Like many specialties, dermatology has long been constrained by the competing demands of cost, access and quality.
THE CHALLENGE
In traditional practice models, optimizing one of these dimensions can come at the expense of the others. Dermatology is a fast-paced, high-demand specialty with a limited supply of trained physicians. Patients often wait weeks or even months for appointments only to receive brief, expensive visits that may not have been completely necessary, or worse, hazardously delayed.
Furthermore, healthcare has become increasingly complex. With vast amounts of information readily available, patients are more informed and discerning, and expect up-to-date, evidence-based care.
Additionally, keeping pace with the rapidly evolving medical literature is a full-time endeavor – especially in a field as nuanced and specialized as dermatology, said Dr. Ryan M. Trowbridge, owner of Bridge Dermatology.
"Even board-certified dermatologists must engage in continuous study to stay current," he observed. "For primary care providers, who face similar demands across all organ systems, the challenge is exponentially greater. While triaging patients to the appropriate specialist is ideal for both accuracy and efficiency, it isn't always feasible due to access opportunities and an effective triage system.
"Dermatologic care also is highly variable in its delivery," he continued. "Providers manage thousands of diagnoses, spanning acute and chronic conditions across all age groups. One visit may require a detailed counseling session on isotretinoin for acne, while the next demands an impromptu surgical procedure."
A provider might shift from discussing complex treatment plans to quickly evaluating a lesion – only to determine that a feared melanoma is simply a benign seborrheic keratosis, he added. This level of clinical unpredictability makes it extremely difficult to run an efficient, on-time clinic, he said.
"There often is a disconnect between the actual value of a service provided and the patient's perception of that value – especially in a healthcare system plagued by poor price transparency," he noted. "In dermatology, this gap can be particularly pronounced. Dermatologists are trained to recognize complex conditions quickly and efficiently, often making nuanced diagnoses appear deceptively simple.
"As a result, patients may undervalue the expertise required, not realizing the clinical complexity behind a brief encounter," he continued. "Even common conditions like psoriasis or eczema can be completely unfamiliar to patients, leading to confusion or skepticism about the diagnosis and treatment plan."
Similarly, full skin exams – while appearing quick and routine – require focused attention, clinical judgment and experience to perform thoroughly, he added.
"And in many cases, patients are asked to return for follow-up visits that seem unnecessary, driven less by clinical need than by payer documentation requirements," he said. "All of this contributes to a perception that dermatologic care is rushed or overpriced, even when it is clinically appropriate and highly efficient.
"Quality control also presents an ongoing concern," he continued. "As demand outpaces physician availability, many practices rely heavily on advanced practice providers. While many APPs are skilled and compassionate, dermatology-specific training varies widely, and their scope of practice often is poorly defined."
Without standardized education and consistent oversight, the quality of care becomes uneven, and serious diagnostic or therapeutic errors are more common than many realize, Trowbridge added. "These realities contribute to a care environment that feels expensive, rushed, difficult to access and inconsistently effective," he said.
"For a long time, there was no easy solution to many of these challenges," he explained. "Compounding the issue is the unfortunate dynamic that can emerge in any profitable, high-demand specialty: Efficiency and scalability often take priority over personalized, high-quality care. As a result, overall care quality can suffer.
"However, with the emergence of telemedicine platforms, advancements in imaging technology and the growing integration of artificial intelligence, many of these longstanding barriers – along with the competing demands of cost, access and quality – are beginning to collapse," he added.
PROPOSAL
To overcome these challenges, Bridge Dermatology decided to work with vendor Miiskin to shift dermatologic care toward an asynchronous, image-based model that could scale across clinical settings without sacrificing diagnostic quality.
Rather than replacing in-person care, the aim was to leverage telemedicine as a complementary layer – one that could integrate seamlessly into existing care models or stand alone when needed. This approach was designed to enable dermatologists to operate at the top of their license, focusing more deeply on diagnostic decision making rather than clinic throughput.
"Asynchronous tele-dermatology enables patients – or referring providers – to submit high-resolution images and clinical histories through secure platforms," Trowbridge explained. "These cases then are reviewed by board-certified dermatologists outside of real-time constraints.
"For conditions not requiring immediate physical evaluation – such as acne, rashes, follow-ups or suspicious lesions – this format would allow for timely, convenient and high-quality care," he continued. "It also would address significant geographic and specialist access gaps."
In this model, the competing demands of cost, access and quality can be fundamentally rebalanced, he added.
"Telemedicine improves access and cost-efficiency, and with ongoing advances in imaging technology and AI-assisted diagnostics, diagnostic accuracy also is improving," he noted. "Furthermore, the written nature of asynchronous communication often enhances patient comprehension, leading to potentially better adherence, engagement and outcomes.
"From a systemic perspective, this model enhances consistency, accuracy and efficiency in both documentation and quality assurance," he continued. "Templated workflows and automatically generated clinical notes – derived directly from written correspondence – help standardize care delivery while reducing the administrative burden on providers."
This structured approach not only ensures regulatory compliance but also facilitates peer review, auditing and longitudinal tracking of clinical outcomes, he added.
"For primary care providers, the platform functions as an effective triage mechanism," Trowbridge explained. "It allows for rapid dermatologic input without disrupting clinic workflow, enabling PCPs to manage cases more confidently while ensuring that complex or uncertain presentations are escalated to specialists in a timely, coordinated manner.
"The Miiskin platform takes a different stance from many direct-to-consumer health companies like Hims, Roman or Amazon Clinic," he continued. "These platforms often prioritize prescription fulfillment as the core business model, with consultations positioned more as lead-generation tools. This incentivizes default prescribing, limits treatment scope and can undermine the value of clinical evaluation."
In contrast, Miiskin is structured to preserve physician and patient autonomy, elevate clinical dialogue, and support human interaction at the center of care, he added.
"By alleviating the non-clinical burdens – like scheduling bottlenecks, administrative overhead, documentation and prior authorizations – technology becomes an enabler rather than a replacement," he said.
"The ultimate proposal was clear: to deliver smarter, more scalable and more patient-centered dermatologic care that aligns with how modern tools can and should be used – without sacrificing clinical nuance or the human aspect of healthcare," he added.
MEETING THE CHALLENGE
Bridge Dermatology implemented the asynchronous, image-based tele-dermatology platform designed for both direct-to-patient access and integration into IT that doesn't require providers to abandon their current workflows or have a parallel track for telemedicine-only patient care.
Patients or referring clinicians submit structured clinical information and high-resolution images via a secure portal, accessible on desktops or mobile devices. This platform has the potential to integrate with major EHRs or operate as a standalone system.
"The workflow is optimized for efficiency and quality," Trowbridge said. "Submissions can be triaged based on clinical urgency using standardized protocols. Board-certified dermatologists, including myself, review cases throughout the day – unbound by traditional appointment slots. This enables focused, thoughtful evaluation.
"We respond with customized treatment plans, educational evidence-based responses to questions, and ongoing step-by-step guidance via secure messaging that can last as short or as long as the provider determines is appropriate," he continued. "When needed, we can escalate to video calls, phone consultations or in-person referrals."
The platform includes e-prescribing capabilities for medications, along with potential for internal peer-review tools and audit trails that will allow for internal quality monitoring, ensuring documentation meets payer and clinical standards.
"We prepared to deploy this system across multiple use cases including direct-to-consumer as well as provider-to-provider workflows that could be used in both outpatient, inpatient, and urgent or emergency care settings, in large health systems or in small, standalone practices," he said.
RESULTS
Trowbridge has aspired to create a patient-centric, comprehensive tele-dermatology practice. Most existing platforms prioritize quick prescription generation and offer only minimal or superficial provider-patient interaction, which makes achieving that vision difficult, he said.
"Through Miiskin, I've been able to build my own solo tele-dermatology practice as a complement to my full-time, in-person role with another healthcare group," he explained. "I could not have done this without the flexibility and support the platform provides.
"It also has significantly expanded my reach – about 99% of my consultations now are with patients outside my home state," he continued. "Because I am not employed by Miiskin, I have the autonomy to run my practice in the way I believe best serves my patients."
Trowbridge said the vendor genuinely is committed to supporting both patients and providers.
"It works with dermatologists to enhance their work experience and improve their bottom line – not just the platform's own interests," he noted. "I feel confident I am not a replaceable number tasked with the assignment of churning out prescriptions for acne and hair loss.
"You certainly can set up your practice geared toward specific patient needs, but I treat the entire spectrum of dermatology conditions through the platform," he added.
ADVICE FOR OTHERS
Technology should always be designed to enhance, not burden, clinical care and workflows, Trowbridge said.
"As medical information and digital capabilities evolve at a rapid pace, the future of healthcare soon may look entirely different from today's models," he observed. "However, there's real risk in rushing to incorporate emerging technologies without clear alignment to clinical needs or operational realities.
"Take artificial intelligence, for example," he continued. "Much of the current focus is on using AI to support diagnosis and treatment decisions. While this is an exciting frontier with real potential, it may also represent one of the areas least in need of radical transformation – at least in dermatology."
Dermatologists already are highly skilled at diagnosing and treating skin conditions with high accuracy and efficiency. The more complicated aspect of clinical dermatologic care often is explanation and management of obscure, idiopathic and chronic conditions that may not have easy or easily accessible treatment options, he added.
"Instead, the more immediate – and arguably more impactful – opportunities for improvement lie in areas that often fall outside the clinical spotlight: meeting patient expectations, improving the clarity of communication, ensuring accurate and thorough documentation, and managing the growing administrative burdens of prior authorizations and payer requirements," Trowbridge said.
"These elements, while less glamorous than AI-driven diagnostics, are critical to the patient experience and to the sustainability of high-quality care delivery," he concluded.
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