DERMATOETHICS

CONSULTATION

A high-tech ethical twist on the curbside consult Andrew Kelsey, MSIV, Jane M. Grant-Kels, MD, and Michael Payette, MD, MBA Farmington, Connecticut

CASE SCENARIO A 4-year-old boy is brought to the children’s hospital emergency department by his mother. He presents with a diffuse rash composed of clusters of macules, papules, and ulcerations that developed over the preceding week. The lesions are painful and the child is inconsolable. He was evaluated by a general dermatologist 2 days earlier, at which time a biopsy was performed. The results are not yet available. The patient has stable vital signs. He takes no medications, and has no known allergies, recent illnesses, or known exposures. There is no pediatric dermatologist on staff and the pediatrician, infectious disease doctor, and rheumatologist are not comfortable making a diagnosis. The emergency department staff is considering admitting the patient for observation and supportive care. The mother is very worried and is pushing for answers. What is the best initial course of action? A. Locate the hospital’s medical photographer to have the patient professionally photographed and transfer encrypted images to a pediatric dermatologist. B. Keep the patient in the hospital until biopsy specimen results return and follow up with the previous dermatologist. C. Take a cell phone photograph and send the image and a short history via a cellular text message to a pediatric dermatologist. D. Obtain informed consent to photograph the child and send images and history via secured electronic mail to a pediatric dermatologist. E. Transfer the patient to an academic center where a pediatric dermatologist is on call.

DISCUSSION In our health care system there are barriers to clinical dermatology evaluations including insurance referral processes, wait time for appointments, and appointment costs. A 2011 editorial in The New England Journal of Medicine stated that the average wait time to see a dermatologist was 3 months.1 Newer options, involving telemedicine, can help address these issues. The store-and-forward model of teledermatology involves photographing a lesion or rash in question and sending the photographs electronically and securely to the appropriate specialist for review. Unfortunately, there are few formally established teledermatology programs in the United States and the vast majority of .From the Department of Dermatology, University of Connecticut Health Center, Farmington, Connecticut. Funding sources: None. Conflicts of interest: None declared. Correspondence to: Michael Payette, MD, MBA, Department of Dermatology, University of Connecticut Health Center, 21 South Rd, Farmington, CT 06032. E-mail: [email protected].

patients do not have this as an option for evaluating questionable lesions. The American Telemedicine Association reported in 2012 that there were 37 teledermatology programs available in 22 states. Some programs accept consults from distant states and even different countries.2 However, for most physicians in the country a formalized teledermatology consult is not an option. Many doctors in this situation will photograph the findings with their smartphone and send the photographs and a history to a dermatologist colleague. This type of informal consult has been described as ‘‘routine’’ for dermatologists.3 However, when it comes to telemedicine there are ethical issues to be addressed beyond the obvious technical J Am Acad Dermatol 2015;72:349-51. 0190-9622/$36.00 Ó 2014 by the American Academy of Dermatology, Inc. http://dx.doi.org/10.1016/j.jaad.2014.09.052

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concerns and compliance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996. Because technology is now integral to all aspects of medicine, including communication between physicians, we sought to consider the ethical implications of informal consultations that include photographs of patients transmitted electronically in search of a ‘‘curbside’’ consult. An issue central to the use of photographs of a patient is protection of his or her autonomy. This ethical principle states that each patient ultimately has control over his or her own body. As physicians we respect this boundary by using informed consent to explain to our patients the advantages and disadvantages of any diagnostic or treatment procedure in consideration. These formal avenues of patient interaction are straightforwardethere is no ethical dilemma.4 The issue is the off-the-record nature of an informal, or curbside, consultation. HIPAA states that any information, images, or documentation that ‘‘identifies the individual or reasonably may be used to identify the individual’’ is to be regarded as protected health information (PHI). Digital images are specifically mentioned in the HIPAA regulations published in March 2013 that came into effect on September 23, 2013. Images captured by cell phones, which fulfill the above criteria, are considered PHI and are also protected under HIPAA.4 Therefore, all images used in the care of a patient, either in an official or curbside capacity, are considered PHI and should be regarded as such. As previously alluded to, informed consent is a key step in the process of collecting images for a high-tech and ethical curbside consultation. It has previously been suggested that the patient should be informed of the use of the photographs and the

ANALYSIS OF CASE SCENARIO Given the current medicolegal landscape and the presentation of this patient there is no simple solution. Option D is the most expedient option for the child that satisfies the recommendations set forth by HIPAA. Before photographing the rash we recommend explicitly obtaining informed consent from the mother on which images will be captured, who they will be sent to, and how they will be transmitted. Some possibilities include Tiger Text (Tiger Text Inc, Santa Monica, CA), a secure multiplatform messaging application that allows images to disappear from the phone or server, or encrypted institutional email. This option will likely lead to an expert opinion, quickly. If the pediatric dermatologist

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security measures in place to protect privacy. The patient should also provide informed consent for each use of the photograph, whether for diagnosis, educational purposes, or other uses.4,5 An important addition in today’s technological climate would be to inform the patient as to who will be analyzing the images and how the images will be transmitted. The latest practice guidelines for teledermatology recommend securing images with watermarking and transmitting images with encryption or through private networks.6 Once the image and appropriate history have been transmitted to the dermatologist there are additional ethical questions. It has been suggested that curbside consultations play a role in improving communication and care coordination in medicine.7 One proposed model suggests that although no payment is rendered for these dermatologic services, there is a value to the consulted physician in the form of the honor associated with being asked to render an opinion and to teach.7 This study identified benefits including receiving an immediate answer, confirming information, optimizing patient care, and saving costs in the form of avoiding additional appointments and travel. The liabilities include the unpredictable interruption of the consult, the perception of legal risk, potential lost revenue, and the potential for suboptimal management.7 There are guidelines in the literature for how the initiator of a curbside consultation should behave and for the expert who receives the consultation. Importantly, the expert is advised to request a formal consultation if warranted.7 The literature is full of references to the fact that the legal liabilities of a curbside consultation have yet to be completely adjudicated in a court of law.4,7

who receives this information cannot make recommendations based on the images and history, he or she would likely be able to schedule the patient for an in-person and more thorough evaluation. As written, option A is the second-best choice because it satisfies the recommendations set forth by HIPAA. However, it is likely more difficult to locate the hospital photographer, if such a position exists, than to photograph the child with a portable device. In addition, we would like to acknowledge the possibility that the mother would prefer officially sanctioned photography to amateur photography. This option should be offered as an additional modality for capturing the images during the informed consent process.

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As written, option C is riskier than option D as one cannot be certain how or where the images are stored, nor can they be certain of the security measures implemented on the receiving device. Hence at this time we do not recommend transmitting patient data or PHI via cellular text messages. Option B is far too expensive given the ability for technological solutions to assist in this dilemma. The child saw a general dermatologist several days prior and a biopsy specimen was taken at that visit. Although the results were not available upon admission to the children’s hospital, the child was

BOTTOM LINE HIPAA has been updated so that PHI now includes digital images. Patients who participate in high-tech curbside consults are afforded the same legal protections under HIPAA as those who share any other health information.7 In addition, there is a body of research that proposes a framework for how the initiating and responding physician should participate in such consultations.6 These boundaries help organize and facilitate the flow of information between physicians in situations where a formal consultation may not be necessary or may not be possible.

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not in immediate or life-threatening danger. Once the child is no longer in such severe discomfort, there is no justification for continued hospitalization. Therefore, the patient can be discharged and followed up as appropriate once the biopsy specimen results are available. Option E, although it may expedite obtaining a diagnosis, is too drastic given this case. Because the child is stable, there is no need to transfer the patient to another hospital just for a pediatric dermatology evaluation. Furthermore, depending on geographic location, this may not even be a viable option.

REFERENCES 1. Darves B. Physician shortages in the specialties taking a toll. [editorial]. NEJM Career Center. 2011. 2. Hilton L. Teledermatology continues to gain as a consultation option. [editorial]. Dermatology Times. 2012. 3. Grant-Kels JM, Kels BD. The curbside consultation: legal, moral, and ethical considerations. J Am Acad Dermatol. 2012;66:827-829. 4. Scheinfeld N, Rothstein B. HIPAA, dermatology images, and the law. Semin Cutan Med Surg. 2013;32:199-204. 5. Lakdawala N, Fontanella D, Grant-Kels JM. Ethical considerations in dermatologic photography. Clin Dermatol. 2012;30:486-491. 6. Krupinski E, Burdick A, Pak H, et al. American Telemedicine Association’s practice guidelines for teledermatology. Telemed J E Health. 2008;14:289-302. 7. Cook DA, Sorensen KJ, Wilkinson JM. Value and process of curbside consultations in clinical practice: a grounded theory study. Mayo Clin Proc. 2014;89:602-614.

A high-tech ethical twist on the curbside consult.

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