A teledermatology assessment service for combined routine and 2 week wait (2WW) skin lesions
The growing prevalence of skin cancers and pressure on primary care clinicians has increased waiting times for a skin lesion assessment.
If routine waiting times are long and the primary care assessor is not confident with the diagnosis, 2WW is sometimes overused. This leads to an increase in 2WW and routine waits where potentially life-threatening cancers may sit unrecognised.
Specialists often have to travel far to cover patient areas for assessment.
Situation
The Isle of Wight (IOW) is geographically isolated.
It has a small integrated dermatology unit that provides community and secondary care services to the residents.
An elderly population and lots of sunshine has led to much higher rates of skin cancer compared to national averages. This puts primary care services under huge pressure from the workload.
Clinicians who helped to reduce the workload had minimal dermatology training. This led to more referrals for lesions that were not skin cancer.
Aspiration
The IOW NHS Trust wanted to develop a solution that is easily used in primary care and readily accepted by patients.
The solution needed to:
- take quality images
- combine dermoscopy with skin lesion history
- securely send all information over the internet to dermatology consultants
Solution
Wessex Academic Health Science Network collaborated with:
- the IOW Clinical Commissioning Group
- IOW NHS Trust
- Lighthouse Medical Ltd
The group also collaborated with Gnosco, a Swedish company with experience using an app and platform for similar purposes.
The Trust’s teledermatology assessment service uses Gnosco's Dermicus app, iPhones and dermatoscope attachments. Clinicians in primary care are given training on how to use the app and kit. Practices were initially given 1 set.
GPs gain the patient's consent. Advanced nurse practitioners or paramedics then use the app and the dermatoscope attachment to take images and history. The app sends this instantly to an online platform which can be accessed through 2-factor authentication.
Dermatology consultants then diagnose the lesion and outline a management plan.
The administration team in the dermatology unit enact the plan. They place the patient into the correct clinic if a face-to-face assessment or treatment is needed. If not, the team sends the patient information about the lesion.
The administration team also phones patients who are assessed and need to be downgraded from melanoma or squamous cell carcinoma. As well as the phone call, the team sends patients information about their diagnosis.
The hospital notes system stores patients’ biopsy images. This makes it easy to share information with multidisciplinary teams and for onward referral.
Impact
The service has reduced the number of patient journeys, allowing assessment to take place at a GP surgery. Physical space in waiting rooms and clinics is freed up because of the decrease in face-to-face assessments.
Waiting targets for skin cancer services were not negatively affected by necessary changes to delivery during the COVID-19 pandemic. Consultant assessments were able to continue because the service was already set up.
The collaboration was nominated for the 2021 HSJ Primary Care Innovation Award.
Functionality
All data is encrypted in the app during transfer and no data remains on the phone itself.
The app connects to the Personal Demographic Service to confirm the patient’s identification details.
A short form is completed which is designed to cover the criteria for 2WW assessment and include any additional notes.
The app has a built-in consent function as well as photographs of the signed physical information and consent form.
The referring clinician receives a receipt notification and unique reference code. They also receive an email once the referral is assessed.
They can then log into the online platform to see the outcome of their referrals. This access is restricted by practice and the functionality can be switched off by the individual users.
The dermatology specialist and administration team then receives an email notification of a referral.
After logging into the platform, they can view and assess the images and decide on an outcome. Administration then receives an alert that the referral has been assessed.
Appointments or letters to the patient and GP are created and the case is closed. All cases can be accessed at any time or transferred into hospital notes.
The app enables the referrer to add another referral without having to enter the patient details again. This means more images can be sent for a patient with multiple moles or lesions.
Capabilities
- User-friendly app designed collaboratively with primary care.
- Full-colour high-quality images, including dermatoscopic and polarised light.
- Secure data transfer and storage to NHS Digital standards.
- Web-based platform for remote access by consultant assessment.
Scope
Primary care clinicians can easily take images of potential skin cancer lesions and record the patient history. They can do this during consultation in the surgery or at the patient’s residence.
Once familiar with the physical kit, it takes 2 to 3 minutes to put information into the app and send the referral.
Key figures and quotes
The average waiting time for routine, urgent and 2WW was 26 days.
Now, the average waiting time for referrals through Dermicus is 0.6 days, a significant reduction.
The first referrals were made in July 2019.
All GP practices on the IOW have used the service since July 2020. It has assessed more than 1,000 patients so far.
“The biggest benefit is both the speed in which we can send images across to specialists, and also how easy it is to use. Not only do patients get access to a specialist reviewing their case quicker, it can also help with the earlier detection of cancer and speed up the process for receiving treatment.”
Dr Christine Seiger, GP, Argyll House Surgery
“This system has proved to be excellent. Dermicus was very useful in separating the concerned and anxious patients with benign conditions or ones that can be easily treated in local GP practice.”
Dr Richard Ashton, Consultant Dermatologist, IOW Integrated Dermatology Service
Find out more
Case study on the Dermicus website
Wessex Academic Health Science Network Dermicus case study
Key contact
Helen Gasior, Service Lead, IOW Integrated Dermatology Service
Dr Richard Ashton, Consultant Dermatologist, IOW Integrated Dermatology Service
Dr Amy Poyner, GP with an Extended Role Dermatology, IOW Integrated Dermatology Service
Philip Daniels-May, Business Development Director, Gnosco
Disclaimer
Any virtual teledermatology 2 week wait pathway will require:
- the use of high-quality macroscopic and dermoscopic images as the ‘reasonable diagnostics’ required to exclude cancer
- a triage outcome that permits the specialist clinician to request to see the patient face-to-face if required
- the facility to communicate directly with the patient and their GP
Outcomes from the virtual teledermatology 2 week wait pathway
The clock can be stopped in 2 ways:
- if the macroscopic and dermoscopic images are taken by a member of the specialist dermatology team (for example, a medical photographer or a nurse), this counts as ‘1st diagnostic test’ so the clock can be stopped at the time the image is taken
- if the images are taken by the primary care team or in a primary care-led community hub and then reviewed by the specialist, the clock stops when ‘an appropriate member of the specialist team’ contacts the patient by telephone, video or face-to-face consultation. Determining who is ‘an appropriate member of the specialist team’ is a decision for the specialist department who have the overall clinical accountability or responsibility for this part of the pathway
For more information, read the guidance: suspected skin cancer 2 week wait pathway optimisation on the Dermatology Future NHS site.
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