Teledermatology assessment service for combined routine and 2-week wait (2WW) skin lesions
Increasing prevalence of skin cancers nationally, combined with increased pressure on primary care clinicians, has adversely affected waiting times for skin lesion assessment. Where routine waiting times are long, 2-week wait (2WW) is sometimes overused if the primary care assessor is not confident with the diagnosis. This leads to an increase in 2WW, further increasing routine waits where potentially life-threatening cancers may sit unrecognised. Geographical differences for service delivery also add to transport distances for assessments by trained specialists in many areas.
The Isle of Wight (IOW) is geographically isolated, with a small integrated dermatology unit providing community and secondary care services to the residents. An elderly population, together with high sunshine levels, has led to a much higher rate of skin cancer compared to national averages. Primary care services are under huge pressure from workload. However, increasingly clinicians working to support that pressure have minimal dermatology training, leading to increasing referral rates for non-skin cancer lesions.
To develop a solution that is easily used in primary care and readily accepted by patients, to take quality images, including dermoscopy together with a skin lesion-focussed history, sent by secure app to a mobile web platform that can be read by the dermatology consultant.
Solution and impact
Wessex Academic Health Science Network collaborated with the IOW clinical commissioning group (CCG), IOW NHS Trust, Lighthouse Medical Ltd and Gnosco (a Swedish company with a proven history of use of such an app and platform in Sweden).
iPhones and dermatoscope attachments were purchased by the department and training provided to clinicians in primary care on how to use the app and kit. One set per practice was initially provided.
Patients were consented in primary care by GPs, advanced nurse practitioners (ANPs) or paramedics who have been trained in using the app and the dermatoscope attachment. Images and history were taken and sent instantly to an online platform accessed through 2-factor authorisation, where the department’s dermatology consultant can diagnose the lesion and enter a management plan.
The administration team in the dermatology unit then enacted the plan, placing the patient directly into the correct clinic or sending the patient and GP information about the lesion if face-to-face assessment and treatment was not required.
Patients who came in for a biopsy would have their images additionally stored within the hospital notes system to allow for easy sharing of information for multidisciplinary team and onward referral.
All data is encrypted within the app during transfer with no data remaining on the phone itself. The app connects to the Patient Demographic Service to confirm correct patient identification details. A short tick and scroll template is completed that has been carefully designed to cover the criteria for 2WW assessment as well as there being a free text section for any additional notes.
There is a built in consent function within the app, together with photographs taken of the signed physical combined information/consent form. The referring clinician receives a receipt notification and unique reference code and also receives an email once the referral has been assessed. They can then log into the online platform to view the outcome of their referrals. This access is restricted by practice and the functionality can be switched off by the individual users if wished.
The dermatology specialist and administration team then receives an email notification of a referral arriving. After logging into the platform, they can view and assess the images online and decide on an outcome action which then sends an auto alert to administration that the referral has been assessed. Appointments or letters to the patient and GP are created and the case then closed. All cases are stored securely within the platform and can be accessed again at any time or transferred into hospital notes as necessary.
The app referral has a function where the referrer can add another 'referral' without having to re-enter the patient details again. This means more images can be sent through for a patient with multiple moles or lesions.
- 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
The app is designed for ease of use by primary care clinicians to be able to take accurate history and images of potential skin cancer lesions during consultation in the surgery or at the patient’s residence. Once familiar with the physical kit, it takes 2 to 3 minutes to input the information into the app and send the referral.
Combined waiting time average, including routine, urgent and 2WW was previously 26 days prior to the implementation of Dermicus and are shown below:
- Average wait for routine referrals = 33 days
- Average wait for urgent referrals = 27 days
- Average wait for 2WW referrals = 10 days
The average waiting time for referrals that have been through the Dermicus assessment is 0.6 days, which represents a clear reduction in waiting times from the previous.
The Teledermatology Assessment Service has reduced the number of patient journeys, allowing assessment to take place at own GP surgery. Physical space has been freed within the waiting room and clinics due to a decrease in face-to-face assessments.
First referrals were made in July 2019, with all GP practices on the IOW using the service since July 2020. The service has assessed more than 1,000 patients so far.
Skin cancer service waiting targets were not adversely affected by necessary changes required for delivery during the COVID-19 pandemic. Consultant assessment was able to continue due to the dramatic influence of having the service already set up.
The collaboration has been nominated for the 2021 HSJ Primary Care Innovation Award.
“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/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
Helen Gasior, service lead
Philip Daniels-May, business development director, Gnosco
Dr Richard Ashton, consultant dermatologist, IOW Integrated Dermatology Service
Dr Amy Poyner, GPwSI dermatology, IOW Integrated Dermatology Service
Current two-week wait (2WW) national cancer waiting times do not allow consultants to downgrade or withdraw a 2WW referral without discussion and agreement of the referring GP. However, NHS England and NHS Improvement supports patients being given the choice to be diagnosed virtually during the COVID-19 pandemic, with prior GP authorisation and patient agreement. Virtual 2WW dermatology pathways should:
- maintain the ability for referring clinicians and patients to choose to access 2WW face-to-face appointments if required
- maintain the ability for provider clinicians to request to see patients face-to-face if required
- use all reasonable diagnostics to exclude cancer (high quality macroscopic and dermoscopic images)
- provide direct communication with the patient and referring GP
- record the point at which, if the patient is discharged back to their GP, this is communicated to them, as the end of the 28-day Faster Diagnosis Standard pathway
These case studies summarise user and patient experiences with digital solutions along the relevant care pathway. Unless expressly stated otherwise, the apps and digital tools referenced are not supplied, distributed or endorsed by NHSX, NHS England and NHS Improvement or the Department of Health and Social Care and such parties are not liable for any injury, loss or damage arising from their use.
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