JMIR Publications

ABSTRACT

Teledermatology has expanded across pediatric care because it improves access to specialist input and can reduce delays for patients in remote locations or time-sensitive settings such as the emergency department.1,4 Informal “curbside” consultation represents a common but understudied form of teledermatology, enabled by electronic medical records and smartphone photography.2-4 Prior survey and cohort data suggest that these encounters are frequent, often poorly standardized, and associated with substantial uncompensated clinical workload.2,3 These exchanges may expedite disposition and spare unnecessary bedside consultations, yet they also occur with limited history, variable image quality, inconsistent documentation, and uncertain reimbursement or medicolegal frameworks.2,3,6 Because access to pediatric dermatology remains constrained, understanding how these informal workflows function in practice is important.4,6 We therefore characterized informal consultations between pediatric emergency medicine (PEM) and pediatric dermatology (PD) at a freestanding children’s hospital, with emphasis on management recommendations, follow-up, and diagnostic concordance. This research letter characterizes the nature, frequency, and accuracy of informal dermatology consultations in the pediatric emergency department. After institutional review board approval, we performed a retrospective electronic medical record screen of PEM encounters from January 1, 2018, through December 31, 2022, that were linked to a PD telephone encounter. Encounters were included when a PEM clinician requested advice from PD without a formal bedside dermatology consultation. We recorded call timing, the roles of the PEM requester and PD consultant, the presence of photographs, prior dermatologic history, and the types of recommendations given. When PD clinic follow-up was recommended, we also recorded whether follow-up occurred within the advised timeframe and whether the final PD clinic diagnosis was concordant with the emergency department impression. Among 3,010 screened telephone encounters, 394 met inclusion criteria. Consultation volume increased after 2019 and most requests occurring on weekends (n=158, 40%) or weeknights (n=123, 31%) (Table 1). The median patient age was 5 years (IQR 10), and 205 (52%) were female. One hundred thirty-eight (35%) had a prior dermatologic diagnosis, and 105 (27%) had previously been seen by PD. Requests came from a mix of PEM residents, attendings, or advanced practice providers, whereas 98% of consultations (n=388) were handled by PD residents, and 85% (n=336) of resident-managed calls were discussed with a PD attending. Photographs accompanied 81% (n=319) of requests. Management advice most often involved medication recommendations (n=277, 70%), followed by diagnostic testing (n=130, 33%) (Table 2). The most common discharge diagnosis given by PEM was rash (n=79, 20%). PD follow-up was advised in 78% (n = 306) of encounters, and 74% (n=227) completed a PD visit, of which 93% (n=212) of patients followed up within the recommended timeframe. Diagnostic concordance between the PEM impression and the PD follow-up was 68%. These findings suggest that informal PEM-to-PD consultation was both common and operationally useful, particularly after hours when a formal bedside evaluation may be less feasible. The workflow likely improved access to specialty input and emergency department throughput, but it also relied heavily on trainee communication and non-standardized photographs. That context may help explain why concordance in our cohort was moderate rather than high. Our 68% concordance exceeded the 58% agreement reported for in-person pediatric emergency department consultations in one prior study, yet it was lower than the 70-89% concordance reported in pediatric store-and-forward teledermatology settings, where structured image capture and defined review processes are typical.1,4 In a prior study performed at our institution, the diagnostic concordance between photographs and in-person diagnosis was reported to be 82%.5 We hypothesize that limited history, variable photo quality, incomplete chart review, and selective follow-up all contributed to the moderate concordance. Prior prospective work has also shown that curbside pediatric dermatology consultations consume substantial unreimbursed physician time, reinforcing the need for more deliberate systems of care.2,3 The study highlights how difficult it is to judge the true performance of informal consultation from retrospective documentation. Concordance could only be assessed among patients who came to clinic, and one quarter of those advised to schedule a PD appointment were lost to follow-up. Some may have improved, whereas others may have encountered barriers such as cost, transportation, or the perception that they had already received definitive dermatologic care.2,3 In addition, our EMR search strategy depended on creation of a PD telephone encounter, so the true volume of informal consultations was likely underestimated. Even with these limitations, the frequency of after-hours consults, the reliance on photographs, and the moderate follow-up concordance support efforts to standardize image capture, documentation, and triage pathways for emergency dermatology questions. As formal interprofessional telehealth consultations are increasingly being implemented, it is important to have quality safeguards in place and recognize that diagnostic accuracy may still be limited.