviews the language in such bills and provides
on rural areas or designating a mileage requirement,
feedback on how it could be updated to align with the
Medicaid is moving to state-wide coverage, notes the
Academy’s position statement on teledermatology
ATA in its State Telemedicine Gaps Analysis: Coverage
(available online at www.aad.org/Forms/Policies/
& Reimbursement published in September 2014.
ps.aspx).
MEDICARE EXPANDS COVERAGE
Currently, 22 states and the District of Columbia
Meanwhile, Medicare coverage is very limited. There
mandate that private payers cover telemedicine.
is little latitude with regard to the originating site and
Despite that number doubling in the last four
38 DERMATOLOGY WORLD // April 2015
www.aad.org/dw
practitioners who can provide telemedicine under
Medicare, said Bruce A. Brod, MD, an advisor to the
Academy’s State Policy Committee and member of its
Congressional Policy Committee and Patient Safety
and Quality Committee who offers consults through
AccessDerm. It’s really designed for beneficiaries
living in very rural areas and only covers live interactive
telemedicine. Store-and-forward telemedicine is
only covered in Alaska and Hawaii as part of a
Demonstration Project.
But like Medicaid, Medicare is slowly expanding
its parameters for telemedicine coverage. The 2014
Medicare physician fee schedule expanded the
geographic areas where telehealth services are covered.
The 2015 Medicare physician fee schedule expands the
services covered under telehealth.
When it comes to telemedicine legislation, there
is a lot more bipartisan collaboration than in the
past, noted Carrie Kovarik, MD, who chaired the
Academy’s Telemedicine Task Force until this March.
As an example, the Medicare Telehealth Parity Act
of 2014 proposed a three-phase rollout of changes to
the way that telemedicine services are reimbursed by
Medicare and would expand coverage for residents
of both rural and urban areas. With each two-year
phase, the availability and use of store-and-forward
technologies would be expanded to larger populations.
The bill would also introduce coverage for some
telehealth services provided at home and in walk-in
retail health clinics. Rep. Mike Thompson (D-Calif.)
plans to reintroduce the bill with bipartisan support
this spring.
In January, a draft House bill started to circulate
that includes a provision that would require the
Centers for Medicare and Medicaid Services (CMS) to
implement a methodology for Medicare’s expanded
coverage of telehealth services that would either
reduce costs or not result in a net increase in program
TEN STATES COVER STORE-AND-FORWARD TELEMEDICINE
States that define telemedicine as the delivery of services occurring in “real time” exclude the use of storeand-forward technology. Of the states that do reimburse for store-and-forward, some have limitations on
what is reimbursed. For example, California only reimburses for teledermatology and teleophthalmology.
To date, 10 states reimburse for store-and-forward telemedicine under Medicaid, according to the
Center for Connected Health Policy. They are:
MINNESOTA
SOUTH DAKOTA
ILLINOIS
VIRGINIA
CALIFORNIA
ARIZONA
NEW MEXICO
OKLAHOMA
PI
SIP
SIS
MIS
ALASKA
DERMATOLOGY WORLD
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/// April 2015
39
READY FOR
TAKEOFF?
spending. “It’s very broad and vague,” Dr. Brod
said. “I think they’re looking for a lot of input from
stakeholders, like us, to try to shape that.”
In February, the public comment period ended for
a proposed rulemaking published by CMS that would
waive certain restrictions on the use of telemedicine
by accountable care organizations (ACOs). In addition,
CMS is proposing that ACOs describe how they
will encourage and promote the use of enabling
technologies, such as telehealth, for improving care
coordination for Medicare beneficiaries. The agency
reports there are now 330 ACOs in 47 states, providing
care to more than 4.9 million beneficiaries.
Dr. Alam said, as it could create a perverse incentive
to push the least resource-intensive method. “Codes
should be developed through the normal process to
keep everyone honest,” he said. They should be valued
appropriately by the Relative Value Scale Update
Committee to ensure that the service is reimbursed at
an appropriate level and the patient has received the
most appropriate service. The goal is to provide access
to care for people who don’t currently have it, Dr. Alam
noted, not to create strong incentives that would limit
patient access to face-to-face dermatology visits.
The AAD has been approached by various federal
legislators for guidance as to how teledermatology
services should be coded and billed through Medicare,
CODING FIRST, LICENSURE NEXT
Dr. Alam said. There have been a lot of discussions
The primary reason that teledermatology
about this at meetings of the Telemedicine Task Force,
reimbursement is lacking is because there are no
State Policy Committee and Congressional Policy
Committee, Dr. Edison
noted.
Another issue
The goal is to provide access to care,
that must be resolved
before reimbursement
not to create incentives that would
can move forward
limit access to face-to-face dermatology visits.
is licensure and
professional
accountability as it
relates to cross-state
current procedural terminology (CPT) codes that
practice. Most states require physicians to be licensed
capture the service appropriately, according to
to practice in the state where the patient is located. The
Karen Edison, MD, deputy chair of the Academy’s
Interstate Medical Licensure Compact proposed by the
Telemedicine Task Force and a member of the ATA’s
Federation of State Medical Boards (FSMB) would allow
Teledermatology Special Interest Group. “You can’t get
for expedited multiple state licensure, but leaves the
paid unless you have a code for it,” she said.
authority over patient safety and quality of care issues
Private insurers can choose to use existing CPT
with individual state medical boards, which the AAD
codes for telemedicine services and reimburse services
supports, Dr. Edison said. “It will help more physicians
they select at rates they choose, noted Murad Alam,
to serve more patients in multiple states,” she said.
MD, chair of the AAD’s Telemedicine Reimbursement
This year, legislators in nine states have formally
Advocacy Workgroup. Some private telemedicine
introduced the interstate compact, according to FSMB.
networks, like DermatologistOnCall, routinely use
In January, the South Dakota Senate Committee
CPT code 99444 to describe online evaluation and
adopted it. Getting the FSMB compact through can
management services. CPT sometimes approves new
be challenging because each state has to go through
“category III” codes, which are temporary codes for
either a legislative or regulatory process to change the
emerging technologies; if such codes were created for
law in order to join the compact, Dr. Brod said. “The
specific telemedicine services, private payers would
more states that join the FSMB compact, the easier it is
have the option to cover them before they were accepted for physicians to obtain a license across state lines, the
or valued by Medicare.
more feasible telemedicine becomes.”
Coding needs to be developed with the input of
EXPAND TECHNOLOGY, GEOGRAPHY
specialty societies to ensure that it’s fair and reflects the
The store-and-forward model will have to be more
work and complexity of the service being provided, the
widely adopted and the geographic restrictions
same way codes do for a live visit, Dr. Brod explained.
eliminated to move telemedicine forward, Dr. Brod
Congress and CMS shouldn’t rush this process just
added. “That will take an act of Congress with a lot of
to get codes out there. “Codes need to be developed
input from stakeholders, physicians, technology experts,
carefully because once they’re developed, it’s hard to go
and patient advocacy groups,” he said.
back and fix them,” he added.
Des Moines, Iowa dermatologist Timothy G.
It’s probably not a good idea to use the same code
Abrahamson, MD, is convinced that store-and-forward
for a teledermatology encounter as a face-to-face visit,
40 DERMATOLOGY WORLD // April 2015
www.aad.org/dw
is the only viable option for teledermatology. Storeand-forward technolology allows the requesting
physician to take the pictures and send the information
to the dermatologist within minutes of deciding to
make the consult. The dermatologist can review the
photographs without coordinating with the patient
or requesting physician. “It will speed access to a
specialist and improve access in rural states,” he
said. Dr. Abrahamson speaks from experience,
having participated in a pilot program using live
interactive teledermatology for inpatients at one of
the five hospitals at which he has privileges. “It is very
cumbersome and logistically difficult which makes its
use very limited,” he said.
Dr. Abrahamson is a proponent of expanding
the definition of “rural areas,” as well. Iowa is just
as rural as Hawaii and Alaska when looking at the
percentage of the population that has to travel from one
to three hours to reach a specialist, he said. Not only
do hospitals in Des Moines, the largest metropolitan
area in Iowa with more than 500,000 residents, lack
access to dermatologists, but outside of Iowa City, 80
percent of the hospitals have little or no current access
to a dermatologist, Dr. Abrahamson said. A store-andforward system could be used to link these hospitals
and clinics.
Dr. Edison concurs that the geographic restrictions
must go. She has patients in a nearby rehabilitation
hospital who require therapy all day long. Taking these
patients out of therapy for nearly three hours to go
across town for an in-person appointment is neither
in the patient’s best interest nor is it cost effective,
she said. Dr. Edison believes that CMS is warming up
to store-and-forward technology. “We need another
legislative push,” she added.
CLIMATE CHANGE
That push may be in Health and Human Services
Secretary Sylvia Burwell’s recent announcement of a
transition from volume to value payments. The goal
is to move 30 percent of fee-for-service Medicare
payments to alternative payment models, such as
ACOs or bundled payment arrangements, by the end
of 2016, and 50 percent by the end of 2018. As this
transition unfolds, payment for telemedicine services
should accelerate. “As we move from paying for
volume to paying for value, all of a sudden store-andforward teledermatology makes a whole lot of sense,”
Dr. Edison said.
Telemedicine is already known to work in closed
health systems such as Kaiser-Permanente and the
Veterans Health Administration, Dr. Kovarik noted.
Furthermore, Medicare can be more innovative through
its ACOs, she said. ACOs will serve as a good working
lab for telemedicine because they have a lot more
flexibility in determining an appropriate originating site
and who can provide the service, Dr. Brod said. “They
are not bound by current laws,” he said. “It’s a way to
put telemedicine out there with low risk to generate
more evidence and models of best practice.” In ACOs
or patient-centered medical homes, dermatologists can
have an established relationship with the patient and
communicate with the patient’s primary care provider,
Dr. Edison said. “What’s more patient centered than
taking the care to the patient?”
And speaking of patients, younger ones in particular
might be the ones who actually move telemedicine
forward quicker than the lawmakers. “The adoption of
these services is probably going to be much greater in
younger people who are very used to doing everything
over an electronic interface,” Dr. Alam said. “We might
see Medicare slower to adopt and more private insurers
taking the forefront,” Dr. Redbord added. “Younger
people are better with technology, so they might serve
as more of the demonstration than Alaska and Hawaii.”
Dr. Seraly believes that consumers will drive
the adoption of telemedicine because the timing
is perfectly aligned with technology and consumer
preparedness. “I believe that in 10 years, 50 percent or
more of all skin care will be accessed online and will
be a covered benefit,” he said. Dr. Seraly indicated that
DermatologistOnCall is receiving significant interest
by carriers nationwide that are looking at telemedicine
as a way to provide access to patients who don’t have it
and at a lower cost. In early 2014, DermatologistOnCall
was in one state with 12 board-certified dermatologists;
a year later, it is in 17 states with nearly 100
dermatologists, he said.
“Private payers will drive it because they will
see a cost benefit,” Dr. Edison said. If more private
insurers develop reimbursement policies for
telemedicine, that may incentivize more vendors to
provide virtual office platforms, which may lead to
more physicians participating, Dr. Brod added. As
important as maintaining the quality of integrated
care is demonstrating the value of telemedicine
so that physicians are fairly compensated for their
participation, he said. “The ultimate success or failure
of telemedicine is finding a fair reimbursement method
to make sure physicians are compensated for their skill,
work, and time,” Dr. Brod concluded. “The devil is in
the details and the details need to be worked out not
just by Congress because they’re not the experts in this,
but with a lot of input from physicians.” dw
DERMATOLOGY WORLD // April 2015
41
from the president
academy perspective
BY MARK LEBWOHL, MD
A clear path
not without
obstacles
am delighted to commence my term as your Academy president. It is an honor
to serve our profession and our patients. This year, our priorities will continue
to focus on preserving patient access and safeguarding the value of dermatologic
care. But there is no denying that the path to achieve our goals will be fraught with
many challenges. Many are challenges we have battled for years, but there will also
be many new issues to test us.
It is no secret that insurance providers are looking to cut costs, often at the
expense of our patients. Several Medicare Advantage plans have been narrowing the
scope of their provider networks which has reduced patient access to dermatologic
care. Additionally, some insurers are changing their payment schemes, not only
reducing physician reimbursements but transitioning to high-deductible plans. As
a result, patients may think twice about going to the dermatologist regardless of
their ailment. If a patient has a concerning mole, precious time and the opportunity
for an easy surgical cure may be lost if the patient delays seeing a dermatologist.
Many insurance companies are also balking at the price of critical treatments and
medications and, as a result, patients are not receiving adequate treatment. Psoriasis
patients with extensive disease, for example, are often treated with numerous topical
therapies when they should be treated systemically. Because the costs of many of our
systemic therapies are high, insurers create many hurdles to their prescription. We
must continue to fight for our patients and ensure that they are receiving adequate
and timely care.
We are also enduring policy changes from the public sector that will affect how
we practice. Convoluted HIPAA regulations and onerous RAC audits aside, we are
also facing the removal of 10- and 90-day global periods in the Medicare physician
fee schedule in 2017 and 2018 respectively. Additionally, the U.S. Department of
Health and Human Services (HHS) recently pledged that 30 percent of Medicare
provider payments will go to alternative payment models (APM) by 2016, and 50
percent by 2018. This initiative stems from an increased interest in cutting costs and
improving care — yet, how the HHS accurately measures the quality of care for these
APMs remains uncertain. One thing is for sure: we will have to prove our worth to
APMs, such as accountable care organizations, so we are not only invited to join
these frameworks, but considered equal partners.
With all of these changes and increased regulations, our patients are feeling the
squeeze when trying to get an appointment. In order to fulfill numerous require-
I
42 DERMATOLOGY WORLD // April 2015
ments such as EHR meaningful use,
continuing medical education, maintenance of certification, and quality measure
reporting, we are spending less time with
our patients — productivity in many offices
and medical centers has been reduced by
up to a third. So what will our patients do?
They will visit non-physician clinicians —
many of whom go out on their own and
pretend to function as physicians — or
medical spas run by non-physicians. We
must figure out a way to bring our time
back to our patients, and ensure that there
are proper truth-in-advertising regulations
in place for those who are eager to pick up
the slack.
Dermatology will face a lot of challenges in the near future. Therefore, I call
on all Academy members to do their part.
Learn more about SkinPAC, the American
Academy of Dermatology Association’s
political action committee, at www.skinpac.
org, and find out how SkinPAC can affect
many of these items on our list. Write letters — it works. When the Academy issues
a call to action, log on to the Dermatology
Advocacy Network at www.aad-dan.com
and email your members of Congress.
Also, support your patient organizations
and ask for their support on the issues
that affect our patients in return. When
doctors lobby for issues, we are viewed as
self-serving; when patients lobby for the
same issues, their voices are much louder.
Finally, the Academy is fortunate to have a
very active Board of Directors and a reliable
staff. If you are dealing with an issue, reach
out to them. They will be responsive.
There is no doubt that our plates
are full this year. However, as you were
confident in my ability to lead this great
organization, I am confident in our specialty’s ability to work together and make
a difference with these important issues
so that we can continue to provide the best
quality care for our patients. dw
www.aad.org/dw
academy update
Meet the 2015 election candidates
NOMINATING COMMITTEE
MEMBER REPRESENTATIVE
BOARD OF DIRECTORS
VICE-PRESIDENT-ELECT
PRESIDENT-ELECT
MEMBERS CAN VIEW the candidates’ background materials their videotaped statements, the ballot book, and the Board statement and statements in support for and opposition to the proposed dues increase at www.aad.org/aadelection.
Henry W. Lim, MD
Clifford Warren Lober, MD, JD
Brian Berman, MD, PhD
Hugh Greenway, MD
Seemal R. Desai, MD
Kimberly J. Butterwick, MD
Erin Boh, MD, PhD
Neil Alan Fenske, MD
Brent Moody, MD
Andrew F. Alexis, MD, MPH
Neil S. Sadick, MD
Linda Stein Gold, MD
David M. Pariser, MD
Daniel M. Siegel, MD
Members can learn more about the candidates in the Election Town Hall, an established online forum where candidates have the opportunity to respond to member questions. Individual members may submit up to two questions, with a limit of 100 words per question,
to candidates@aad.org. All questions will be reviewed by the chair of the Ad Hoc Task Force on Election Oversight (AHTF). Should a
question be considered duplicative, inflammatory, offensive, or otherwise inappropriate in nature, it will be forwarded to the entire AHTF
for evaluation. The AHTF has the authority to consolidate, edit, or refuse to post such questions. Candidates are under no obligation to respond to posted questions. The questions and responses will be available at www.aad.org/townhall for membership viewing until the close
of the election on April 20. (Refer to the Excerpt of the Administrative Regulation on Nomination and Election Procedures 13. h.)
VOTING DEADLINE IS APRIL 20
Paper and online voting concludes on Monday, April 20. Ballots must be received or electronically posted on April 20 by 11:59 p.m. (EDT).
Members can access the Academy election site at www.aad.org/aadelection or use the direct link at https://www.esc-vote.com/aad2015 to
vote. Election Services Corporation (ESC) sent access codes to all eligible voting members on March 2 via email or mail (for those without
email addresses). When voting, use your secure access code and AAD member identification number. ESC will continue to provide access
codes via email each week through April 20.
If you require assistance with your secure access code, please contact ESC between 9 a.m. and 5 p.m. (EDT) at their toll free number,
(866) 720-4357 or via email at aadhelp@electionservicescorp.com.
44 DERMATOLOGY WORLD // April 2015
www.aad.org/dw
news + events
news + events
Academy launches DermCare Team initiative
IN AN EFFORT to take a more comprehensive approach to educating and training dermatology non-physician clinicians, the Academy has initiated the AAD DermCare Team. The AAD
DermCare Team is a new educational opportunity for dermatologists to enroll their physician
assistants, medical assistants*, nurse practitioners, and registered nurses and to provide their
care team with professional development and the latest research findings to assist them in
providing high-quality care to the patients they serve.
Benefits for the AAD DermCare Team include:
• Complimentary electronic versions of JAAD and Dermatology World;
• Complimentary circulation of e-newsletters such as Dermatology Daily;
• Discounted pricing to attend the Annual and Summer Academy Meetings
(Note: DermCare Team enrollees will not be eligible to attend restricted sessions);
• Discounted pricing on patient education, practice management, and professional
education products;
• Access to many password-protected pages on the AAD website;
• Opportunity to participate in volunteer activities;
• Complimentary access to the AAD CME Transcript Program;
• Access to certification maintenance resources and education opportunities.
DATEBOOK
WHAT’S COMING UP
HOW TO ENROLL STAFF IN THE DERMCARE TEAM
Academy fellows, associates, and affiliate DOs can enroll any or all of their PA, NP, MA*, and
RN staff members in the DermCare Team. Participants of the AAD DermCare Team will
not be considered members, and cannot enroll without a dermatologist’s approval. To enroll,
members should visit www.aad.org/DermCareTeam and click on “add your care team.”
Members will then list the names and unique email addresses of the individuals they wish to
enroll. The dermatologist will then attest and each enrollee will receive an email with information to complete an application. Enrollment is free for 2015. Enrollees will pay $150 for the
2016 calendar year. Learn more about the DermCare Team at www.aad.org/dermcareteam,
or contact Krista Kauper, senior director of constituent relations and strategic planning, at
kkauper@aad.org. – VICTORIA HOUGHTON
*For this purpose, medical assistants are defined as those who care for dermatologic patients and have direct patient contact, including military medical
personnel and Mohs histotechnicians, although excluding aestheticians, cosmetologists, and non-dermatologist physicians.
Registration, housing for Summer Academy Meeting 2015 opens in May
REGISTRATION AND HOUSING for the Summer Academy Meeting 2015, Aug. 19-23 in
New York City, will be available online at www.aad.org beginning at 12 pm CT, May 20 for
physician, life, and honorary members, and May 27 for all others. Housing reservations at
the New York Hilton Midtown and The London Hotel must be made online in conjunction
with registration for the meeting to receive the discounted housing rate. See registration
website for hotel deadlines and cancellation and change polices. More information about
Summer Academy Meeting 2015 is available at www.aad.org/meetings/2015-summer-academy-meeting, as well as the Advance Program Announcement, which will be mailed to all
members in late April. – SUSAN JACKSON
Make an impact
WHEN YOU REGISTER for the 2015 Summer Academy Meeting, you can also make a donation and join
in helping change lives through two vital AAD programs.
SPOT Skin Cancer™ seeks to encourage sun-safe behavior by integrating public awareness and education, providing access to screenings and shade structures, advocating for increased legislation, and
supporting research.
Camp Discovery gives children with chronic skin conditions a life-changing summer camp experience,
where they can build self-esteem and learn they are not alone in their daily struggles.
Your donation will positively impact patients, the public, and our communities! Make your donation as
you complete your online registration for the meeting.
DERMATOLOGY WORLD // April 2015
45
classifieds
PROFESSIONAL
PROFESSIONAL OPPORTUNITIES
OPPORTUNITIES
LAJOLLA, CALIFORNIA
Seeking a BC/BE dermatologist to join
a busy, well-established, growing
Central Florida Dermatology and Skin Cancer Center (CFD) is seeking an ACMS fellowship trained
Mohs Surgeon and/or a BE/BC General Dermatologist. We are also looking for qualified ARNPs
who have dermatology experience. CFD is located in Winter Haven, FL. Winter Haven is the
home of Legoland and is also known as the Chain of Lakes area. Winter Haven offers the suburb
experience with quick access to Tampa, Orlando, and the beach.
Interested parties, who want to join a busy and successful practice, can submit resumes/CVs to
our Practice Manager, Dan Lackey, at Daniel@centralfldermatology.com or call 863.293.2147
for more information. Please visit us on the web at www.centralfldermatology.com.
If contributing to a team with an expectation for excellence and creating a
balanced and fulfilling life are important to you, St. Vincent Healthcare in
Billings, Montana has the opportunity and community for you!
MOHS SURGEON
Multiple Part Time Opportunities
practice. Recently expanded office
Montrose, CO 1-2 days/mo
just blocks from the Pacific Ocean in
Enfield, CT
2-3 days/mo
the world’s best climate. Competitive
Groton, CT
1-2 days/mo
salary, incentives, benefits and part-
Tampa, FL
1-2 days/mo
nership opportunities. Please send CV
Reno, NV
1-2 days/mo
to shelly@boughtondermatology.com.
Hickory, NC
1-2 days/mo
Sanford, NC
2-3 days/mo
Bountiful, UT 3-4 days/mo
PORTERVILLE, CALIFORNIA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
Contact Karey, (866) 488-4100 or
BOULDER, COLORADO
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
WEST PALM BEACH, FLORIDA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
MONTROSE, COLORADO
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
CALUMET, IL/DYER, IN
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
GROTON, CONNECTICUT
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
HICKORY, NORTH CAROLINA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
OCALA, FLORIDA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
SANFORD, NORTH CAROLINA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
TAMPA, FLORIDA
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
SANTA FE, NEW MEXICO
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
www.MyDermGroup.com.
St. Vincent Healthcare in Billings, Montana seeks U.S. trained BE/BC
certified physician for our Dermatology & Skin Cancer Center
• Full time employed position
• Dermatopathologist in house
• St. Vincent Healthcare’s laboratory is accredited by the College of
American Pathologists (CAP) and our cancer program is recognized
by the Commission on Cancer (CoC) as an Approved Cancer Program
• Full complement of medical specialties available.
• Thriving medical community in a family-oriented suburban location
• Excellent School System
• Abundant recreational activities year round – hiking, skiing, fishing,
biking and camping
• Competitive salaries with productivity incentives
• Start date bonus, Moving Allowances and CME reimbursement
For more information, please contact Therese Teske,
Physician Recruiter at (406) 237-4017 therese.teske@sclhs.net
or visit our website at www.svh-mt.org
************
Billings, Montana listed 4th in cities with highest satisfaction –
Business Insider, Gallup 2014
Manchester & Wolfeboro, NH
APDerm® is a vibrant, growing practice of clinically accomplished and patient-focused dermatologists who practice in a community distinguished as among the best places to live on the east coast/
Boston area.
We are seeking a full or part-time dermatologist/Mohs surgeon to join our group of twelve
board certified dermatologists in a professionally run practice with dermatopathology lab, Mohs
surgery and medical aesthetics. This opportunity would allow a highly qualified dermatologist/
Mohs surgeon to practice with excellent support staff in a collegial practice in our Manchester and
Wolfeboro, New Hampshire offices with competitive salary, benefits and opportunity for practice
ownership. For more information, please contact: Glenn Smith, MHA, Administrator and Chief
Operating Officer, at (978) 849-7501 or email gsmith@apderm.com.
46 DERMATOLOGY WORLD // April 2015
www.aad.org/dw
ad index
PROFESSIONAL
PROFESSIONAL OPPORTUNITIES
OPPORTUNITIES
We gratefully acknowledge the following advertisers in this issue:
BOUNTIFUL, UTAH
Associate Opportunity. Contact
Karey, (866) 488-4100 or www.
MyDermGroup.com.
WASHINGTON, DC
Partnership available. Established
practice. Contact Karey, (866) 4884100 or www.MyDermGroup.com.
PRACTICES FOR SALE
NEW ROCHELLE, NEW YORK
Well established, solo, derm practice
for sale. IPL, NBUvB, Blu-U on site.
Beautiful facility in historic building
in downtown New Rochelle. Walk to
train. Close to Manhattan. Owner
will stay on to ease transition. Please
email: barbaralukash@hotmail.com.
TEXAS
Well-established , small, solo medical
dermatology practice in south Dallas
suburb. Considering retiring for the
right offer that is best for loyal patient
base and excellent staff of two. Contact correspondencecym-practice@
We Buy Practices
• Why face the changes in Health
Care alone?
• Sell all or part of your practice
• Succession planning
• Lock in your value now
• Monetization of your practice
• Retiring
Please call Jeff Queen at
(866) 488-4100 or e-mail
WeBuy@MyDermGroup.com
Visit www.MyDermGroup.com
Company
Product/Service
3Gen, LLC............................................DermLite DL1 ....................................... 29
Allergan...............................................Aczone................................................. 5-6
American Society for Mohs Surgery ..CME ..................................................... IBC
Canfield Scientific ...............................Vectra H1............................................... 17
Care Credit ..........................................Patient Financing.................................... 3
Iagnosis ...............................................DermatologistOnCall ............................ 11
Merz ....................................................Mederma................................................. 9
Modernizing Medicine ........................EMR ..................................................IFC-1
NexTech ..............................................EHR ...................................................... BC
Pacific World .......................................Bio Oil .................................................... 35
VisualDX ..............................................Corporate .............................................. 43
Recruitment Advertising
Adult & Pediatric Dermatology, PC ................................................................... 46
Central Florida Dermatology & Skin Cancer Center........................................ 46
St. Vincent Healthcare ....................................................................................... 46
yahoo.com. No brokers please.
CO
MI
weekly
NG
SO
Dermatology World Weekly.
ON
Classified ads are welcomed from dermatologist members of the American Academy of
Dermatology, from dermatology residents of approved training programs and institutions
with which they are affiliated, as well as from recruitment agencies or organizations that
acquire and sell dermatology practices and equipment. Although the AAD assumes the
statements being made in classified advertisements are accurate, the Academy does not
investigate the statements and assumes no liability concerning them. Acceptance of classified advertising is restricted to professional opportunities available, professional opportunities wanted, practices for sale, office space available, and equipment available. The
Academy reserves the right to decline, withdraw, or edit advertisements at its discretion.
The publisher is not liable for omissions, spelling, clerical or printer’s errors. For more
information about classified advertising, contact Carrie Parratt at cparratt@aad.org.
FOR DISPLAY ADVERTISING INFORMATION, CONTACT:
Ascend Integrated Media, Publisher’s Representatives
One email every Wednesday.
Just a few stories.
The ones that really matter.
Because you're busy.
But you still want to know
what's going on.
Bridget Blaney (Companies A-D and Q-R)
Email: bblaney@ascendintegratedmedia.com
Phone: (773) 259-2825
Cathleen Gorby (Companies E-L and S-T)
Email: cgorby@ascendintegratedmedia.com
Phone: (913) 780-6923
Maureen Mauer (Companies M-P and Tu-Z)
Email: mmauer@ascendintegratedmedia.com
Phone: (913) 780-6633
ADVERTISING STATEMENT:
The American Academy of Dermatology and AAD Association does
not guarantee, warrant, or endorse any product or service advertised
in this publication, nor does it guarantee any claim made by the
manufacturer of such product or service.
THE AD INDEX IS PROVIDED AS A COURTESY TO OUR ADVERTISERS. THE PUBLISHER IS NOT
LIABLE FOR OMISSIONS OR SPELLING ERRORS.
DERMATOLOGY WORLD // April 2015
47
facts at your fingertips
data on display
ALL EYES ON DERMATOLOGY
J
ournalists want eyeballs—in the form of consumers of the stories they create. 2014 saw dermatologists demonstrate once again that
their work is fascinating to the public, with dermatology-related topics generating 2.1 billion media impressions, equivalent to reaching
each American more than six times. The most-covered topics were skin cancer and sun protection (43 percent of coverage) and acne (42
percent).
In addition to all of this coverage, the Academy also helped keep the public informed about skin, hair, and nail health via its public service
advertisements, which have received $14.5 million in free placements to date. Watch them at www.aad.org/PSA.
The AAD also increased its social media presence in 2014. Among its successes:
• Facebook page likes increased by 219 percent, with 34,078 new likes. The public can like the AAD at www.facebook.com/AADskin.
• Twitter followers increased by 57 percent, with 3,719 new followers. The public can follow the AAD at twitter.com/AADskin.
• Derm A to Z videos attracted significant viewership on YouTube at www.youtube.com/user/AcademyofDermatology. The top three were:
o How to check for bedbugs: 184,901 views
o Tips for treating poison ivy: 78,544 views
o Eczema: Bleach bath therapy: 14,305 views
Want to know about the stories your patients may be seeing and hearing in the media? Keep up with the Academy’s monthly Media Update
newsletter. Available in the Academy’s Media Relations Toolkit at www.aad.org/members/media-relations-toolkit, it can keep you current on
the stories patients may find in the media and ask you about when they come to your office.
Meanwhile, look below to see how the attention paid to dermatology has grown since 2002. – RICHARD NELSON dw
Media impressions about dermatology
2,500
2.2
billion
2,000
2.11
billion
2.1
billion
MILLION
2.0
billion
1,500
1.57
billion
1.61
billion
1.6
billion
1.6
billion
1.42
billion
1.39
billion
1,000
0.72
billion
0.73
billion
2002
2003
0.78
billion
500
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
YEAR
48 DERMATOLOGY WORLD // April 2015
www.aad.org/dw
Upcoming CME Activities
Closure Course and Dermatologic Surgery: Focus on Skin Cancer
Hyatt Regency Grand Cypress – Orlando, Florida
May 20-21, 2015 – Closure Course
This intense learning experience provides didactic instruction and practical experience in multiple closure
techniques, and includes numerous anatomic site-specific discussions. A hands-on laboratory session allows for
closely-monitored practice of new and complex reconstruction techniques on realistic visco-elastic models.
Information presented in the course strongly complements the activities featured in Dermatologic Surgery:
Focus on Skin Cancer (below), without direct overlap or duplication of material.
May 22-24, 2015 – Dermatologic Surgery: Focus on Skin Cancer
Top experts in cutaneous oncology and dermatopathology will present a multi-faceted program for dermatologists
and dermatologic surgeons. Presenters in interactive panel discussions will share their unique perspectives on
special tumor management, melanoma diagnosis and treatment, and reconstruction challenges. Advanced Mohs
techs will receive updates on quality assurance measures, troubleshooting, safety, and regulatory compliance in
the Mohs lab. Meeting provides an excellent follow-up to our Fundamentals of Mohs surgery technician training.
Basal and Squamous Cell Cancer Pathology for Mohs Surgeons and
Fundamentals of Mohs Surgery
DoubleTree Hotel San Diego, Mission Valley – San Diego, California
November 4, 2015 – Basal and Squamous Cell Cancer Pathology for Mohs Surgeons
Taught by Board-certified dermatopathologists, this intense one-day course will provide a “pure pathology”
experience for physicians interested in understanding the subtler characteristics of basal and squamous cell
carcinoma, the tumors most commonly treated with Mohs surgery. Participants will learn to accurately interpret
BCC and SCC in all its variations, as well as to differentiate tumor characteristics from background findings,
reactive changes present in recently biopsied tissue, etc. The Fundamentals of Mohs Surgery course, either the
full meeting or only the slide review portion – where you will be reading a large number of Mohs cases set up
as “unknowns” – is perfect for applying the knowledge gained from this pathology course.
November 5-8, 2015 – Fundamentals of Mohs Surgery
Dermatologists and other specialists will be introduced to the basic surgical and histopathologic aspects of Mohs
surgery, preparing a solid foundation for long-term proficiency in the procedure. Microscope laboratory case
review and pathologist-led small group discussions will promote greater understanding and enhanced accuracy
in this most critical facet of Mohs surgery. Intensive cryostat lab instruction will benefit Mohs technicians at all
levels of training and experience, deepening their understanding of Mohs tissue processing and the importance
of the physician-technician “team” in successful Mohs surgery.
For additional information regarding ASMS educational activities, membership opportunities, and patient resources, please contact:
Novella Rodgers, Executive Director
American Society for Mohs Surgery
5901 Warner Avenue, Box 391
Huntington Beach, CA 92649-4659
Tel: 800-616-2767 or 714-379-6262
Fax: 714-379-6272
www.mohssurgery.org
execdir@mohssurgery.org