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Enhancing GPs' diagnostic skills

Using dermatoscope and camera means a better service for patients. By Mike Korab and Dr Jenny Parkes

Dr Parkes (left): project reduces inappropriate referrals to secondary care. Mr Korab: consulted hospital medical photography staff
Dr Parkes (left): project reduces inappropriate referrals to secondary care. Mr Korab: consulted hospital medical photography staff

Since January 2009, our practice in Hampshire has been involved in a project we funded ourselves to evaluate the use of dermatoscope photographs in the diagnosis of isolated skin lesions, improve GPs' diagnostic skills and reduce inappropriate referrals to secondary care.

Local consultant dermatologist Dr Steve Keohane at Queen Alexandra hospital in Portsmouth is helping us.

Our practice, Dr Sedgwick and Partners, looks after 9,800 patients and is semi-rural with surgeries in Liss and Liphook.

The practice was lucky enough to receive a donation from a local medical charity to buy a Heine Delta 20 dermatoscope and Canon EOS 400D camera to take macro and close-up pictures of skin lesions. Magnified 10 times, the images are stored in the patient's clinical record in our IT system.

Thanks to Dr Keohane's enthusiasm during clinical education sessions with the GPs, we were able to define processes involved. Our ultimate aim is to test the viability of emailing images to him for review and diagnosis.

Internal referral form
When a GP sees a patient with a skin lesion, they complete an internal referral form for dermatoscopy. If the lesion looks suspicious or is a cause for concern, the GP refers the patient to the consultant in the usual way under the two-week rule.

With the patient's consent, our healthcare assistant photographs the lesion using dermatoscope and camera, and the macro and magnified images are stored in the patient's electronic record.

Dr Keohane visits the surgery every four weeks to review the previous month's pictures with Dr Jenny Parkes, who leads on the project, and Mike Korab, the practice manager.

Dr Keohane makes a provisional diagnosis and decides a plan of action. This information is passed to the referring GP who notifies the patient.

The idea for the project came from a discussion at a practice clinical governance meeting. It got off the ground quickly, taking six months to evolve to its present form.

Challenges
Although assisting the GPs with identification and diagnosis of skin lesions sounds straight-forward, there were challenges.

Picture quality was initially a challenge but was overcome by the practice manager receiving advice from the medical photography department at the hospital in Portsmouth. Photography, uploading and resizing images then became additional skills that our healthcare assistant acquired.

Creating a user-friendly internal referral form took some time. The on-screen form has to serve as a recall tool for the reception team, a record of the GP's diagnosis, the treatment plan and a final record of the clinical outcome. Many changes had to be made to the form before we got it right.

When Dr Parkes studied the first 100 pictures, the quality of four were too poor for diagnosis purposes. The lesions concerned were typically non-pigmented and on the nose or ear where good contact with the dermatoscope is difficult.

Of the satisfactory 96 pictures, none of the clinical diagnoses were significantly different from those made on basis of the photograph alone: for example, a GP diagnosing a benign naevus when it was a basal cell papilloma.

When we have another 100 images of lesions to compare with initial diagnoses, we hope that they will show definite improvement in the GPs' identification of individual lesions. The lead GP's impression is that their diagnostic abilities have improved.

We look more closely now at non-pigmented lesions as we have found more early basal cell carcinomas and Bowen's disease. The practice's referral rate to secondary care for pigmented lesions has gone down, but the rate for non-pigmented lesions has increased.

Other important benefits are emerging. Being able to look at a fixed image in the clinical record for comparison purposes is reassuring for GP and patient. We can take another photograph of the same lesion a few months later and compare the two images side by side to look for any change. An onsite dermatoscope is more convenient for patients: they receive a faster diagnosis and their lesion can be monitored closely.

Educationally invaluable
The GPs have found the project educationally invaluable. Using the dermatoscope is now seen as a necessity when reviewing patients' skin lesions.

As this study is still in its early stages, its parameters are reviewed and are sometimes redefined. Although the early results are encouraging, the practice needs to assess many more photographs before conclusions can be drawn.

So far this has been an exciting project and we now regard dermatoscopy as part of the essential service the practice delivers.

It 'ticks the right boxes' for primary care: working closely with secondary care, referrals management and providing care closer to home.

We hope the project can be developed further for the community through East Hampshire Alliance Ltd, a consortium of 14 practices, and the local practice-based commissioning group to which our practice belongs.

In Summary

Practice Seven GP partners.

PMS contract List 9,800 with above average percentage of over-65s.

Location East Hampshire, semi-rural, working across two sites.

Project equipment

  • Heine Delta 20 dermatoscope.
  • Canon E0S 400D camera.
  • Lens adaptor, measuring scale and gel.

Benefits

  • Patient satisfaction - care closer to home.
  • Referrals management.
  • Continuity of care - easy access to images held on patient's record.
  • GP education/reassurance from increased knowledge and awareness of lesion types.
  • Closer collaboration with secondary care.

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