Training for Health Worker


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  • Training for Health Worker

    1. 1. November, 2008 Mobile Teledermatology Training for Healthcare Workers Carrie Kovarik, M.D., University of Pennsylvania Kathleen Tran, M.Sc., University of Pennsylvania Ting Shih, Director of Services, ClickDiagnostics © ClickDiagnostics, Inc. 2008
    2. 2. Outline <ul><li>Introduction to ClickDoc Mobile Teledermatology Service </li></ul><ul><li>Objectives and Tasks of the Healthcare Worker </li></ul><ul><ul><li>Capture and submit information for a teledermatology consult </li></ul></ul><ul><ul><li>Retrieve the reply to your consultation request </li></ul></ul><ul><ul><li>Follow up with patients </li></ul></ul><ul><li>Exercise </li></ul><ul><li>Appendix </li></ul><ul><ul><li>Physical Examination </li></ul></ul><ul><ul><li>Common Skin Diseases in Egypt </li></ul></ul><ul><ul><li>How to Take Good Dermatologic Photographs </li></ul></ul>
    3. 3. Introduction to ClickDoc Mobile Teledermatology Service
    4. 4. The ClickDoc Mobile Teledermatology Service <ul><li>Mobile Teledermatology is the use of a mobile phone with customized software and built-in camera to provide dermatologic services at a distance. </li></ul><ul><li>ClickDoc is a mobile-phone application that enables mobile teledermatology. </li></ul><ul><li>ClickDoc is developed by ClickDiagnostics, Inc. ( ), a social enterprise aimed at providing accessible, affordable healthcare worldwide. </li></ul>
    5. 5. <ul><ul><li>The concept is </li></ul></ul><ul><ul><li>virtual consultation : </li></ul></ul><ul><ul><li>Enabling patients to access quality doctors from anywhere! </li></ul></ul>Mobile Teledermatology
    6. 6. Mobile Teledermatology: The Benefits <ul><li>Enables fast, anywhere exchange of clinical information between healthcare workers and dermatologists </li></ul><ul><li>Eliminates the need for an interposing computer and internet where technologic resources are scarce </li></ul><ul><li>Helps combat shortages of dermatologists </li></ul><ul><li>Cost Savings </li></ul><ul><ul><li>Teledermatology will reduce the number of patients needing dermatology referrals by 80-90%* </li></ul></ul><ul><ul><li>Minimal overhead—no support staff needed </li></ul></ul>
    7. 7. Mobile Teledermatology: The Benefits <ul><li>For the PATIENT: Improves access to health care </li></ul><ul><ul><li>Patients prefer to be evaluated via telemedicine versus waiting to be seen by a provider face-to-face </li></ul></ul><ul><li>For the PROVIDER: Empowers with knowledge </li></ul><ul><ul><li>Arms the healthcare provider with medical expertise </li></ul></ul><ul><ul><li>Improves quality of care </li></ul></ul><ul><li>For the health care ORGANIZATION: </li></ul><ul><ul><li>More efficient utilization of dermatologic resources </li></ul></ul><ul><ul><li>Helps triage patients effectively </li></ul></ul>
    8. 8. Is Teledermatology Effective? <ul><li>A 2006 study of 508 patients showed that clinical outcomes using teledermatology are nearly identical to those using standard, face-to-face dermatology. 1 </li></ul><ul><li>A study showed that 90% of dermatologic conditions can be adequately managed through teledermatology </li></ul><ul><li>A study showed that diagnoses from teledermatologic and face-to-face consultations are highly concordant </li></ul>1. Pak H, Triplett C, et al. “Store-and-forward teledermatology results in similar clinical outcomes to conventional clinic-based care.” Journal of Telemedicine and Telecare. 2007; 13:26-30.
    9. 9. Objectives and Tasks of a Healthcare Worker
    10. 10. Objectives and Tasks of a Healthcare Worker <ul><li>Objectives </li></ul><ul><ul><li>Capture sufficient information for evaluation of skin conditions by a remote dermatologist </li></ul></ul><ul><ul><li>Provide diagnosis and treatment plan to patients </li></ul></ul><ul><li>Tasks </li></ul><ul><ul><li>Record patient information following instructions from ClickDoc mobile application </li></ul></ul><ul><ul><li>Submit consultation by choosing “sync” option when mobile network is in range and Obtain case ID </li></ul></ul><ul><ul><li>Take dermatologic photographs using Macro model on phone: press “send”, choose [email_address] , and type case ID in text field to submit </li></ul></ul><ul><ul><li>Check results by entering case ID </li></ul></ul><ul><ul><li>Communicate consultation results and follow up with patient </li></ul></ul>
    11. 11. 1. Record Patient Information
    12. 12. Patient’s Information <ul><li>Age </li></ul><ul><li>Gender </li></ul><ul><li>Condition </li></ul><ul><li>Duration </li></ul><ul><li>History </li></ul><ul><li>Medication Information </li></ul>
    13. 13. Patient’s Information <ul><li>1. Key in number corresponding to the age of the patient, e.g. press 5 if the patient is between 20 and 40 years old. </li></ul>2. Key in number corresponding to patient’s sex, e.g. press 2 for “Female” To go to the next screen, press # To go back to the previous screen, press *
    14. 14. Patient’s Condition <ul><li>3. Key in all numbers that apply, for instance 2, then 3. </li></ul>4. Key in correct condition duration, e.g. press 1 for “1-2 days.” To go to the next screen, press # To go back to the previous screen, press *
    15. 15. Patient’s History <ul><li>5. Key in appropriate response, e.g. key in 2 for “No.” </li></ul>To go to the next screen, press # To go back to the previous screen, press *
    16. 16. Patient’s Symptoms – First Areas <ul><li>6. Key in appropriate response for first occurrence of condition, e.g. 0 to “See more choices - ” then 9 for “All over” </li></ul>To go to the next screen, press # To go back to the previous screen, press *
    17. 17. Patient’s Symptoms – Current Areas <ul><li>7. Key in all numbers that apply, e.g. key in 1 for “Back”, 2 for “Chest”, 5 for “Legs.” </li></ul>To go to the next screen, press # To go back to the previous screen, press *
    18. 18. Patient’s Symptoms – Affected Area <ul><li>8. Key in all numbers that apply. </li></ul>To go to the next screen, press # To go back to the previous screen, press *
    19. 19. Patient’s Medication Information <ul><li>9. Key in all numbers that apply. </li></ul>To go to the next screen, press # To go back to the previous screen, press *
    20. 20. Voice Record Any Additional Information <ul><li>1. If there is any other </li></ul><ul><li>information you wish to </li></ul><ul><li>record, press 1 and </li></ul><ul><li>speak into the phone. </li></ul>2. Press 1 to stop recording. 3. If you wish to erase your voice recording and record it over again, press 1.
    21. 21. 2. Submit Consultation
    22. 22. Save Record <ul><li>Key in a pin number and remember it </li></ul>2. If you wish to save this case, press 1. If you wish to discard it, press 3. 3. Write down the case number
    23. 23. Submit for Consultation Press 3 to send patient data for consultation. To exit the application, press *
    24. 24. 3. Take Dermatologic Photographs
    25. 25. Take Picture with Phone <ul><li>Choose camera photo option and select “macro” mode (flower sign) and turn off flash </li></ul><ul><li>Stand/sit under area without direct light, shade or shadows </li></ul><ul><li>Hold camera-phone steady with two hands to ensure image is not blurry </li></ul><ul><li>Point lens toward the affected area (~1-2 inches/2.5-6cm away). Take multiple images if need to capture areas needed for diagnosis. </li></ul><ul><li>Save image or retake until image is sufficient </li></ul><ul><li>Email image to via MMS to “” and enter case ID in the text field. </li></ul>
    26. 26. 4. Check Results
    27. 27. Receiving the Reply to Your Consultation Request 1. Press 6 to view consultation result, which will outline a diagnosis and treatment plan 2. Type in patient ID To go to the next screen, press # To go back to the previous screen, press *
    28. 28. 5. Communicate and Follow Up with Patient
    29. 29. Follow-Up Guidelines <ul><li>Communicate to the patient his or her diagnosis and treatment plan </li></ul><ul><li>On a weekly basis, you should: </li></ul><ul><ul><li>Follow up with the patient on the progress of treatment </li></ul></ul><ul><ul><li>Assess whether additional consultation is needed </li></ul></ul><ul><li>Once treatment is completed, document treatment completion </li></ul><ul><li>For any mobile phone application questions or support, email [email_address] </li></ul>
    30. 30. Exercise
    31. 31. Instructions <ul><li>Start ClickDoc Application </li></ul><ul><ul><li>Turn on phone </li></ul></ul><ul><ul><li>Select Entertainment </li></ul></ul><ul><ul><li>Select Games and More </li></ul></ul><ul><ul><li>Select ClickDoc application </li></ul></ul><ul><li>Find a partner to role-play as the patient </li></ul><ul><li>Follow instructions on phone </li></ul><ul><ul><li>Record patient information </li></ul></ul><ul><ul><li>Submit consult </li></ul></ul><ul><ul><li>Capture and send dermatologic images </li></ul></ul>
    32. 32. APPENDIX <ul><li>Gathering the Patient’s History </li></ul><ul><li>The Dermatologic Physical Exam </li></ul><ul><li>Common Skin Diseases in Egypt </li></ul><ul><li>How to Take Dermatologic Photographs </li></ul><ul><ul><li>Standard Sets </li></ul></ul><ul><ul><li>Other Factors to Consider </li></ul></ul>
    33. 33. Gathering the History: The Chief Complaint <ul><li>P rovocation/Palliation </li></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>Physical factors: light, heat, cold </li></ul></ul><ul><ul><li>Trauma </li></ul></ul><ul><li>Q uality </li></ul><ul><ul><li>Itching </li></ul></ul><ul><ul><li>Burning </li></ul></ul><ul><ul><li>Painful </li></ul></ul><ul><ul><li>Initial lesion </li></ul></ul><ul><li>R adiation </li></ul><ul><ul><li>Localized vs Generalized </li></ul></ul><ul><ul><li>Centrifugal vs Centripetal </li></ul></ul><ul><li>S everity </li></ul><ul><ul><li>What made you come in? </li></ul></ul><ul><ul><li>Worsening? </li></ul></ul><ul><li>T iming </li></ul><ul><ul><li>Onset </li></ul></ul><ul><ul><li>Duration </li></ul></ul><ul><ul><li>Acute vs Intermittent vs Chronic </li></ul></ul><ul><li>In addition to clinical information prompted by the phone, the following characteristics of the condition should be noted: </li></ul>
    34. 34. Physical Examination
    35. 35. The Dermatologic Physical Exam <ul><li>Consists of inspection and palpation </li></ul><ul><ul><li>Inspection : Visual examination to characterize the morphology (form or structure) and appearance of each skin lesion </li></ul></ul><ul><ul><li>Palpation : Allows one to assess the texture, consistency (softness, firmness, fluctuance), and tenderness of a lesion. This also reassures the patient that you are not afraid of their skin lesions. </li></ul></ul>
    36. 36. The Physical Exam: What to Look for? <ul><li>Primary Lesions – examples: papules (bumps), vesicles (blisters), plaques (raised areas) </li></ul><ul><li>Secondary Changes – examples: scale, ulcers, scarring </li></ul><ul><li>Size of the lesions </li></ul><ul><li>Color of the lesions </li></ul><ul><li>Configuration – examples: circular, unilateral, well-demarcated </li></ul><ul><li>Distribution – examples: generalized, grouped, localized </li></ul>
    37. 37. Common Skin Diseases <ul><li>Eczema/Dermatitis </li></ul><ul><li>Contact dermatitis </li></ul><ul><li>Atopic dermatitis </li></ul><ul><li>Drug reactions </li></ul><ul><li>Insect Bites </li></ul><ul><li>Psoriasis </li></ul><ul><li>Other </li></ul><ul><li>Vitiligo </li></ul><ul><li>Acne </li></ul><ul><li>Infections </li></ul><ul><li>Pyoderma </li></ul><ul><li>Scabies </li></ul><ul><li>Lice </li></ul><ul><li>Tinea capitis/corporis </li></ul><ul><li>Verrucae vulgaris </li></ul><ul><li>Herpes / Zoster </li></ul><ul><li>Varicella zoster (chickenpox) </li></ul><ul><li>Molluscum contagiosum </li></ul>
    38. 38. How to Take Dermatologic Photographs (Images/information provided in this section are courtesy of Dr. Hon Pak, LTC MC)
    39. 39. Standard Views <ul><li>Standard Views </li></ul><ul><ul><li>Human body can be separated into anatomic units </li></ul></ul><ul><ul><li>Each anatomic units will have standard image sets </li></ul></ul><ul><li>Standard views/framing should be used for most if not all conditions. </li></ul><ul><ul><li>Show entire anatomic unit (e.g. trunk) if a lesion or rash is within this unit </li></ul></ul>
    40. 40. Anatomic Regions or Units (Standard Sets) <ul><li>Hands/feet/ Nails </li></ul><ul><li>Face/ Scalp </li></ul><ul><li>Genitals </li></ul><ul><li>Arms </li></ul><ul><li>Trunk </li></ul><ul><li>Legs </li></ul>
    41. 41. Face Standard Set Then Take: - Complementary Views if appropriate - Close ups (of representative lesions)
    42. 42. Hair Protocol <ul><li>Take Standard image sets for Head and Scalp </li></ul><ul><li>Take close up of involved area </li></ul><ul><li>Photos should clearly show any erythema, hair loss, scaling, or crusting </li></ul><ul><ul><li>May have to part and/or clip hair to expose the involved area </li></ul></ul>
    43. 43. Truncal Standard Set Then Take: - Complementary Views if appropriate - Close ups (of representative lesions)
    44. 44. Arm Standard Set Then Take: - Complementary Views if appropriate - Close ups (of representative lesions)
    45. 45. Leg Standard Optional Set: Then Take: - Complementary Views if appropriate - Close ups (of representative lesions)
    46. 46. Hand/Feet Standard Set Then Take: - Complementary Views if appropriate - Close ups (of representative lesions)
    47. 47. Complementary Sets If a condition involves certain locations, “complementary areas” may need to be examined or photographed. If Involved: Include Look / Ask / ? Include Hands Feet Elbows/Knees Feet Hands Groin Elbows Knees Scalp Knees Elbows Scalp Scalp Face Knees, Elbows Popliteal fossa Antecubital fossa Neck, Face, hands Antecubital fossa Popliteal fossa Neck, Face, hands Nail (any) All nails Oral Mucosa Groin Buttocks Hands & Feet Face (Eyebrows, NLF) Scalp Oral Mucosa Genitals
    48. 48. Dermatologic Photography: Factors to Consider <ul><li>Orientation </li></ul><ul><li>Framing </li></ul><ul><li>Leveling & centering </li></ul><ul><li>Close up & location </li></ul><ul><li>Symmetry </li></ul><ul><li>Background </li></ul><ul><li>Marking lesions </li></ul><ul><li>Preparation of room </li></ul><ul><li>Preparation of patient </li></ul>
    49. 49. Orientation <ul><li>Orient the camera to allow maximal utilization of space </li></ul><ul><ul><li>Most anatomic units are longer than wide –just like the image frame. </li></ul></ul><ul><ul><li>Turn the camera on its side when taking most anatomic unit pictures (face) </li></ul></ul>Good Bad
    50. 50. Framing <ul><li>Ensure that the framing shows the extent of involvement </li></ul><ul><li>Must include involved AND uninvolved area </li></ul>
    51. 51. Level & Center (BAD) Examples
    52. 52. Level & Center (Good) Examples + +
    53. 53. Close Ups <ul><li>Centered : </li></ul><ul><ul><li>The primary lesion(s) must be clearly identified, focused and centered in the close up view </li></ul></ul><ul><li>Perpendicular : </li></ul><ul><ul><li>In general, the image should be taken on a plane perpendicular to that of the lesion. </li></ul></ul><ul><li>Anatomical Location : </li></ul><ul><ul><li>Ensure that the location/anatomy is identifiable at least on one of the images </li></ul></ul>
    54. 54. Symmetry <ul><li>If the pt has multiple lesions, be sure to document symmetry </li></ul><ul><ul><li>Front/back, left/right </li></ul></ul><ul><ul><li>Take pictures of symmetric parts even if there is no abnormality on other side </li></ul></ul>
    55. 55. Background <ul><li>Background can be very distracting </li></ul><ul><li>Use a non reflectant (blue or gray) background </li></ul>Good Bad Bad
    56. 56. Marking <ul><li>If the lesion is subtle, mark it! </li></ul>
    57. 57. Preparation of room/patient <ul><li>Room size 10’ minimum </li></ul><ul><ul><li>Full length photo </li></ul></ul><ul><li>Dark blue/ Green non-reflectant cloth </li></ul><ul><ul><li>Background (Wall) </li></ul></ul><ul><ul><li>Portable drape </li></ul></ul><ul><li>Well lit room </li></ul><ul><ul><li>Avoid direct light (window) </li></ul></ul><ul><li>Stools/ Exam Table </li></ul>
    58. 58. Preparation of Patient <ul><li>Inform the patient why you are taking pictures </li></ul><ul><li>Position the patient (and yourself) comfortably </li></ul><ul><ul><li>Leads to less movement </li></ul></ul><ul><li>Instruct patient to undress appropriately </li></ul><ul><ul><li>Gown </li></ul></ul>
    59. 59. Acknowledgements <ul><li>Dr. Hon Pak </li></ul>