Published: 17.06.2020 (replaces previous version from 23.03.2020)
Teledermatology: Advice and Guidance, teletriage, video consultation and remote working
As hospital services come under increasing pressure and dermatologists are re-deployed to front line services, clinicians need to work differently. Departments will need to rapidly adapt to run significantly reduced services to support dermatology care, both in the short and long term. The focus is to reduce patient travel to GP and Provider organisations while maintaining continuity of care.
This guidance should be used to help dermatology units maintain urgent services, optimise use of medical staff, minimise additional work for GPs, and provide continuity of care with virtual patient management where possible. Dermatologists will need to comply with their own commissioners and organisations guidance in this unprecedented situation; this document aims to provide guidance and share good practice.
1. Streamline skin cancer patients on 2WW pathways, using teledermatology to triage referrals and book patients directly to surgery where possible
2. Manage urgent / on-call patients and in-patient referrals using secure nhs.net email or mobile messaging apps where possible
3. Redirect new patients through Advice and Guidance services where possible rather than referral
4. Manage referred patients by switching face-to-face clinics to teleconsultation +/- video consultation where possible (new and follow-up)
5. Optimise remote access to allow dermatology staff to continue to provide patient care from home if required
6. Facilitate virtual staff team meetings to coordinate patient care
7. Establish patient consent policies for receiving reviewing and storing patient images from health care professionals and patients.
Further information about these key principles is detailed below.
1. 2 week wait patients
Ensure that booking slots and clinic templates are adjusted to protect 2ww and urgent slots. Consider changing directly bookable 2WW services to Referral Assessment Services (RAS) with images attached, to optimise triage +/- directly book patients to skin surgery. If teledermatology is used for 2WW triage patients should ideally have their skin lesions photographed by a GP with dermoscopic training or by appointment with a medical photographer. Patient images are unlikely to be adequate for suspected melanoma / pigmented lesion triage, but may allow triage of patients with squamous cell carcinoma direct to surgery. Secure clinical image smartphone apps (eg Consultant Connect® and Pando®) can aid clinical image capture in primary care. Triage should ideally be carried out by a dermatology consultant (core member of LSMDT/SSMDT).
2WW triage models are described in Dermatology Outpatient Case Studies December 2019: Using technology to enhance service delivery
2. Urgent / on-call and emergency in-patient consultations
NHSX has produced Information Governance Advice recognising the unprecedented challenges we are all facing during the Coronavirus (COVID-19) pandemic, particularly when there is a need to share information quickly. This advice is endorsed by the Information Commissioner’s Office, the National Data Guardian and NHS Digital.
COVID-19 Information Governance Advice
Mobile messaging can be used to communicate with colleagues and patients/service users as needed, including commercial applications such as WhatsApp where there is no practical alternative. Consider what type of information you are sharing and with whom, and as much as possible limit the use of personal/confidential patient information. Commercial medical smartphone apps such as Consultant Connect®, Pando® and Hospify® can support sharing of clinical information securely between health care professionals. Departments may set up a central nhs.net e-mail address or use individual nhs.net mail for photographic images transfer between health care professionals.
3. Advice and Guidance
Dermatology departments should encourage GPs to consider Advice and Guidance (A&G) requests, or other established teledermatology pathways, rather than routine referral where possible. Advice and Guidance services can be provided through the NHS e-Referral service (e-RS) or commercial platforms. See guidance from NHSD:e-RS features that many help organisations during the Coronavirus (COVID-19) situation: Advice and Guidance
Standard NHS Advice and Guidance services involve GP / Consultant communication rather than patient / Consultant communication. However a number of platforms are already in use in primary care which can allow patients to send photographic images to the GP securely (eg eConsult® and accuRx ®), and these images can be attached to Advice and Guidance requests to reduce patient travel.For patients having images taken in the GP surgery, smartphone apps (e.g. Consultant Connect ® and Pando ®) can allow easy capture and transfer of images into A&G requests by primary care staff.
Dermatology departments with existing teledermatology Advice and Guidance or other teledermatology services should work with local GPs / commissioners to mobilise these services rather than referrals where possible. Consider working with regional dermatology departments to temporarily open wider A&G services or cross-cover for colleagues. Support for Dermatology departments who do not currently run an Advice and Guidance teledermatology service is available through the BAD or using the NHS A&G toolkit
NHS e-RS Advice and Guidance Toolkit
Although A&G usually involves direct GP and Consultant communication, a wider referrer and provider workforce may be appropriate in the response to COVID-19, including non-Consultant grade doctors and specialist nurses, in order to free up senior front-line staff for acute care.
4. Managing routine referrals
Patients should be offered the opportunity for a telephone or video-consultation at their previously allocated face-to-face appointment time-slot if possible. Trusts may already have an established videoconferencing solution such as NHS Attend Anywhere® or accuRx®.
COVID-19 Information Governance Advice encourages the use of videoconferencing to carry out consultations with patients and service users to reduce the spread of COVID 19, using video conferencing tools such as Skype, WhatsApp, Facetime as well as commercial products designed specifically for this purpose. The consent of the patient or service user is implied by them accepting the invite and entering the consultation. Safeguard personal/confidential patient information in the same way you would with any other consultation.
Departments may choose to set up a central nhs.net email for photographic images to be sent through for review by the consultant to assist teleconsultation. Patients should be advised that e-mails sent from personal email addresses to nhs.net are not guaranteed to be encrypted. Voice recognition software (eg M-modal®) is available in some Trusts to support clinic letter documentation.
Routine dermatology referrals are likely to decrease during the coronavirus pandemic, referred patients will continue to be added to provider waiting lists, with uncertainty as to when they can be seen. NHS Digital has produced advice on managing routine referrals, monitoring provider worklists and managing cancellations
e-RS features that many help organisations during the Coronavirus (COVID-19) situation
5. Providing patient care from home
Members of staff may be away from their usual place of work and isolating for different reasons. Many dermatologists will already have hospital laptops with Virtual Private Network (VPN) access to hospital systems from home. Hardware requests for laptops, and issuing of VPN licences is being accelerated in many hospitals – please discuss with your hospital Chief Clinical Information Officer, service manager and IT teams.
Hospital-approved laptops with VPN and smartcard access can allow dermatologists working from home to provide;
· Electronic Advice and Guidance to GPs
· Teletriage of GP referrals
· Telephone consultations with access to electronic patient records and blood results
Commercial platforms used through NHS contracts enable users to work on non-NHS equipment from home within Virtual Private Networks.
6. Virtual staff team meetings
NHS mail, Zoom®, Microsoft Teams® or Cisco WebEx® are widely used platforms to maintain team communication throughout the COVID-19 pandemic.
7. Patient consent
Photographic consent policies should be discussed with your health care organisation information governance and medical photography teams, as policies may vary across organisations. The following guidance relates to COVID.
Consent is required for patient images to be used for patient care, including diagnosis or triage. The consent process;
· informs the patient that there may be a difference between the accuracy of clinical care using photographs as compared to face-to-face clinical assessment
· explains how the images will be used, transmitted and stored in the health care organisation
· obtains wider consent for teaching / publication / research if relevant
Written consent is recommended (see specimen consent forms)
UK guidance on the use of mobile photographic devices in dermatology
However, where planned face-to-face consultations have been changed to non-face-to-face consultations then written patient consent may not be possible or practical. Where verbal consent only is given, the healthcare professional should document this and consent would not extend beyond direct provision of care.
When patients capture and transfer their own images – specific considerations
Patient images are usually sent to Dermatologists from GPs, via secure transfer (e.g. using e-RS or other approved platforms). During the COVID-pandemic, many new temporary pathways for transfer of patient images to dermatology departments have been established, including direct transfer of images from patients using generic e-mail services or mobile messaging. These images are often used to support telephone consultations, in a similar way to video-consultation but using ‘still’ images.
· If a clinician requests that the patient sends images, patients need to understand that there are the usual risks associated with sending any images via the internet. This constitutes a non-secure transfer and images are not subject to information governance and data protection until they have been received by the healthcare professional. Likewise any images patients take and hold on their own phones may not be secure.
· Once the image has been received by a healthcare professional, any onward data transfer and storage should meet the NHS data protection and information governance requirements of the health care organisation.
· If a clinician requests that the patient sends images, the routine documented consent process should be undertaken verbally and documented with a message explaining consent (eg ‘by sending these images you consent to them being held in your medical record’) or by sending a written patient consent form for the patient to complete and return.
· Where images are suitable for teaching, consent forms can be sent to patients electronically and either completed electronically (eg with e-signature) or patients can return a photograph of the completed printed form.
· For temporary COVID-19 generic email addresses it is advisable to set up an autoreply which can relay important information to patients, highlighting that the mailbox is not monitored actively and that the photos are sent on the understanding that the process is not secure. Mail box capacity can quickly fill up; we recommend liaising with your medical photography team to ensure photographs can be moved into a shared access point in your organisation where they can be accessed by other health care professionals as required.
· The BAD are aware that in the context of COVID-19 some dermatologists are deleting e-mailed patient images following the virtual consultation, and managing patient images as a ‘still’ form of video-consultation (where no data is stored eg NHS Attend Anywhere). Images are deleted based on clinical judgement, with documentation of verbal consent, and patients are advised to retain the images. This option is being used where there are significant resource barriers for clinicians +/- medical photographers to archive large volumes of emailed images, (particularly of common conditions such as eczema or acne where images would not normally be taken within a face-to-face consultation) or when patients do not wish to have their images stored in their hospital record. It is recommended that images are retained when they have been used to make clinical judgements on patient care.
The guidance above is intended to support departments manage patients in whom image transfer has not involved their GP, particularly patients referred prior to COVID-19 lockdown.
As part of COVID-19 recovery it is recommended that departments develop or reinstate secure long term pathways for new patients, involving either image capture in the GP surgery or secure image transfer between patient and GP (eg eConsult® and accuRx ®) with written consent attached, followed by secure transfer to dermatology departments using A&G or e-RS referral pathways, where images are automatically stored in approved NHS systems.
BAD teledermatology: http://www.bad.org.uk/healthcare-professionals/teledermatology
BAD Clinical Services Unit: https://www.bad.org.uk/healthcare-professionals/clinical-services
COVID-19: Guidance for dermatology patients for remote consultations