Using the RE-AIM framework to assess national teledermatology expansion

Abstract

Background: Teledermatology has been utilized in the United States Department of Veterans Affairs (VA) for decades but continues to have incomplete penetration. VA has funded an initiative to enhance access to dermatology services since 2017 to support asynchronous teledermatology for Veterans living in rural areas. As part of an ongoing evaluation of this program, we assessed the teledermatology activity between the fiscal years 2020 and 2022. We focused on the second cohort of the initiative, comprising six VA facilities and their 54 referral clinics.

Methods: We studied teledermatology programs at cohort facilities using the reach, effectiveness, adoption, implementation, and maintenance framework. We used a mixed-methods design including annual online reports completed by participating facilities and VA administrative data. When possible, we compared the data from the 3 years of teledermatology funding with the baseline year prior to the start of funding.

Findings: Reach: Compared with the baseline year, there was a 100% increase in encounters and a 62% increase in patients seen at the funded facilities. Over 500 clinicians and support staff members were trained. Effectiveness: In FY 2022, primary or specialty care clinics affiliated with the funded facilities had more dermatology programs than primary or specialty care clinics across the VA (83% vs. 71% of sites). Adoption: By the end of the funding period, teledermatology constituted 16% of dermatology encounters at the funded facilities compared with 12% nationally. This reflected an increase from 9.2% at the funded facilities and 10.3% nationally prior to the funding period. Implementation: The continued funding for staff and equipment facilitated the expansion to rural areas. Maintenance: By the end of the funding period, all facilities indicated that they had fully implemented their program for patients of targeted primary care providers. The Program Sustainability Index scores generally increased during the funding period.

Conclusions: Targeted funding to support asynchronous teledermatology implementation for rural Veterans increased its reach, adoption, and implementation, ultimately improving access. Providing program guidance with staffing and training resources can increase the impact of these programs. Ongoing efforts to maintain and increase communication between primary care and dermatology will be needed to sustain success.

Keywords: REAIM; Veterans; asynchronous care; dermatology; expansion; implementation science; rural health; teledermatology.

Figure 1

Teledermatology activity (reach). Cohort 2 activity including FY 2019 baseline year activity is represented by (A) overall encounters and unique (i.e., individual) patients and (B) hub-specific encounters (hubs are labeled A–F).

Figure 2

Patient travel distance (effectiveness). Average FY 2022 patient travel distance to primary and specialty care clinics by rurality for funded and non-funded VA facilities. Error bars represent standard deviation. Data is based on all patients at funded and non-funded facilities whether they participated in teledermatology or not.

Figure 3

Rates of skin cancer diagnoses (effectiveness). Rates for each category of (A) number of lesion diagnoses per 1,000 veterans and (B) number of lesion diagnoses per 1,000 rural Veterans, during FY 2019–2022. Teledermatology consults were compared with all dermatology consults at funded hubs for all veterans for 2019 (year immediately preceding funding) through the funding period (FY 2020–2022). Melanoma, squamous cell carcinoma, and basal cell carcinoma are skin cancers, actinic keratosis is a pre-cancerous skin lesion, and neoplasm of uncertain behavior (NUB) is a concerning, unbiopsied skin lesion that requires further evaluation. Note that the y-axis varies per diagnosis code.

Figure 4

Teledermatology spokes by hub (adoption). FY 2022 distribution of spokes by both rural (darker bars) and urban (lighter bars) sites is grouped by hubs (labeled A–F), distinguishing between interfacility (red) and intrafacility (blue).

Figure 5

Concerns about teledermatology (implementation). Sites reported concerns from different groups of staff about their involvement and resources supporting the teledermatology program for each funding year. Concerns (none/minor or major) are represented as different colors.

Figure 6

Stages of implementation (maintenance). Colored boxes show how many hubs responded annually during the funding period.

Figure 7

Program Sustainability Index (maintenance). Mean of overall sustainability as measured by the PSI elements and each sustainability element is shown for FY 2020–2022.