By Dr Faisal Ali
Consultant dermatologist at Vernova Healthcare CIC, Macclesfield
As a consultant dermatologist I was already interested in innovation but the sudden onset of COVID-19 made it happen sooner rather than later.
I am based at Vernova Healthcare (BMJ Awards Dermatology Team of 2018), a secondary care department uniquely run by a community interest company which is owned by 17 GP practices in East Cheshire.
Compared to the conventional NHS, we are adaptable and it is relatively quick and easy for us to innovate where this enhances patient care. For instance, we had already gone paperless and were using the EMIS electronic patient record system to access, update and share patient information and send out documents and letters.
But the coronavirus outbreak changed things overnight as we had to radically rethink the way we work.
Our dermatology service involves carrying out the diagnosis and treatment of a wide range of skin conditions from skin cancer and psoriasis to acne and vitiligo and the majority of our work was previously carried out face to face with patients.
Social distancing created a challenge for patients and staff who would be unable to come into the clinic so the managers and clinicians had a conversation to figure out how to deliver our services remotely.
We had already been using AccuRX to communicate with our patients, which can be used to text information about appointments, share advice or notify patients of normal test results. It also links to the EMIS system and messages can be saved to patients’ medical records.
Next, we needed a virtual platform that would allow us to conduct video consultations with patients. A critical consideration was patient confidentiality and the need for any solution to meet NHS data security standards. We also needed a system that would connect with our Clinical Information System (EMIS). This ruled out some of the “off-the-shelf” digital service providers.
We were already aware of Nye - a secure browser-based consultation tool – and it was something I had wanted to trial as it enables clinicians to telephone and video call patients on any device, from anywhere, so staff could work from home and still carry out consultations.
Also, it is already being used in the NHS (Oxford region) and has been developed and tested by clinicians with due diligence paid to security issues.
We started to trial Nye on a Monday and were fully operational by Friday.
Our new consultation process now involves emailing patients a questionnaire to ask questions such as: Have you got a rash? Is the rash itchy? Is it painful? Are you taking any medication?
We ask them to email or text a photo of their rash or skin problem if they are happy and able to do so, so we can take a look at it before arranging a virtual video call.
We had never worked this way before so it was a process of trial and error at first.
Some people are unable to download the questionnaire so we will paste the questions into an email for them. But we found that over 90 per cent of patients can complete the questionnaire online and send photos to us before their video consultation.
Of course, it doesn’t work for everybody and we were concerned that a lot of our population are older people who may not have access to a computer or be confident with using email.
To make sure our services are fully accessible, we give them the option of doing the questionnaire over the phone with our healthcare assistants.
The photos being sent in by patients are of varying quality – some good, some bad, some people were sending lots which was filling up our inbox. We now tell them to send the best three pics.
Dermatology is a highly visual speciality. You can’t always tell what the skin condition is from a photo so it’s good to be able to see patients on video as a back-up.
The Nye camera features reasonable resolution which allows us to macroscopically view the patients’ skin conditions.
I’d say this new process is very effective for many patients who are social distancing. It saves them time and money travelling to the clinic and they are happy to cooperate and have a virtual consultation as they are grateful that they can be treated during lockdown.
However, for skin lesions, you can’t be 100 per cent certain it’s not cancerous so on many occasions, we do need to follow it up with a physical examination using a specialist tool known as a dermoscope, so there is an element of duplication.
One in 10 people will have a cancerous lesion on their skin that they are totally unaware of. When we see people in person, we may spot it but if we don’t see them we may miss it.
We may also miss out on non-verbal cues such as body language, facial expressions – are they itching and scratching? This can tell you a lot about how they are feeling.
One drawback I have noticed is that older people miss the social interaction and when we phone them they are happy to chat for long periods.
It makes you appreciate the face to face aspect of the job and speaking to patients - something we took for granted before.
But on the whole, it has been successful and I think it is fantastic. I’m pleased we’ve made things more efficient, accountable and accessible for patients.
The cultural mindset has shifted. The belief that dermatologists need to meet all patients face to face has been debunked as we find a lot of our work can be done virtually.
And tech has suddenly accelerated in terms of security over the last three months.
I do think virtual consultations are the way forward – accuRX and Nye are an integral part of our working practices now and I can see us continuing to do a significant proportion of remote consultations post-lockdown. It will enable staff to work more flexibly around childcare and caring for family.
But the healthcare system shouldn’t lose sight of people’s mental wellbeing and the need for social interaction and that certain conditions (such as skin cancers) may be more accurately diagnosed in person.
- Don’t be scared to innovate
- Don't underestimate the patients you're serving
- Don’t put pressure on people to use technology if they don’t want to
Story told: 22 July 2020