Teledermatology

Teledermatology service by UHBW

Including:

BNSSG eRS Advice and Guidance Quick Reference Guide

BNSSG guidance on Information Governance Standards when using smartphones

Continuing education with UHBristol Teledermatology Team

Bristol Dermatology provide a Teledermatology service to GP practices in Bristol and North Somerset, Somerset and beyond. This is done through a team of 7 local dermatologists who provide a turnaround time of 24-72 hours for each case. The GP and their team take a history and photographs of the skin problem and send them through a secure online system to the hospital. These are then reviewed and the consultant provides advice on the management and diagnosis of the person's skin problem.

Annually we review 3-4,000 patients using teledermatology. Approximately 70% of consultations provide guidance on how to care for the patient in the community, usually within the GP practice. The remaining 30% need hospital referral and sometimes this is through the oncall system to ensure urgent assessment. The main service provided is to:

give helpful patient management advice so that people can be managed more effectively for a range of skin problems by their own GP
provide education and guidance to GPs, so that they can use the episode to use online educational tools where relevant and include details in their appraisal education report
the service is not a substitute for the 2WW system of referral, but where a further comment is needed on a probably benign lesion, it can be done through teledermatology. A good history, high quality images and dermoscopic views are required for such assessments.
3% of the enquiries illustrate people with severe or complex problems where more urgent help might be needed through the hospital and the teledermatology service can highlight these people and provide advice as to where they should be seen.

Skin Analytics

Please see below patient information sheet 'Clinical Photography Teledermatology with Skin Analytics'.

You will have received a call from a booking co-ordinator informing you that you have been booked for a Skin Analytics appointment. Please see the guide for more information.

For local GPs in Bristol, South Glos, North Somerset and Somerset

The current platforms for Teledermatology are Rego and eRS Advice and Guidance (formerly Choose and Book). Rego is available for Somerset GPs and is hosted by UHBW.

For GPs in Bristol, North Somerset and South Glos we will be providing eRS Advice and Guidance from June 2019. The service outline and design is set down by BNSSG CCG and is the same for services run through North Bristol Trust and University Hospitals Bristol. The turnaround time for that service will be within 5 days and the norm is 1 to 2 days.

Dermatology on call

Bristol Dermatology has a range of options for clinicians requiring on call advice. See the Dermatology On Call pages. eRS can be used for on call dermatology, using the same platform and accessing in the same way. Please select the "eRS oncall Dermatology" service for this option.

BNSSG eRS Advice and Guidance Quick Reference Guide

What is it?

A service enabling GPs across BNSSG to obtain advice and guidance on diagnosis and management of skin conditions in primary care for patients who would otherwise have been referred into secondary care.

Inclusion criteria

A patient is registered with a GP practice in BNSSG
There is diagnostic or management uncertainty and would normally be referred to secondary care
Do not meet suspected cancer 2 week wait referral guidance https://cks.nice.org.uk/skin-cancers-recognition-and-referral#!scenario
Do not have a dermatological problem affecting the genital area

Things you need to send

Clinical images (regional, local and dermoscopy for lesions) (from digital camera or smartphone)
Consent form
A referral letter or dermatology referral form

Here's how

Print consent form
Take photos. Photograph the signed consent form at the same time
If the patient has good photographs on their own smartphone consider asking them to email them in instead of taking your own.
Dictate letter or complete dermatology referral form (can use skin templates integrated into EMIS to autopopulate this form)
Email photos to practice secretary (using secure NHS.net account) OR upload directly from camera into EMIS.
Secretary uploads information via the e-Referral System (e-RS), which is used for all NHS referrals nationally.
Response through the e-RS within 5 working days.
Patient will need a follow up appointment to discuss outcome and plan further treatment if required.

Using Smartphones:

If using your smartphone camera this will need to be linked to your NHS.net email account and a few other tweaks made which are outlined in the box below.

As Data Controllers you should carry out your own risk assessment regarding the use of your personal mobile phone. This helps to protect you and your patients.
To transfer the image from your smartphone onto the clinical record so it can be used in the referral you will need to either:
- Email the image to the practice secretary using NHS.net
- Alternatively hardwire the phone using its USB charging cable.

BNSSG guidance on Information Governance Standards when using smartphones:

Images shared only with secure NHS.net email
Use NHS number or patient number and initials ONLY as identifier in email header
Handset must auto-lock after 5 minutes
Handset must be passcode protected
Cloud photo sharing must be toggled off (unless using PowerPDF app)
Always Disable the Photo geotagging on smart phones
Always set the privacy controls to restrict the access of 3rd party applications to the smart Phone Camera and albums
Images must be deleted immediately after sharing/upload

Photography tips:

Remember, if the photos are not adequate, it will not be possible to comment on them and will waste your time and the time of the patient and the Dermatologist.

Assuming you will use a mobile phone or similar:

Take photo against a plain/uncluttered background eg wall of consulting room
use flash - but from > 30cm so you don't get bleach effect
if no flash have excellent lighting
take between 2 and 5 photos
for lesions remember rule of 3: Regional image (for context), local image (Macro), dermoscopy (for detail with mm scale)
take photos from different angles
take a detailed image and some from distance
for focus, tap your screen on the area of defined focus (defined by line box) for light exposure, hold your finger tip for 2-3 seconds on your screen on the area of defined focus (AE/AF lock)

Better photos get better responses

Please look at the phototips and share it with colleagues in your practice. Poor quality photos make it very difficult to provide quality teledermatology comment. photo tips

Continuing education through Teledermatology

UHBW provide monthly update sessions for GPs and their teams on how to get the most out of the Teledermatology service and to review diagnosis and treatment of people who have been referred using teledermatology. Tips on histories, taking useful and high quality photographs and reviewing examples that help GPs manage their patients better. GPs can contact david.deberker@uhbw.nhs.uk using their nhs.net accounts to find out more details and availability.