For patients in rural areas the closest dermatology practice may be hundreds of miles away. This geographic obstacle causes some people to postpone seeking specialty care, which can lead to treatment delays that can put patients at increased risk. Geisinger Health System, an academic, vertically integrated tertiary care center in Northeastern and Central Pennsylvania, utilizes physician assistants Lauren Zajac and Ashley Klinger in teledermatology so that rural Pennsylvanians can have better access to dermatological care.
The term “teledermatology” was coined in 1995 and referred to using telecommunications to improve dermatology care in rural Oregon. The model within which Zajac and Klinger practice is unique compared to how most of teledermatology is practiced nationwide.
Their practice sites are located at Geisinger satellite clinics, which house full-time primary care providers and rotating specialists. Zajac’s clinics are located in Lock Haven and Phillipsburg, and Klinger practices in Frackville. They take histories, perform examinations and photograph every patient. Biopsies, when needed, are performed by Zajac and Klinger. The clinical photos are attached to detailed notes that include treatment plans they’ve already initiated—reflecting a store-and-forward model, as opposed to live-action video conferencing.
Via Geisinger’s robust electronic medical record system, their supervising physician, Dr. Victor John Marks, reviews chart notes and photos on large high-definition computer screens in his office one to two hours away from Zajac and Klinger. Dr. Marks adds attestations to each note, commenting on diagnoses and treatment plans. The teams use various modes of communication throughout the day to enhance or modify diagnoses or management of the patients.
“At anytime, we can pick up the phone or page Dr. Marks and he’s available,” says Klinger. “If he isn’t, whoever’s covering for him is, and we have a whole team of dermatology doctors at Danville available to consult.”
Dr. Marks visits their sites each month, consulting on complicated patients whom Zajac and Klinger have scheduled specifically for those dates. It also gives him an opportunity to see how the clinic itself is operating and hear any concerns or needs they may have. The PAs return to their home base in Danville each month to see patients, participate in a journal book club and attend grand rounds.
Geisinger ensured Zajac and Klinger were well trained in the specialty before establishing their remote clinics. The two PAs spent six months at the Danville headquarters rotating among clinics in general, pediatric and surgical dermatology. They participated in educational programs involving chapter assignments, clinical images and journal reviews. Toward the end of their training period they were evaluated on clinical images, procedural dermatology and clinical pharmacology and therapeutics.
“The training in Danville was excellent. We were well prepared for practicing in the telederm program,” says Zajac, who spent five years in general dermatology before her current position.
Zajac and Klinger perform skin biopsies and some excisions of skin cancer and dysplastic nevi in their clinics. They do not perform more complicated surgeries, such as on the head and neck, instead referring those patients to Geisinger’s dermatologic surgeons. Likewise, they refer occasional cases of complex or refractory skin conditions to dermatologists in Danville, Wilkes-Barre and State College.
All three clinics are booked for months, and Geisinger is hiring additional PAs for teledermatology soon. “[Teledermatology] is a new concept for patients and providers in our area, but everyone is very receptive to this revolutionary form of medicine. This process allows Geisinger dermatology to provide another avenue for rural patients to access healthcare,” says Klinger.
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