Chapter 9: Teledermatology

“Around 2001, teleconsultation of a 17 days old child from Louisiana with a red patch on the face was performed with dermatologists at Brooke Army Medical Center (see Figure 9-1). Given the association of hemangiomas on lips with upper respiratory involvement, the dermatologists requested additional information and confirmed some respiratory symptoms that the pediatrician was attributing to potential asthma. The mother drove 8 hours and brought her child to San Antonio, Texas for an in person evaluation the next day where the child was found to have increasing respiratory difficulty. Ear, nose, and throat (ENT) consultation revealed a significant hemangioma in the upper airway. A few days later, the patient had surgery and left the hospital in great condition. We saved a life.”

Teledermatology is the practice of dermatology using information communication technologies. Teledermatology has experienced an explosive growth in the last several years as health care reform accelerates. As technologies continue to evolve, teledermatology will also evolve as digital skin imaging advances. Teledermatology is well suited for telehealth given the visual nature of the specialty, and it is one of the most mature and well-studied telemedicine applications. Use of teledermatology was first published by Murphy and Bird using a two-way audiovisual microwave circuit at Massachusetts General Hospital to 1,000 patients 2.7 miles away at the Logan International Airport. ¹ Teledermatology is now widespread in its use, as documented by an American Telemedicine Association (ATA) Current Active Teledermatology Programs survey ² (survey is being updated; personal communication with Dr. April Armstrong et al.). Teledermatology is being used by many health care organizations, including federal and state entities (eg, Department of Veterans Affairs [VA], Department of Defense [DoD], Federally Qualified Health Center [FQHC]), academic medical centers, and private/group practices and is being reimbursed by many payors. Although Medicare reimbursement for teledermatology has not changed, state and commercial reimbursement is rapidly evolving to cover teledermatology. Recent health care reforms emphasize value-based care. As virtual care becomes more integrated into mainstream medicine, there is also a shift of focus to a) education of providers and patients, b) quality assessments, and c) resource utilization as part of the value-based care. Finally, direct to patient/consumer teledermatology has had exponential growth, and it will likely increase in demand.

This chapter will review the different modalities used in the practice of teledermatology and the different models of implementation, such as teleconsultation and teletriage. The current status of legislation and its impact on the practice of teledermatology, credentialing and privileging, prescribing, and licensure will be discussed. The challenges facing teledermatology will be addressed, including reimbursement, quality management, and electronic health record (EHR) integration. Existing practice guidelines and other teledermatology resources will be presented. The chapter will conclude with a brief review of teledermatology's evidence base and resources.

Live Video (Synchronous)

Live two-way interaction between a person and a provider using audiovisual telecommunications technology. This type of service is also referred to as “real-time” or “synchronous.” Live video can be used for both consultative and diagnostic and treatment services.

Store-and-Forward (Asynchronous)

Transmission of recorded health information (eg, history, digital photos, pre-recorded videos) through a secure electronic communications system to a practitioner, usually a specialist, who uses the information to evaluate the case and render a diagnosis or disposition. As compared to a real-time visit, this asynchronous service provides access to data after they have been collected and involves communication tools such as a secure website, mobile application, or email.

Hybrid

A combination of store-and-forward and live interactive modalities can be used to leverage the strengths of each modality. However, it suffers from the live video limitation of scheduling scalability.

We do not consider mobile health a separate modality because it can support any of the three modalities. It typically involves the use of mobile communication devices such as cell phones and tablet computers. Applications range from self-education, self-referrals, and on-demand care or as part of traditional teledermatology programs specifically to increase convenience and access to patients.

Teleconsultation

A referring provider (commonly primary care but could be any specialty, including dermatology) sends a consult to a dermatologist for diagnostic review and/or management recommendation. In this model, the consultant's recommendation is returned to the referring provider for all management and follow-up. The referring provider takes full ownership of the patient. There is usually a history and data capture from the referring site.

Telereferral

In this model, the referring provider sends the patient as is done with traditional referral to a dermatologist, but the dermatologist who is evaluating the patient virtually takes control over managing the patient.

Teletriage

A variant of the telereferral model, a virtual dermatologist typically evaluates each case being referred for triaging and disposition purposes with the goal of improving access to appropriate conditions requiring urgent evaluation. Typically, this model is used by an organization to optimize resources to route patients to the most appropriate level of care (eg, Kaiser Permanente).

Direct to Patient

We are proposing new terminology to differentiate direct to patient (DTP) and direct to consumer (DTC). Although many feel that this differentiation is subtle, we believe that this new proposed categorization will help inform regulatory policy; but most importantly, it will bring clarity and transparency to patients utilizing teledermatology. We propose that in this model, a provider either has an established relationship with a patient or has access to necessary medical records and is able to provide appropriate follow-up. This can be done most easily within the VA, Kaiser Permanente, or other large integrated delivery systems that have integrated EHRs.

Direct to Consumer

We are proposing that we limit this term to interactions without an established provider–patient relationship and/or without an integrated delivery system and available EHR. This is largely on-demand teledermatology where the information submitted (via smart phone, laptop, or personal computer) is provided by the consumer and used for the convenience of the consumer. Separating DTC from DTP reflects how teledermatology is being conducted and its implications related to quality and safety.

Miscellaneous

Given the rise of urgent clinics now using EHRs and telemedicine, teledermatology in this setting could be seen as a teleconsultation or telereferral. Mobile apps are not a separate model, but rather a technology that can enable any modality or that can support any of the models. Mobile apps are increasingly used for self-help or education. In the future, imaging diagnostics may be supported via mobile apps; however, at this time, we are not aware of any validated apps that allow patients to accurately auto-diagnose skin conditions.

Policy

There are numerous policy challenges. Providers must be licensed in the state where the patient is located. Full and unrestricted licenses are required with rare exceptions. Few states allow reciprocity with neighboring states or conditional telemedicine licenses. Interstate licensure for telemedicine continues to be a barrier to wider adoption and will not be discussed in detail here. However, the Federation of State Medical Boards (FSMB) Interstate Medical Licensure Compact was originally adopted in 2015 by legislators in Alabama, passing the threshold of seven states needed to enact the compact. ³ Eighteen states have enacted the compact to date. The compact simplifies the licensing procedure and will enable more physicians to treat people in more states through the use of telemedicine. Updates on the compact are available. This compact aims to expedite physician licensure in the states that have adopted it. Licensees would still need to be licensed in each state where they treat patients, either in person or using telemedicine. Physicians also need to comply with the law of each state in which they provide care, and states retain disciplinary authority. The compact does not create reciprocity or a single multistate license. Participation in the compact is voluntary for both states and physicians.

Electronic Health Record Integration

With the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 and Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), whose final rule was released in October 2016 by the Centers for Medicare & Medicaid Services (CMS), EHR adoption has substantially increased. ⁴ In 2015, 96% of all nonfederal acute care hospitals possessed certified health information technology (HIT). Small rural and small urban hospitals had the lowest rates at 94%. Ninety-six percent of critical access hospitals (CAHs) had certified HIT, whereas 98% of large hospitals and 97% of medium hospitals had certified HIT—the highest rates among these hospital types.

EHR certification did not include a telehealth requirement or, importantly, the interoperability needed to support telemedicine. Most telemedicine services in use today are not present or fully integrated into EHRs. There are exceptions, such as the VA, which is using its EHR to support store-and-forward teledermatology capability. Furthermore, the large EHR vendors do not have integrated telehealth capabilities (store-and-forward or real-time), which renders the use of telemedicine burdensome to providers. Some existing and new EHR vendors have begun offering telemedicine capability, but do not support interoperability outside the system. As an example, most EHRs cannot send a virtual consult order from the existing consult module to an outside network provider who can answer and return the consult back to the originating provider in the EHR where the consult was generated. We believe that there is a significant opportunity, especially through Fast Healthcare Interoperability Resources (FHIR) and Health Information Exchanges (HIEs), to support teledermatology portability and interoperability.

Maintaining Quality

The ATA and the American Academy of Dermatology (AAD) have established a set of guidelines for teledermatology. Although many programs are using these guidelines, there is currently no concrete measure of the level of compliance for quality and patient safety. The ATA offers an accreditation program to address the growing issue of quality, especially for virtual health or DTC or DTP telemedicine service providers who are seeing rapid growth.

In a recent study, Resneck and colleagues noted that DTC teledermatology is expanding rapidly but has not been well studied. ⁵ To test some of these DTC sites, the researchers posed as patients with skin-related symptoms. They received responses from 16 DTC sites for 62 online visits in February and March 2016. The hypothetical patients submitted photos of various cancerous, inflammatory, and infectious skin conditions to teledermatology websites offering services to California residents. They claimed to be uninsured and paid fees using Visa gift cards. Incorrect diagnoses, inappropriate treatments, lack of information about possible side effects and risks, and lack of transparency about a doctor's credentials were among the concerns raised in the study. No sites asked for proof of identification, and licensing information was provided in only about a quarter of cases. Some of the sites used foreign physicians without California licenses. In less than a quarter of cases did the sites ask the name of the patient's primary care physician. In only 10% of cases did they offer to send medical records. Furthermore, if patients would need in-person care because their condition worsens or they have a medication side effect, many teledermatology clinicians do not have local contacts and cannot facilitate an appointment. Quality assessment and improvement programs are a focus for gap analysis in telemedicine, and many stakeholders, including the National Quality Forum, are convening specific workgroups to tackle this practice gap. ⁶

Regulations and reimbursement for telemedicine are quickly evolving to keep pace with patient demand and technology. This section reviews the core concepts that providers should be cognizant of when practicing teledermatology.

Legislation

Credentialing and Privileging

Credentialing and privileging refers to the assessment of a provider's qualifications and competence. In 2011, CMS issued a Final Rule that included two components that promoted telemedicine adoption in hospitals and CAHs. The Final Rule allowed providers to deliver telemedicine services to patients through written agreements with a distant-site hospital or a distant-site telemedicine entity. The Final Rule also streamlined credentialing and privileging for telemedicine providers and allowed hospitals and CAHs to rely, when granting telemedicine privileges, upon the privileging decisions of a distant-site hospital or telemedicine entity where they have a written agreement that meets Medicare requirements. This aligned CMS with the privileging by proxy standards initially set forth by The Joint Commission. ⁷

Online Prescribing

Regulation of prescriptions obtained virtually varies significantly with state legislation, as well as by state medical and pharmacy boards. Policies have been created to protect patients from online “pill mills.” At the time of this publication, 12 states allowed electronic means to establish the patient–physician relationship and exam. Few states require an in-person follow-up appointment after a telemedicine encounter. There are no requirements to obtain patient information regarding underlying past medical history, allergies, drug adverse effects, other medications and potential drug interactions, contraindications, and safety in pregnancy or lactation. Patient safety and ethical concerns arise from whether an appropriate patient–provider relationship is established; the adequacy of the physical exam; patient education on the diagnosis, risks, benefits, and alternatives of treatment and follow-up if adverse events occur; and continuity and coordination of care with the patient's other health care providers.

Medicolegal Liability

Telemedicine possesses the same duty of care as traditional in-person medicine does. To date, there have been no legal actions concerning teledermatology. There is much debate surrounding clinical and quality standards of care in telemedicine and whether it should or should not differ from that of traditional in-person medicine. Prior to practicing teledermatology, it is prudent to contact one's liability carrier to discuss specific plans (technical modality, patient populations, prescription capacity, etc.) and whether current or supplemental coverage is sufficient.

Reimbursement

In traditional fee-for-service models, reimbursement has expanded with the passage of parity laws that apply to private insurers and self-pay with the emergence of DTP/DTC care. Parity laws can include coverage parity that mandates telemedicine services be covered to the same extent and in the same manner as in-person services and/or payment parity that requires the same rate of payment for services delivered via telehealth. Twenty-nine states have parity laws for private insurers, and there is a trend towards removing eligible provider, technology, and patient setting restrictions for reimbursement. With the explosive growth in direct care teledermatology services and prevalence of high-deductible insurance plans, many patients are paying out of pocket or using flexible spending accounts for their teledermatology care. In a recent study by Fogel and Sarin, asynchronous, store-and-forward teledermatology consultations typically range from $25 to $100 per encounter. ⁸

Reimbursement by federal payors such as Medicare and Medicaid lags behind private payors and has significant room for improvement. Medicare currently reimburses live interactive teledermatology encounters with geographic restrictions to health professional shortage areas (HPSAs) and only reimburses store-and-forward teledermatology in Alaska and Hawaii. In addition to geographic restrictions, Medicare limits the type of eligible providers and eligible facilities that it will reimburse. Medicaid coverage resembles Medicare coverage in its preference for live interactive modalities, and only nine states reimburse for store-and-forward technologies. Medicaid is even more restricted than that of Medicare with significant geographic restrictions, limited eligible patient populations, eligible providers, authorized technologies, and patient consent. Forty-eight state Medicaid programs have some type of coverage for telemedicine, which includes a number of states covering store-and-forward teledermatology (as of 2016). One area of expanded coverage is reimbursement for telemedicine under state employee health plans. Twenty-four states now (as of 2016) have some type of coverage for telehealth under one or more state employee health plans. ⁹

With the enactment of MACRA in 2015, there is an increasing focus on value-based reimbursement models and alternative payment models such as capitation, bundled payments, shared savings, medical home model, or pay for performance. A recent study by Rosen et al. demonstrates the feasibility and viability of such business models as well as traditional reimbursement schemes in teledermatology. ¹⁰

Legislative Landscape

With an increasing focus on population health management and value-based care, telehealth will continue to be a popular topic for state and federal legislation in the foreseeable future. The definition, appropriate use, licensure, and reimbursement of telehealth are quickly evolving in an attempt to catch up with the pace of practice.

Because of dermatology's early role in telemedicine and extensive experience, both the ATA Teledermatology Special Interest Group and the AAD have created guidelines to promote appropriate, high-quality teledermatology practice. Although not specific to teledermatology, the American Medical Association (AMA) and the ATA offer general guidelines for implementing and practicing telemedicine.

Dermatology Specific

American Academy of Dermatology Position Statement

Revised in 2016, the AAD Position Statement defines live interactive and store-and-forward teledermatology and outlines the pertinent benchmarks for technology, credentialing and privileging, privacy and confidentiality, licensing, reimbursement, responsibility, and liability. Most importantly, the position statement specifies criteria for delivering high-quality teledermatology. ¹¹

American Telemedicine Association Practice Guidelines for Teledermatology

Updated in 2016 after an extensive review of the evidence base, the ATA Practice Guidelines for Teledermatology comprehensively cover clinical practice and technological and administrative processes. ¹² The clinical practice guidelines highlight important preliminary considerations before engaging in teledermatology practice, management recommendations, and quality and ethical suggestions. The technical guidelines review the communication modes and applications, devices and equipment, image quality, display, and privacy. The administrative guidelines include security, licensing and credentialing, and liability recommendations.

American Telemedicine Association Quick Guide for Store-and-Forward and Live Interactive Teledermatology

Created in 2012, the ATA Quick Guide for Store-and-Forward and Live Interactive Teledermatology includes concise, practical information on clinical workflows, technical specifications, and insightful tips on optimizing image quality. ¹³

Dermatology Nonspecific

American Medical Association Telemedicine Guidelines

Created in 2014 and accessible to AMA members only, the AMA's Telemedicine Guidelines offers safeguards and standards on the practice of high-quality telemedicine, reimbursement, and coverage concerns. ¹⁴

American Medical Association Steps Forward

The AMA's Steps Forward program includes straightforward, concrete steps to consider prior to creating and implementing a telemedicine program. This includes online resources as potential continuing medical education (CME) credits. ¹⁵

A comprehensive review of the teledermatology literature is beyond the scope of this book, but an excellent review was recently carried out by Bashshur et al. ¹⁶ It should be noted, however, that teledermatology is one of the most studied disciplines in telehealth. The following briefly summarizes research findings for some clinically relevant aspects of delivering telehealth care via teledermatology. Most of the data are from provider-to-provider teleconsultation because data from DTC/DTP are limited.

Diagnostic Agreement

Diagnostic agreement refers to whether two or more clinicians can agree on a diagnosis. Although agreement does not predict whether the clinicians have provided a correct or accurate diagnosis, it is nonetheless an important diagnostic feature. Diagnostic disagreement occurs in all medical disciplines and with all modes of health care delivery. The most important question to answer is: How does diagnostic disagreement rendered by teledermatology compare to disagreement found among different clinicians examining patients during an in-person encounter? A few studies have addressed that issue for store-and-forward teledermatology. ^17–19

Diagnostic agreement among teledermatologists has been comparable to diagnostic agreement recorded among different in-person dermatologist examiners. Likewise, one study that assessed live interactive teledermatology found comparable diagnostic agreement among teledermatologists compared to examinations performed by in-person dermatologists. ²⁰

Diagnostic Accuracy

Diagnostic accuracy refers to whether a particular diagnosis is correct or not. Ideally, accuracy is measured against a gold standard, when one is available or can be applied. For example, the presumptive diagnosis of a skin lesion as a squamous cell carcinoma can be measured against the gold standard test: histopathological review of biopsied tissue. For store-and-forward teledermatology, accuracy studies have yielded varying results. Most studies have demonstrated comparable diagnostic accuracy when compared to in-person diagnoses. ^17,21–24 However, other studies have demonstrated inferior diagnostic accuracy, in particular for pigmented skin lesions. ^25,26 In general, store-and-forward teledermatology is considered an accurate means of diagnosing of skin conditions, but teledermatologists should be cognizant of the evidence to date that suggests diagnostic inferiority when evaluating pigmented skin lesions with store-and-forward teledermatology. This is an area that would benefit from further research to add clarity. No definitive data on the accuracy of live interactive teledermatology diagnoses currently exist.

Clinical Outcomes

Clinical course refers to the clinical outcome that patients experience through their interaction with a health care system and any treatment they may receive. Two studies have compared the clinical course experienced between patients receiving conventional referrals with clinic-based evaluations and store-and-forward teledermatology interventions in a randomized trial study design. ^27,28 Both studies found no evidence for a difference in clinical course experienced by patients who received a teledermatology referral compared to the conventional referral process and in-person visit. In both studies and in both referral groups, the majority of patients were rated as having an improvement and/or resolution of their referred condition at the study endpoints. A wide range of ambulatory skin conditions were represented among the patient populations assessed. Studies with a similar design have not been conducted using real-time interactive teledermatology.

Economic Outcomes

The conclusions drawn from economic analyses often depend on the type of analysis used and the economic perspective(s) taken by those analyses. For example, a cost analysis only considers the costs involved with teledermatology implementation, whereas cost effectiveness considers both costs and the chosen measure(s) of effectiveness with the intent of generating incremental cost-effectiveness ratios. The most common economic perspectives represented in the teledermatology literature are societal and the health care system. The conclusions drawn are varied. This reflects, in part, differences in the health care system under review, the population and geographic areas being served, and the economic perspective(s) considered. In various settings, teledermatology has been found to be both more economical and more costly when compared to conventional dermatology referrals and care. When effectiveness measures have been analyzed, teledermatology is generally considered to be a cost-effective intervention. ²⁹ As an example, prior evidence that clinical course (effectiveness) was not found to differ between store-and-forward teledermatology and conventional referrals ²⁷ was the basis for a cost minimization analysis of those two referral systems. ³⁰ Cost data revealed that from the economic perspective of the U.S. DoD health care system, teledermatology was the more costly alternative, with an average cost per patient of $294 versus $283 for conventional referrals. From the more comprehensive societal economic perspective, teledermatology was less costly at $340 per patient versus $372 for conventional care. Thus, with similar effectiveness, costs were lower with teledermatology from a societal perspective and were incrementally higher by $11 per patient from the health care system perspective. Teledermatology would be the favored economic strategy from a societal perspective and may be considered cost effective from the health care perspective, particularly if the implementation of teledermatology accrues other benefits such as improved access to care or shorter wait times.

Quality of Life

Quality of life is an important metric in all aspects of health care and is arguably the most important one in dermatologic health care. A study that compared quality of life between patients undergoing a store-and-forward teledermatology referral and a conventional referral with a clinic-based visit found no difference in quality of life between the two referral groups. ³¹ Patients in both groups experienced an improvement in quality of life at the study's endpoint, indicating that quality of life improved with both store-and-forward teledermatology and the conventional referral process. Although no comparison group was included, when real-time teledermatology was used, quality of life improved between baseline and the end of the study period. ³² Because of its importance in dermatology, further research and other applications of quality-of-life assessments would make important contributions to our knowledge base.

American Telemedicine Association (www.americantelemed.org/home)

The ATA is a leading source of telemedicine information. The association's Teledermatology Special Interest Group (http://www.americantelemed.org/main/membership/ata-members/ata-sigs/teledermatology-sig) is the repository for teledermatology-specific information. Resources that can be found at the Teledermatology Special Interest Group site include the Quick Guide to Store-and-Forward and Live Interactive Teledermatology for Referring Providers, Practice Guidelines for Teledermatology, Current Active Teledermatology Programs (which is a compendium of health care entities that engage in teledermatology), and a Summary of the Status of Teledermatology Research providing an updated overview of teledermatology research publications on select topics.

American Academy of Dermatology (www.aad.org)

The AAD hosts a teledermatology site and Teledermatology Toolkit at www.aad.org/practice-tools/running-a-practice/teledermatology. The site includes a summary of modalities, links to educational and policy resources, and a description of AccessDerm. AccessDerm is a teledermatology initiative for the provision of dermatology care to underserved populations. The policy links include the AAD's Position Statement on Teledermatology. A video tutorial, Introduction to Store-and-Forward Teledermatology, is another educational resource found at this site.

Center for Connected Health Policy (www.cchpca.org)

The Center for Connected Health Policy (CCHP) is a national resource supported by funding from the Office for the Advancement of Telehealth, Health Resources and Service Administration, Department of Health and Human Services. The site covers the broad spectrum of telemedicine and includes a link to the other telehealth resource centers that provide telehealth advice at the state level (www.telehealthresourcecenter.org). The Telehealth Resource Center site provides information related to features common to all aspects of telemedicine, such as reimbursement, legal and regulatory issues, and marketing issues, among others. The consortia of telehealth resource centers are listed, many of which include information specific to teledermatology. For example, the Mid-Atlantic Telehealth Resource Center includes a site dedicated to teledermatology (www.matrc.org/teledermatology).

Other Resources

• – The British Association of Dermatologists (www.bad.org.uk) includes Quality Standards for Teledermatology Using “Store and Forward” Images. Although the document is written for practice within the United Kingdom's National Health Service, much of the text includes useful information relevant to teledermatology implementation in any setting.

• – The Center for Telehealth and e-Health Law (www.ctel.org) provides information and expertise on legal and regulatory aspects of telemedicine.

• – Two journals are dedicated to publishing telemedicine-related content. The Journal of Telemedicine and Telecare is published by Sage Publications Limited (http://jtt.sagepub.com/), and Telemedicine and e-Health is published by Mary Ann Liebert, Incorporated (www.liebertpub.com/overview/telemedicine-and-e-health/54/).

• – Dermatology-specific journals that publish teledermatology research and other teledermatology-specific content include:

  • JAMA Dermatology published by the AMA (http://jamanetwork.com/journals/jamadermatology)

  • Journal of the American Academy of Dermatology published by Elsevier, Incorporated (www.jaad.org)

  • International Journal of Dermatology (www.onlinelibrary.wiley.com/journal/10.1111/(ISSN)1365-4632) published by John Wiley and Sons, Incorporated

  • British Journal of Dermatology (www.onlinelibrary.wiley.com/journal/10.1111/(ISSN)1365-2133) published by John Wiley and Sons, Incorporated

• – Books dedicated to teledermatology include:

  • Teledermatology: A User's Guide (Pak, Edison, & Whited, eds.) published by Cambridge University Press, 2008

  • Teledermatology (Wootton & Oakley, eds.) published by The Royal Society of Medicine Press, Limited, 2002

  • Telemedicine in Dermatology (Soyer, Binder, Smith, & Wurm, eds.) published by Springer, 2012

  • Telemedicine and Teledermatology (Burg, ed.) published by Karger Medical and Scientific Publishers, 2003

• – Another important resource is the U.S. Department of Veterans Affairs Health Services Research and Development Evidence Synthesis Program report titled Teledermatology for Diagnosis and Management of Skin Conditions (http://www.hsrd.research.va.gov/publications/esp/telederm.cfm). This document is a systematic review of the literature related to teledermatology's use in the diagnosis and management of dermatologic conditions.

As the case report at the beginning of this chapter illustrates, the goal of teledermatology is to deliver timely, effective, and high-quality care that, in some cases, may not be available without the use of telemedicine technology. The evidence base for teledermatology suggests that it is a reliable and accurate means of making diagnoses, and it results in comparable clinical and quality-of-life outcomes. It is an economically viable method of delivering dermatology care and can even be a cost-saving strategy. There are many sources of guidance on teledermatology that are ever expanding and constantly undergoing refinement. However, teledermatology is not without its challenges. Licensure as it relates to interstate practice, EHR-related issues such as support of telehealth technology and “out-of-network” communication, and quality assurance in teledermatology settings are among the most pressing of challenges. Other matters such as online prescribing, medicolegal liability, and reimbursement are evolving areas of interest to the teledermatology community. Perhaps the area of greatest current controversy is the application of DTC and DTP teledermatology, areas that have experienced tremendous growth in recent years—likely fueled in part to the ubiquitous use of smart phones coupled with consumer demand. Because of its achievements and in spite of its challenges, teledermatology is widely practiced and continues to grow because at its core, it is simply a way for patients to get the timely dermatology care that they need and a way for clinicians to efficiently serve those patients.