Sharing digital images of skin conditions from primary care directly with consultants at the hospital is helping reduce avoidable attendance, improve clinic utilisation and reduce waiting times for those most in need.
Skin conditions are common but, in some cases, can be life threatening. Around 13 million people in England and Wales visit their GP with a skin problem annually, and GPs can see any one of around 2,000 possible dermatological diagnoses, with each potentially presenting in a different way.1
With this complexity and frequency, it is understandable that many patients will be referred to a specialist for further review and will likely have an appointment booked with a consultant in clinic at the hospital. However, a large portion of these patients’ conditions are minor, or not in need of treatment, meaning that a lot people attending clinics, simply didn’t need to be there.
Clinicians and patients across the Royal Free group came together to deep dive into current practice, assess where improvements could be made, and rebuild the pathway from the ground up as part of their clinical practice groups (CPGs).
The outcome is a completely new and enhanced teledermatology pathway.
GPs in Barnet and Enfield are now able to refer to a local teledermatology service where, with appropriate consent, high-quality images of patients’ skin conditions are being taken by a medical photographer in primary care. Thereafter, these images are securely shared with dermatology consultants at Royal Free London via the Cerner Millennium® electronic health record (EHR). The consultants are able to remotely review photographs within the EHR and quickly make their assessment to determine the appropriate action. They can then fast track those most in need of follow-up to a clinic, helping them rapidly start treatment if they need it, or avoid individuals who need no treatment having to come to a clinic unnecessarily.
Above: The new teledermatology pathway developed by the CPG
The redesigned workflow was first trialled on paper and immediately delivered value. Once the workflow was digitised into the EHR in November 2018, the results became even more impressive. The new pathway helps to ensure patients are seen promptly, at the right place, at the right time, and with the appropriate expert for their condition.
Local GP, Dr Janet High, who was involved in the design of the new pathway sees the benefits. “We often referred patients to a general dermatology clinic with long waiting times. This meant patient anxiety, a delay in diagnosing some patients with significant diseases, and lots of patients taking up valuable appointments who didn’t need them. The teledermatology pathway has transformed this.
“Significant problems are now fast tracked into a biopsy clinic and the remaining patients rapidly receive reassurance or a management plan.”
Figure 1: Previously, all of the patients would have been referred to a clinic. An average of 35 patients each week can now avoid going to the hospital, saving time for both them and their consultants.
GPs' actions show that they are embracing the new pathway, with 38% more teledermatology referrals in 2019 than a year prior, and a decline in other types.
On average, 3,516 patients are being referred through the new pathway each year. On remote review by consultants, 1,794 patients - approximately 50% - do not require further action and can be referred back to their GP with no required treatment or put on a referral management plan.2 These are people that previously would have likely been referred to attend a clinic without having needed to. Additionally, 18% of patients are now booked directly in for a surgical procedure by the reviewing consultant - removing one extra clinic visit to the hospital prior to surgery for these people (figure 1).
While this may actually reduce income to the hospital based on their payment by results (PbR) arrangement with commissioners, it is helping the wider health system avoid the equivalent of £269,100 of unnecessary care every year.3
Thanks to digital images being accessible to them remotely, consultants are able to review more patients within their available time, from wherever is convenient for them. By identifying those who do need treatment, they can refer those individuals into clinics sooner for rapid diagnosis and treatment. The capacity of their clinic is optimised, ensuring that they are utilising their time seeing those most in need.
The pathway also helps consultants to save time communicating with GPs. Once they have completed their assessment of the photograph in Millennium, the system automatically pre-populates a letter template with their diagnosis for the Trust to send back to the patient’s GP with the consultant’s recommendations.
Most people, if asked, would choose to avoid visiting hospital and waiting to see a clinician. It can be especially frustrating for both patients and clinicians if that patient didn’t need to be there and could have avoided the trip. Ensuring that only the patients in need of follow up are referred into clinic can reduce these unnecessary trips and help those requiring treatment to be seen faster.
Waiting times have also been vastly reduced using the technology and pathway. The current waiting time for a routine face-to-face dermatology appointment at the Trust was around thirty weeks, but with teledermatology this is now just three - 90% quicker.
“Teledermatology gives us an alternative, more efficient and significantly quicker pathway, where we can review our patients and provide the right care, at the right time and at the right clinic. We are also able to share images back to the GP with diagnoses to really help educate our primary care colleagues, and help them to reassure their patients.”
- Ioulios Palamaras, CPG lead and consultant dermatologist, Royal Free London NHS Foundation Trust
With this new pathway, and the data behind it, Royal Free London is able to better understand and review ongoing clinical outcomes. They can review clinicians’ actions to ensure professionals are best using the pathway to maximise their clinics’ utilisation.
It also saves time and simplifies the process of reporting to commissioners. Previously, many hours of administration were needed to collate data and compile into their report. Now, with the majority of information generated automatically from Millennium, effort needed by RFL staff is significantly reduced, helping ensure timely reporting.
CPG lead, Ioulios Palamaras, said, “This is one of the few times that a medical software system was designed and developed with full participation of the future users and clinicians during all stages of the process. This resulted in an excellent, user-friendly and efficient IT platform that actually delivers all the requirements of the teledermatology service for all key stake holders.”
What are clinical practice groups?
London’s Royal Free group, in partnership with high-performing health system Intermountain Healthcare, and technology partner Cerner, have prioritised a number of areas that have the potential to be redesigned to reduce variance, save money, improve efficiency and provide a better patient experience.
Clinical practice groups (CPGs) are clinically-led ways of working across several hospital sites and services, aimed at tackling these areas. Pathways co-developed by the CPGs are digitised, and help to reduce unwarranted variation, ensuring that patients receive the best standard of care, wherever they are treated.
1 NHS Careers (2019) www.healthcareers.nhs.uk/explore-roles/doctors/roles-doctors/medicine/dermatology
2 Data analysed from 17 Nov 2018 - 9 Aug 2019 (265 days). 2,553 patients were reviewed, 1,250 were referred to clinic and 1,303 back to GP. Extrapolated to 3,516 appointments and 1,722 clinic referrals per year, 3,516 – 1,722 = 1,794 avoided unnecessary referrals avoided.
3 Episode cost of £150 based on NHS Improvement and NHS England 2019/20 National Tariff Payment System (outpatient code 330) of £125 + 20% uplift per dermatology referral.