Training for Health Worker

November, 2008

Mobile Teledermatology Training

for Healthcare Workers

http://ClickDiagnostics.com

Carrie Kovarik, M.D., University of Pennsylvania

Kathleen Tran, M.Sc., University of Pennsylvania

Ting Shih, Director of Services, ClickDiagnostics

© ClickDiagnostics, Inc. 2008

http://telederm.org/click/default.asp


OutlineOutline Introduction to ClickDoc Mobile Teledermatology Service Objectives and Tasks of the Healthcare Worker

1. Capture and submit information for a teledermatology consult2. Retrieve the reply to your consultation request3. Follow up with patients

Exercise Appendix

o Physical Examinationo Common Skin Diseases in Egypto How to Take Good Dermatologic Photographs


Introduction to Introduction to ClickDocClickDoc Mobile Teledermatology ServiceMobile Teledermatology Service


The The ClickDocClickDoc Mobile Teledermatology Service Mobile Teledermatology Service Mobile Teledermatology is the use of a mobile phone with

customized software and built-in camera to provide dermatologic services at a distance.

ClickDoc is a mobile-phone application that enables mobile teledermatology.

ClickDoc is developed by ClickDiagnostics, Inc. (http://www.clickdiagnostics.com), a social enterprise aimed at providing accessible, affordable healthcare worldwide.


The concept is virtual consultation:

Enabling patients to access quality doctors from anywhere!

Mobile TeledermatologyMobile Teledermatology


Mobile Teledermatology: The BenefitsMobile Teledermatology: The Benefits Enables fast, anywhere exchange of clinical information

between healthcare workers and dermatologists

Eliminates the need for an interposing computer and internet where technologic resources are scarce

Helps combat shortages of dermatologists

Cost Savingso Teledermatology will reduce the number of patients

needing dermatology referrals by 80-90%*o Minimal overhead—no support staff needed


Mobile Teledermatology: The Benefits

For the PATIENT: Improves access to health careo Patients prefer to be evaluated via telemedicine versus waiting to

be seen by a provider face-to-face

For the PROVIDER: Empowers with knowledgeo Arms the healthcare provider with medical expertiseo Improves quality of care

For the health care ORGANIZATION: o More efficient utilization of dermatologic resourceso Helps triage patients effectively


Is Teledermatology Effective? Is Teledermatology Effective?

A 2006 study of 508 patients showed that clinical outcomes using teledermatology are nearly identical to those using standard, face-to-face dermatology.1

A study showed that 90% of dermatologic conditions can be adequately managed through teledermatology

A study showed that diagnoses from teledermatologic and face-to-face consultations are highly concordant

1. Pak H, Triplett C, et al. “Store-and-forward teledermatology results in similar clinical outcomes to conventional clinic-based care.” Journal of Telemedicine and Telecare. 2007; 13:26-30.


Objectives and Tasks Objectives and Tasks of a Healthcare Workerof a Healthcare Worker


Objectives and Tasks of a Healthcare WorkerObjectives and Tasks of a Healthcare Worker Objectives

1. Capture sufficient information for evaluation of skin conditions by a remote dermatologist

2. Provide diagnosis and treatment plan to patients Tasks

1. Record patient information following instructions from ClickDoc mobile application

2. Submit consultation by choosing “sync” option when mobile network is in range and Obtain case ID

3. Take dermatologic photographs using Macro model on phone: press “send”, choose [email protected], and type case ID in text field to submit

4. Check results by entering case ID5. Communicate consultation results and follow up with patient


1. Record Patient Information1. Record Patient Information


Patient’s InformationPatient’s Information Age Gender Condition Duration History Medication Information


Patient’s InformationPatient’s Information

1. Key in number corresponding to the age of the patient, e.g. press 5 if the patient is between 20 and 40 years old.

2. Key in number corresponding to patient’s sex, e.g. press 2 for “Female”

To go to the next screen, press #To go back to the previous screen, press *


Patient’s ConditionPatient’s Condition

3. Key in all numbers that apply, for instance 2, then 3.

4. Key in correct condition duration, e.g. press 1 for “1-2 days.”



Patient’s HistoryPatient’s History

5. Key in appropriate response, e.g. key in 2 for “No.”



Patient’s Symptoms – First AreasPatient’s Symptoms – First Areas

6. Key in appropriate response for first occurrence of condition, e.g. 0 to “See more choices - ” then 9 for “All over”



Patient’s Symptoms – Current AreasPatient’s Symptoms – Current Areas

7. Key in all numbers that apply, e.g. key in 1 for “Back”, 2 for “Chest”, 5 for “Legs.”



Patient’s Symptoms – Affected AreaPatient’s Symptoms – Affected Area

8. Key in all numbers that apply.



Patient’s Medication InformationPatient’s Medication Information

9. Key in all numbers that apply.



Voice Record Any Additional InformationVoice Record Any Additional Information

1. If there is any other information you wish to record, press 1 and speak into the phone.

2. Press 1 to stop recording.

3. If you wish to erase your voice recording and record it over again, press 1.


2. Submit Consultation2. Submit Consultation


Save RecordSave Record

1. Key in a pin number and remember it

2. If you wish to save this case, press 1. If you wish to discard it, press 3.

3. Write down the case number


Submit for ConsultationSubmit for Consultation

Press 3 to send patient data for

consultation.

To exit the application, press *


3. Take Dermatologic Photographs3. Take Dermatologic Photographs


Take Picture with PhoneTake Picture with Phone

1. Choose camera photo option and select “macro” mode (flower sign) and turn off flash

2. Stand/sit under area without direct light, shade or shadows

3. Hold camera-phone steady with two hands to ensure image is not blurry

4. Point lens toward the affected area (~1-2 inches/2.5-6cm away). Take multiple images if need to capture areas needed for diagnosis.

5. Save image or retake until image is sufficient6. Email image to via MMS to

“[email protected]” and enter case ID in the text field.


4. Check Results4. Check Results


Receiving the Reply to Your Consultation RequestReceiving the Reply to Your Consultation Request

1. Press 6 to view consultation result, which will outline a diagnosis and treatment plan

2. Type in patient ID



5. Communicate and Follow Up 5. Communicate and Follow Up with Patientwith Patient


Follow-Up Guidelines Communicate to the patient his or her diagnosis and

treatment plan

On a weekly basis, you should:o Follow up with the patient on the progress of treatmento Assess whether additional consultation is needed

Once treatment is completed, document treatment completion

For any mobile phone application questions or support, email [email protected]


ExerciseExercise


InstructionsInstructions Start ClickDoc Application

o Turn on phoneo Select Entertainmento Select Games and Moreo Select ClickDoc application

Find a partner to role-play as the patient

Follow instructions on phoneo Record patient informationo Submit consulto Capture and send dermatologic images


APPENDIX Gathering the Patient’s History

The Dermatologic Physical Exam

Common Skin Diseases in Egypt

How to Take Dermatologic Photographso Standard Setso Other Factors to Consider


Gathering the History: The Chief ComplaintGathering the History: The Chief Complaint

Provocation/Palliationo Medicationso Physical factors: light, heat,

coldo Trauma

Qualityo Itchingo Burningo Painfulo Initial lesion

Radiationo Localized vs Generalizedo Centrifugal vs Centripetal

Severityo What made you come in?o Worsening?

Timingo Onseto Durationo Acute vs Intermittent vs Chronic

In addition to clinical information prompted by the phone, the following characteristics of the condition should be noted:


Physical ExaminationPhysical Examination


The Dermatologic Physical ExamThe Dermatologic Physical Exam Consists of inspection and palpation

o Inspection: Visual examination to characterize the morphology (form or structure) and appearance of each skin lesion

o Palpation: Allows one to assess the texture, consistency (softness, firmness, fluctuance), and tenderness of a lesion. This also reassures the patient that you are not afraid of their skin lesions.


The Physical Exam: What to Look for? Primary LesionsPrimary Lesions – examples: papules (bumps), vesicles – examples: papules (bumps), vesicles

(blisters), plaques (raised areas)(blisters), plaques (raised areas) Secondary ChangesSecondary Changes – examples: scale, ulcers, scarring – examples: scale, ulcers, scarring SizeSize of the lesions of the lesions ColorColor of the lesions of the lesions ConfigurationConfiguration – examples: circular, unilateral, well- – examples: circular, unilateral, well-

demarcateddemarcated Distribution Distribution – examples: generalized, grouped, localized– examples: generalized, grouped, localized


Common Skin DiseasesCommon Skin Diseases

Eczema/DermatitisEczema/Dermatitis Contact dermatitisContact dermatitis Atopic dermatitisAtopic dermatitis Drug reactionsDrug reactions Insect BitesInsect Bites PsoriasisPsoriasis

OtherOther VitiligoVitiligo AcneAcne

InfectionsInfections PyodermaPyoderma ScabiesScabies LiceLice Tinea capitis/corporisTinea capitis/corporis Verrucae vulgarisVerrucae vulgaris Herpes / ZosterHerpes / Zoster Varicella zoster Varicella zoster

(chickenpox)(chickenpox) Molluscum contagiosumMolluscum contagiosum


How to TakeHow to TakeDermatologic PhotographsDermatologic Photographs

(Images/information provided in this section are (Images/information provided in this section are courtesy of Dr. Hon Pak, LTC MC)courtesy of Dr. Hon Pak, LTC MC)


Standard Views Standard ViewsStandard Views

o Human body can be separated into anatomic unitsHuman body can be separated into anatomic unitso Each anatomic units will have standard image setsEach anatomic units will have standard image sets

Standard views/framing should be used for most if not all Standard views/framing should be used for most if not all conditions. conditions. o Show entire anatomic unit (e.g. trunk) if a lesion or rash is Show entire anatomic unit (e.g. trunk) if a lesion or rash is

within this unitwithin this unit


Anatomic Regions or Units (Standard Sets)Anatomic Regions or Units (Standard Sets) Hands/feet/ NailsHands/feet/ Nails Face/ ScalpFace/ Scalp GenitalsGenitals ArmsArms TrunkTrunk LegsLegs


Face Standard SetFace Standard Set

Then Take:- Complementary Views if

appropriate- Close ups (of representative

lesions)


Hair ProtocolHair Protocol

Take Standard image sets for Head Take Standard image sets for Head and Scalpand Scalp

Take close up of involved areaTake close up of involved area Photos should clearly show any Photos should clearly show any

erythema, hair loss, scaling, or erythema, hair loss, scaling, or crustingcrustingo May have to part and/or clip hair to

expose the involved area


Truncal Standard SetTruncal Standard Set

Then Take: - Complementary Views if appropriate- Close ups (of representative lesions)


Arm Standard SetArm Standard Set



Leg StandardLeg StandardOptional Set:Optional Set:



Hand/Feet Standard SetHand/Feet Standard Set

Then Take:- Complementary Views if appropriate- Close ups (of representative lesions)


Complementary SetsComplementary SetsIf a condition involves certain locations,

“complementary areas” may need to be examined or photographed.

If Involved: Include Look / Ask / ? Include

Hands Feet Elbows/KneesFeet Hands GroinElbows Knees ScalpKnees Elbows ScalpScalp Face Knees, ElbowsPopliteal fossa Antecubital fossa

Neck, Face, handsAntecubital fossa Popliteal fossa

Neck, Face, handsNail (any) All nails Oral

MucosaGroin Buttocks Hands &

FeetFace (Eyebrows, NLF) ScalpOral Mucosa Genitals


Dermatologic Photography: Factors to Dermatologic Photography: Factors to ConsiderConsider

Orientation Framing Leveling & centering Close up & location Symmetry Background Marking lesions Preparation of room Preparation of patient


OrientationOrientation Orient the camera to allow

maximal utilization of spaceo Most anatomic units are

longer than wide –just like the image frame.

o Turn the camera on its side when taking most anatomic unit pictures (face)

Good

Bad


FramingFraming Ensure that the framing shows

the extent of involvement Must include involved AND

uninvolved area


Level & Center (BAD) ExamplesLevel & Center (BAD) Examples


Level & Center (Good) ExamplesLevel & Center (Good) Examples

++


Close UpsClose Ups Centered:

o The primary lesion(s) must be clearly identified, focused and centered in the close up view

Perpendicular: o In general, the image

should be taken on a plane perpendicular to that of the lesion.

Anatomical Location: o Ensure that the

location/anatomy is identifiable at least on one of the images


SymmetrySymmetry If the pt has multiple lesions, be

sure to document symmetryo Front/back, left/righto Take pictures of symmetric

parts even if there is no abnormality on other side


BackgroundBackground Background can be very

distracting Use a non reflectant (blue or gray)

background

Good

BadBad


MarkingMarking

If the lesion is subtle, mark it!


Preparation of room/patientPreparation of room/patient Room size 10’ minimum

o Full length photo Dark blue/ Green non-reflectant cloth

o Background (Wall)o Portable drape

Well lit roomo Avoid direct light (window)

Stools/ Exam Table


Preparation of PatientPreparation of Patient

Inform the patient why you are taking pictures

Position the patient (and yourself) comfortably o Leads to less movement

Instruct patient to undress appropriatelyo Gown


Acknowledgements Dr. Hon Pak

Health & Medicine

Training for Health Worker