Dr Chris Miller runs Spot Check Clinic in Melbourne, a roaming skin cancer clinic quickly building a reputation for its adoption of the latest patient technology, Dr Miller explains he initially started out in sexual health and travel medicine, but was drawn to skin cancer medicine a decade ago because of the technology being embraced in the field.
I sat down with Chris to find out more about the technology his clinic was using and how these tools and processes were encouraging his patients to play a more active role in their own skin cancer prevention and monitoring.
What does your skin clinic do differently from most?
“Typically, in previous skin cancer clinics where I’ve worked, people come in, you check their skin from top to toe, you identify and address any problems and then the person walks out the door and they forget about you until the next time they have a scare.
“The issue is the period between skin checks when a patient could be developing skin cancers without even knowing. I really wanted to develop a model where it was easier for people to maintain contact with me throughout the year.
“So I set up a year-long service where, instead of a patient coming in once a year or so, they pay one out-of-pocket expense and that covers pretty much everything I would do for the rest of the year. If they need to come back to have a biopsy performed then that is bulk billed. If they need to come back so I can take more photos of their spots that is bulk billed as well.
My idea is that the cost of ongoing visits shouldn’t be a barrier to continuing the interaction between myself and my patients”
“I think this is important because where I’ve worked in the past I’ve reviewed photos of people’s moles and I’ve said, ‘Look it is probably fine and I don’t want to remove it unnecessarily, but I’d like to see if it grows or changes in a couple of months’. Then you get the feeling the person is thinking, ‘This doctor is just trying to take more of my money’.
“This annual programme lets my patients interact with me whenever they need. They can come back and have a photo taken of their moles every week if they are concerned and they don’t have to pay extra. This is all part of a service I’m calling the “Spot Check Comprehensive Service”.
How is technology helping you with your work?
“A few years ago you would need to spend thousands of dollars on photographic equipment. Now I can take perfectly decent quality photos with nothing more than an iPhone and a dermoscope attachment. It means the cost of managing each patient is a little cheaper so I can build in a little bit extra time for online communication, education and that sort of thing.
“I also use a web-based software called Helix, which is a new product by Medical Director hosted in the cloud. It means I can travel virtually anywhere, including to a person’s home or work. Plus, I don’t have to worry about running my own backups, maintaining the database or doing software updates. This has all made a big difference to my work”.
What is DermEngine?
“The DermEngine App is something I’ve been using a lot at my clinic. It’s intended specifically for managing photos of people’s skin lesions. Again, it is hosted in the cloud, so all I need is a web browser to run it. That means I’m now not tied to a huge expensive machine that has a database of photos and a fancy camera sitting on it. I can take the photos using just an iPhone and the DermEngine app. It’s giving me incredible flexibility.
I’m talking to a couple of companies about visiting them on-site and screening employees. Something I would never have been able to do before”
“The other amazing thing DermEngine does is that it has an algorithm, or an artificial intelligence, built into it that has been trained to diagnose skin cancers. The algorithm has been fed thousands of pictures of different skin lesions and cancers, together with the pathology diagnosis, so the system can analyse a new photo and say, for instance, ‘There is 10% chance this is a skin cancer’. It also says what type of skin cancer it might be.
“I have no doubt that in five or ten years computers will be better at diagnosis than doctors. At that stage my role will change a bit as I will not so much be the diagnostician, but instead I’ll be more of an interpreter who guides people through how do we deal with information the computer is giving us. This is something I’m really excited about as a lover of technology”.
How does the DermEngine App help encourage patients to be more proactive?
“This is something I’ve been wanting to do for years and years. That being, giving people access to their own medical records, so they can read what’s going on and make their own contributions.
Patients can access their own clinical file. They can download the app and log in anytime to look at the pictures taken by their doctor. They can also upload their own photos if they want. This really helps them participate in the whole process
“Otherwise, people can’t remember what happened. They can’t remember what the doctor said to them. They don’t have access to the photos taken previously. They forget the name of the skin cancer they had, or even if it was a skin cancer. And, over time, they stop caring or paying attention because they aren’t involved. This is common in all fields of medicine, so I’m really pleased I can give people online access to their information”.
How are patients generally responding to the technology?
“People are really open to the idea. They like the fact that I didn’t just look at the spot, but that I actually photographed it and spent a bit more time pointing out the features of it. It makes it much easier for me to explain why I am or am not worried about it, and how it looks the same or differs from a picture of an actual skin cancer”.
What other technologies are you embracing to encourage proactive health?
“I also use a fascinating bit of technology called ‘My UV Patch’. You stick the patch onto your skin and it measures the amount of ultraviolet radiation you’ve been getting. You usually wear it for about three days and this also syncs with an app on your phone. The app reminds you when to scan your UV patch and then tells you how much ultraviolet exposure you have had and whether you’ve been safe or not.
“I also use the Firstcheck Skin App sometimes. It’s similar to DermEngine, but it is better for people I’ve never met. The app comes with a small magnifying glass, which you attach to your phone. The way it works is that people who are concerned about a spot can take a photo using the app and send it to a doctor to look at. This makes the barrier for entry very small for patients because I don’t have to set up a record for them in DermEngine.
“One advantage of DermEngine, however, is that it gives me a collection of photographs over time for that patient. So it acts more like a traditional medical record, rather than just receiving one photo at a time. They both have different advantages but I tend to use DermEngine a little more.
Aside from technology, how do you encourage proactive health?
“The other thing I do with every patient is that I email them at the end of the consultation saying, ‘I hope all went okay for you. Here’s a bit of information about your specific situation’. Then I will outline what I think they need to do next and encourage them to ask questions.“Usually, I don’t hear from people for a while, but a lot of people will just hang onto that email and they’ll respond to me a few months later saying, ‘I’ve got a new spot, what should I do about this?’
“I also try to spend a bit more time with patients who I feel might struggle to get the full value of the annual packages upfront. I talk to them about their particular risks and the issues with their scans and tailor what we call a ‘Skin Protection Plan’.
“Depending on what they are interested in that can take different forms. They might be the sort of person who loves the idea of being able to take a vitamin, or use a cream. And so you can get a bit of engagement from those people by saying to them, ‘I would really like to know how well this cream has worked for you so we can be sure you’re on the right track and getting value for money. Do you want to pop back and see me in X months so we can see how well it has worked?’
“There are other people who enjoy technology. With these people, I just sort of sit down and show them how the apps work on their phones. I like to show them the Sunsmart app, which tells them what times of day they have to be careful about sun exposure. I explain a little about how the app might relate to their situation. Some people become so intrigued by it.
What advice would you give to other clinics looking to embrace this kind of technology?
“Using this type of technology means giving up a bit of medical ownership and being prepared to let the patient take a bit more control over their own problems. Figuring out how to do that in a way that you’re comfortable with is sometimes a bit of a challenge. It’s a concept I’ve always been extremely comfortable with but some of my colleagues in the past have said, ‘There’s no way I would ever be prepared to look at a photo of a mole that somebody’s sent me’. So that is something you have to be prepared to embrace.
“The other thing I guess is that I’m happy to trust experts on what they do well. For instance, in terms of security of the data, some doctors might say, ‘I’m very worried about having all of the data hosted in the cloud’. My feeling is that this data is being hosted according to very strict legislation about the information and privacy. Still, some doctors have a bit of a problem dealing with those things.