Implementation of Direct-to-Patient Mobile Teledermatology in VA.

BACKGROUND: Innovative technology can enhance patient access to healthcare but must be successfully implemented to be effective. OBJECTIVE: We evaluated Department of Veterans Affairs' (VA's) implementation of My VA Images, a direct-to-patient asynchronous teledermatology mobile application enabling established dermatology patients to receive follow-up care remotely instead of in-person. DESIGN /PARTICIPANTS/APPROACH: Following pilot testing at 3 facilities, the app was introduced to 28 facilities (4 groups of 7) every 3 months using a stepped-wedge cluster-randomized design. Using the Organizational Theory of Implementation Effectiveness, we examined the app's implementation using qualitative and quantitative data consisting of encounter data from VA's corporate data warehouse; app usage from VA's Mobile Health database; bi-monthly reports from facility representatives; phone interviews with clinicians; and documented communications between the operational partner and facility staff. KEY RESULTS: Implementation policies and practices included VA's vision to expand home telehealth and marketing/communication strategies. The COVID-19 pandemic dominated the implementation climate by stressing staffing, introducing competing demands, and influencing stakeholder attitudes to the app, including its fit to their values. These factors were associated with mixed implementation effectiveness, defined as high quality consistent use. Nineteen of 31 exposed facilities prepared to use the app; 10 facilities used it for actual patient care, 7 as originally intended. Residents, nurse practitioners, and physician assistants were more likely than attendings to use the app. Facilities exposed to the app pre-pandemic were more likely to use and sustain the new process. CONCLUSIONS: Considerable heterogeneity existed in implementing mobile teledermatology, despite VA's common mission, integrated healthcare system, and stakeholders' broad interest. Identifying opportunities to target favorable facilities and user groups (such as teaching facilities and physician extenders, respectively) while addressing internal implementation barriers including incomplete integration with the electronic health record as well as inadequate staffing may help optimize the initial impact of direct-to-patient telehealth. The COVID pandemic was a notable extrinsic barrier. CLINICAL TRIALS REGISTRATION: NCT03241589.

Differentiating human keratinocytes are deficient in p53 but retain global nucleotide excision repair following ultraviolet radiation.

Terminally differentiating keratinocytes constitute the predominant cell type within the skin epidermis and play an important role in the overall photobiology of human skin following ultraviolet radiation. However, the DNA repair capacity of differentiating keratinocytes is unclear, and little is known regarding how such repair activity is regulated in these cells. We systematically compared the global genomic nucleotide excision repair response of cultured undifferentiated human keratinocytes to those that were allowed to differentiate in 1.2 mM Ca(2+), in some cases supplemented with phorbol ester or Vitamin C. Differentiated cells ceased replication and expressed typical markers of differentiation. Following ultraviolet radiation, keratinocytes that were differentiated up to 12 days removed cyclobutane pyrimidine dimers and pyrimidine(6,4)pyrimidone photoproducts from the global genome as efficiently as undifferentiated cells. However, following the onset of calcium-induced differentiation, basal levels of p53 were nearly undetectable by 12 days of differentiation when global repair activity was unaffected. Following ultraviolet radiation, induction of p53 following ultraviolet radiation was abrogated by 6 days of calcium-induced differentiation. Basal levels of mRNA encoding the DNA damage recognition proteins, XPC and DDB2, were relatively insensitive to differentiation and p53 levels. However, following ultraviolet radiation, inductions of mRNA encoding the DNA damage recognition proteins, DDB2 and XPC, were differentially affected by differentiation. Rapid loss of DDB2 mRNA induction was associated with differentiation, while XPC mRNA induction diminished more slowly with differentiation. These results indicate that human keratinocytes preserve global nucleotide excision repair as well as expression of genes encoding key DNA damage recognition proteins well into the terminal differentiation process, perhaps using mechanisms other than p53.