Rural doctors rally to save Tele-Derm

A group of rural doctors who use the Tele-Derm dermatology service have set up a petition to lobby the government to continue funding the service, which provides specialist advice and education on dermatology to rural GPs.

Established by the Australian College of Rural and Remote Medicine (ACRRM) and hosted on its Rural and Remote Medical Education Online (RRMEO) online learning platform, Tele-Derm uses store and forward technology to provide specialist advice from a Brisbane-based dermatologist, Jim Muir, usually within 24 hours.

It also has a large educational component, allowing rural GPs and registrars to read through case studies and submit their own cases for discussion, diagnosis and advice on follow-up treatment.

First established in 2004, the service is now under threat, with the Department of Health and Ageing failing to inform ACRRM on whether funding will continue. The potential threat to Tele-Derm has infuriated doctors who regularly use the service, and they have now set up a petition to lobby the government to continue funding.

Gerry Considine, a GP registrar based in the Adelaide Hills who has used the service both as a medical student and registrar since 2009, said the service was invaluable to him.

“The beauty of it is that not only is it for GPs who want a bit of a hand with diagnosing something, but it's also for students and registrars who are still learning to get some experience and to see what other experts are saying,” Dr Considine said. “There's no other specialty where you can get that feedback in that time. It's so quick.

“The one thing I don't see that the government can ignore is that it's just so cost effective, more than face-to-face or video conference. The way that Tele-Derm works is just amazing.”

Ewen McPhee, a GP based in Emerald in Queensland, said Tele-Derm is a very responsive service that is extremely valuable for patients.

“It is fascinating, very powerful and highly valued by rural doctors because it saves people so much money on travel,” Dr McPhee said.

“Jim Muir basically provides professional consulting services 24/7 via the internet. The process is just store and forward. You take photos, you put the history in and you send it off. Sometimes within an hour Jim has got back to you.

“There is that aspect of it – store and forward consultations – but he's got over 1000 different dermatological cases where you can read cases online. It's almost like an online encyclopaedia.”

Dr Muir, a consultant dermatologist at Mater Hospital in Brisbane who also has a private practice in the suburb of Carindale, generally does the consultation work in the early morning and later at night.

“Because it's store and forward, it doesn't interfere with my face-to-face job,” he said. “If I was doing video consulting, I wouldn't be able to do my face-to-face job. You don't need video conferencing – store and forward works better for dermatology.”

Tele-Derm was initially funded as an interpretation of the Medical Specialist Outreach Assistance Program, now known as the Rural Health Outreach Fund (RHOF). As it is difficult to recruit dermatologists to visit rural areas in person, ACRRM decided to develop a virtual program instead, Vicki Sheedy, ACRRM's strategic programs manager for eHealth, said.

“Each year the funding has been extended, and we've delivered and they were happy,” Ms Sheedy said. “Since then, two things have happened that have made us nervous. One is the fact that there is now an MBS telehealth item number, but store and forward is ineligible.

“Store and forward is much better for dermatology as long as the specialist can rely on the GP to take a proper history, to do the appropriate tests and procedures, including ordering pathology or doing a biopsy, and to do the follow-up, including relevant procedures, monitoring and prescribing.

“It's almost like a virtual shared care arrangement. It's got that educational component, the up-skilling component and the specialist advice component. It's a complete package.”

Ms Sheedy said an application for continuing the funding had been sent to DoHA on January 25, with a decision expected to be finalised on March 25. However, ACRRM has yet to hear an answer.

“Funding for our project runs out this year, which is why we are starting to make a bit of a noise,” she said.

Dr Muir is paid a weekly sum for 15 hours' work, but ACRRM would like to extend the service and recruit more specialists, so has applied to extend the funding to 25 hours.

However, even in that 15 hours, Dr Muir manages to consult for over 500 patients a year at a much lower cost than even video consults could provide.

“If you do the maths, it's a third of the price of MBS telehealth initiatives,” Ms Sheedy said. “Additionally, [Dr Muir] contributes to the education of the doctors who use it. He is very respectful of the rural clinician. He knows that they are quite capable of doing procedures like biopsies and he's very supportive of them.”

Dr Muir said he first became interested in remote consultations when he was working at the Royal Brisbane Hospital in 1992 and a doctor from north Queensland with a difficult case sent him photos in the mail.

“I knew what it was from the photo so I rang him up.,” he said. “The patient had a thing called warfarin necrosis. Then when the internet came along people would send me photos in an email saying Jim, can you help me with this thing.”

He later provided a visiting service to rural Queensland, but saw the need to fill the gaps in the three months or so between visits.

“I thought that with the help of the internet, we should be able to provide a good service,” he said. “There was no point in giving doctors advice if they couldn't carry out that advice, so there is online education in how to use dermatological medicaments, how to do procedures like excisions and biopsies and things like that.

“Then it has hundreds and hundreds of cases that they can do blinded, and they are all based on a Q&A. They get a photo, they get a clinical history and they get questions like 'describe what you can see, what is your differential diagnosis, what else would you like to know or tests to order', and then they get the answers.

“Alternatively, they are all coded under their condition so if they see a case of seborrhoeic dermatitis or psoriasis and they want to look up similar cases, they just click on the diagnostic icon, and other cases they can look at will come up. And because they go into very detailed advice and treatment, I'm hoping they can adapt the treatment from that case to their own case.”

If the doctor has a particular case that needs specialist advice, they are able to log on to the website, upload photos and a clinical history, and a text message is sent to Dr Muir.

“I then look at it and send them out an answer, with turnaround in 95 per cent of cases within 24 hours," he said.

ACRRM estimates that if the service were to be funded like the MBS telehealth program, 15 hours of consulting services a week for a year would cost $537,500 to the specialist and $357,375 to the GP. Tele-Derm, on the other hand, can provide the service for $187,500.

A spokeswoman for the Department of Health and Ageing said: “The processes for determining shortlisted fundholders for the RHOF is well progressed and the Government will be able to provide advice about the outcome of the tender process in due course.”

Tele-Derm is free to ACRRM members and RRMEO subscribers, and to GPs working in defined rural areas. The petition is available at Change.org.

Posted in Australian eHealth

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