Digital innovation to support the redesign and delivery of a community dermatology service

In 2017, the dermatology department at Luton and Dunstable University was given the opportunity to comprehensively redesign the service.

Situation

Before the introduction of the new digital pathway for dermatology referrals, 100% of 2 week wait (2ww) cancer referrals were seen in a face-to-face outpatient clinic.

Expensive agency locums were needed to maintain targets.

An audit showed that the locum biopsy rate was higher than if patients were assessed by consultant dermatologists. This meant unnecessary costs for the stretched department.

Aspiration

The department wanted to resolve 4 main challenges.

• The department wanted to keep hospital ward referrals timely and efficient while it relocated to a new purpose-designed space.
• Skin cancer referrals had increased by 20%.
• It wanted to reduce high consultant vacancy rates which forced it to spend a significant amount on locum healthcare providers for the department.
• It wanted to reduce spend on ‘see and treat’ one-stop 2ww cancer clinics which were, in part, maintained by agency locums.

While solving the challenges, the team wanted to:

• demonstrate quality outcomes including high patient and staff satisfaction
• reduce locum costs
• use existing staff to support the wards and cancer pathways without breaching targets

Finally, the team wanted to digitise the inpatient secondary care referral pathway to reduce travel between sites and the 2ww skin cancer clinics.

Solution and impact

The team worked with Open Medical to implement Pathpoint eDerma, a cloud-based teledermatology system.

Pathpoint eDerma streamlines both acute ward referrals and GP 2ww cancer pathways.

The platform supports the entire patient pathway from initial referral in primary and secondary care to management and discharge.

Trained dermatology nurses capture an accurate patient history. They use iPads to take high-quality macroscopic and dermoscopic photos of lesions before a virtual assessment by a consultant dermatologist.

The majority of assessments are remote, which was beneficial during the COVID-19 pandemic.

For ward referrals, nurses capture information on a different customised template. Dermatologists then triage patients and give advice on condition management from their offsite location. This approach meant only 15% of ward patients needed a face-to-face ward round.

Pathpoint eDerma also serves as a clinical workflow tool to organise multiple aspects of the patient pathway. This includes:

• biopsy lists
• multidisciplinary
• clinical governance assessments

Analysis of outcomes shows that the team does not duplicate contact with the service. Their teledermatology diagnosis accuracy is as good as a face-to-face appointment.

Functionality

Pathpoint eDerma:

• has a teledermatology workflow
• includes digital biopsy planning
• integrates with NHS Spine or e-referral service and the local electronic patient record
• includes patient-reported clinical outcomes
• is accessible from any organisation with access to the NHS Health and Social Care Network
• is developed in accordance with the published British Association of Dermatologists Quality Standards for Teledermatology
• is deployed on the Health and Social Care Network and uses 128-bit SSL encryption

Clinicians can:

• triage referrals
• automatically send patient and GP letters
• have video consultations with patients
• safely attach images for patients and other clinicians
• get consent digitally from patients

Capabilities

• Pathpoint eDerma is a paper-free system that reduces administration times.
• Patients are put into the right pathway immediately through efficient remote inpatient and outpatient referrals.
• Pathpoint eDerma is fully compliant with NHS digital information governance requirements, including GDPR.
• It provides an effective, robust and customisable solution for managing a busy multi-site dermatology department.
• The system bridges primary and secondary care services.
• There is now a safe and secure environment to store patient data and share information between doctors.
• Clinicals can save images and code them to specific diagnoses.
• Members of the clinical team can access images and diagnoses at any point to support education and training.
• Assessments include macroscopic and dermoscopic images helping GPs increase their confidence in diagnosing lesions.
• Outcomes are automatically generated and do not need more dictation.
• A built-in minor surgical procedure planner makes tracking easy.

Scope

Pathpoint eDerma is used in a clinical setting.

Demographics are populated automatically from NHS Spine.

Data is captured in real-time and coded using SNOMED CT terminology. As a result, Pathpoint eDerma supports the team with ongoing audit and quality improvements.

Key learning points

Having looked at alternative systems, this model allowed the team to achieve all the aims for their secondary care community service with their permanent staff.

The team would encourage other organisations facing similar challenges to engage at all points with their service redesign projects. This is because clinicians are most likely to develop effective solutions.

Key figures

Patient satisfaction

• 96% of patients surveyed strongly agreed or agreed that they were happy to see a dermatology nurse for assessment in the eDerma clinic. This enabled the 2ww clock to stop, meeting the first attendance target.
• 96% of patients would recommend the eDerma nurse assessment clinic to their friends and family.
• 100% of patients were satisfied with having their assessments reviewed by a dermatology consultant following the nurse-led clinic.

Financials and efficiency

• In the 1st year, the team saved £160,000 on agency locum costs and £100,000 on consultant support for ward referrals.
• 97% of urgent skin cancer referrals were assessed within 48 hours.
• 41% of referrals were discharged at first attendance.
• The average consultant dermatologist assessment took 6 minutes. This means there is potential for 40 2ww assessments per session.

Clinician satisfaction

• 100% of clinicians surveyed agreed managing patients has become more efficient.
• 100% of clinicians surveyed agreed that unnecessary face-to-face appointments have reduced.
• The eDerma teledermatology skin cancer pathway is as good at diagnosing skin cancer as a face-to-face skin cancer clinic.

The department was highly commended at the 11th BMJ Awards for Dermatology Team of the Year 2019. The commendation was for the success of the new department and pioneering digital innovation after the implementation of Pathpoint eDerma and new models of care.

The team has presented their outcomes at national meetings and had a positive Getting It Right First Time review.

Key contact

Dr Bernadette De Silva, Clinical Director for Dermatology, Luton and Dunstable University Hospital, Bedfordshire Hospitals NHS Foundation Trust

bernadette.desilva@ldh.nhs.uk

Open Medical

ederma@openmedical.co.uk