RE‐AIM Framework‐Based Implementation Evaluation of Teledermatology Programs to Serve Rural Veterans

Abstract

Research ObjectiveIn fiscal year (FY) 2017, the Veterans Affairs (VA) Rural Teledermatology Program was established to enhance access to dermatology services via store‐and‐forward teledermatology, which allows primary care providers to consult with dermatologists to diagnose and manage dermatologic conditions via digital transmission of clinical history and skin images. In addition to specific guidance on expanding teledermatology programs, grantees/teledermatology hub sites were funded to support primary care staff effort and training to manage teledermatology patients and dermatologist effort to review consults.Study DesignMixed‐methods evaluation of the VA Rural Teledermatology Program was based on Glasgow (reach‐effectiveness‐adoption‐implementation‐maintenance) implementation evaluation framework. Data were obtained on the utilization of teledermatology services from the VA Corporate Data Warehouse. 14 grantee facilities completed a site report covering the degree of teledermatology implementation, barriers to and facilitators of teledermatology implementation, and state of program sustainability/maintenance for FY‐2019.Population Studied14 primary hub grantees/facilities supporting 247 additional “spoke” care locations, with 235,544 unique dermatology encounters for Veterans in FY‐2019.Principal FindingsReach: Participating hub and spoke sites had 47 342 teledermatology encounters among 44 774 unique patients in FY‐2019, a 42.4% increase since FY‐2016 (year before program began) (P < 001, chi‐square national level data).Effectiveness: For this program, a measure of effectiveness is the percentage of dermatology encounters occurring through teledermatology. In FY‐2019, 20.1% of dermatology visits at the funded sites were via teledermatology, an increase from 15.1% from FY‐2016. Paired t test showed no significant change (P < .10). Nationally, 10.2% of FY‐2019 dermatology encounters were via teledermatology (8.5% if FY‐2016). Among the patients seen by teledermatology at grantee sites in FY‐2019, 1389 had an associated diagnosis of skin cancer, including 58 melanomas.Adoption: Adoption of teledermatology was assessed utilizing a modification of Stages of Implementation Completion. All 14 grantees report broad implementation of teledermatology within their medical center/health care system, compared to approximate half of grantees at the conclusion of the program’s first year.Implementation: There is generally strong support from key stakeholders. However, the greatest areas of most minor concern related to support form telehealth support staff, clinical application coordinators, and primary care providers. Based on analysis of open‐ended survey questions, sites engaged in a wide variety of strategies to enhance implementation of teledermatology, including outreach to primary care providers, events specifically related to teledermatology, and a variety of training activities. Nevertheless, there is a continuing need at some sites to address staffing issues and collaboration between primary care and dermatology.Maintenance: Based on the Mancini and Marek Program Sustainability Index, there is indication that sites generally report a high degree of potential sustainability for the teledermatology programs. Potential challenges may relate to ensuring stakeholder collaboration, funding, and being prepared to respond to changing program needs.ConclusionsAn overall high degree of implementation and sustainability of teledermatology is reflected in the noted successes of grantees and large number of patients served.Implications for Policy or PracticeAsynchronous tele‐health programs may increase access to specialty care, especially for rural patients. Providing program guidance and initial staffing and training resources can increase the impact of these programs. However, specific efforts aimed at enhancing primary care‐specialty collaboration are needed.Primary Funding SourceDepartment of Veterans Affairs.