Teledermatology: A Review and Update

Economic impact and cost savings of teledermatology units compared to conventional monitoring at hospitals in southern Spain

INTRODUCTION

Asynchronous teledermatology (TD) has undergone exponential growth in the past decade, allowing better diagnosis. Moreover, it saves both cost and time and reduces the number of visits involving travel and opportunity cost of time spent on visits to the hospital. The present study performed a cost-saving analysis of TD units and assessed whether they offered a cheaper alternative to conventional monitoring (CM) in hospitals from the perspective of public health-care systems (PHS) and patients.

METHODS

This study was a retrospective assessment of 7030 patients. A cost-saving analysis comparing TD units to CM for patients at the Hospital de Poniente was performed over a period of one year. The TD network covered the Hospital de Poniente reference area (Spain) linked to 37 primary care (PC) centres that belonged to the Poniente Health District of Almeria.

RESULTS

We observed a significant cost saving for TD units compared to participants in the conventional follow-up group. From the perspective of a PHS, there was a cost saving of 31.68% in the TD group (€18.59 TD vs. €27.20 CM) during the follow-up period. The number of CM visits to the hospital reduced by 38.14%. From the patients' perspective, the costs were lower, and the cost saving was 73.53% (€5.45 TD vs. €20.58 CM).

DISCUSSION

The cost-saving analysis showed that the TD units appeared to be significantly cheaper compared to CM.

Increase in Video Consultations During the COVID-19 Pandemic: Healthcare Professionals' Perceptions about Their Implementation and Adequate Management

In response to the COVID-19 pandemic, health care modalities such as video consultations have been rapidly developed to provide safe health care and to minimize the risk of spread. The purpose of our study is to explore Spanish healthcare professionals’ perceptions about the implementation of video consultations. Based on the testimonies of 53 professionals, different categories emerged related to the four identified themes: benefits of video consultations (for professionals, patients, and the health system, and compared to phone calls), negative aspects (inherent to new technologies and the risk of a perceived distancing from the professional), difficulties associated with the implementation of video consultations (technological difficulties, lack of technical skills and refusal to use video consultation among professionals and patients), and the need for training (technological, nontechnical, and social-emotional skills, and adaptation of technical skills). Additionally, the interviewees indicated that this new modality of health care may be extended to a broader variety of patients and clinical settings. Therefore, since video consultations are becoming more widespread, it would be advisable for health policies and systems to support this modality of health care, promoting their implementation and guaranteeing their operability, equal access and quality.

Dermatological consultations in the COVID-19 era: is teledermatology the key to social distancing? An Egyptian experience

BACKGROUND

Coronavirus disease 2019 (COVID-19) has received marked attention globally. A worldwide call for social distancing occurred. Although the reduction of face-to-face consultation is required in order to reduce the risk of infection, dermatological services must be maintained in action and 'teledermatology' should be the solution.Materials & methods: We introduce a cross sectional observational study, demonstrating the patients' behavior regarding dermatological consultations in Cairo, Egypt in both private and Public practice. Synchronous (live interaction via What's app and Zoom) and asynchronous (What's app, emails) teledermatology models were used. After the end of the teleconsultation, patients were asked to fill a questionnaire adapted from the Telehealth Usability Questionnaire (TUQ).

RESULTS

There was an overall satisfaction and future use score among the interviewed patients that received Teledermatology services of 91.0%, a usefulness score of 93.7%, interface and interaction quality scores of 85.9% and 87.0%, ease and use learnability score of 87.8% and reliability score of 86.7%.

CONCLUSION

Teledermatology was efficient in triaging and treatment, hence, decreasing risk of COVID-19 exposure for the physician, the patient and the paramedical personel in heavily populated third world countries. Legislation is needed to sanction physician compensation for tele dermatology where this does not exist.

Primary Care Professionals' Acceptance of Medical Record-Based, Store and Forward Provider-to-Provider Telemedicine in Catalonia: Results of a Web-Based Survey

While telemedicine services enjoy a high acceptance among the public, evidence regarding clinician’s acceptance, a key factor for sustainable telemedicine services, is mixed. However, telemedicine is generally better accepted by both patients and professionals who live in rural areas, as it can save them significant time. The objective of this study is to assess the acceptance of medical record-based, store and forward provider-to-provider telemedicine among primary care professionals and to describe the factors which may determine their future use. This is an observational cross-sectional study using the Catalan version of the Health Optimum questionnaire; a technology acceptance model-based validated survey comprised of eight short questions. The online, voluntary response poll was sent to all 661 primary care professionals in 17 primary care teams that had potentially used the telemedicine services of the main primary care provider in Catalonia, in the Central Catalan Region. The majority of respondents rated the quality of telemedicine consultations as “Excellent” or “Good” (83%). However, nearly 60% stated that they sometimes had technical, organizational or other difficulties, which might affect the quality of care delivered. These negatively predicted their declared future use (p = 0.001). The quality of telemedicine services is perceived as good overall for all the parameters studied, especially among nurses. It is important that policymakers examine and provide solutions for the technical and organizational difficulties detected (e.g., by providing training), in order to ensure the use of these services in the future.

Real-time teledermatology clinics in a tertiary public hospital: A clinical audit

BACKGROUND

Our metropolitan hospital provides a real-time videoconference teledermatology clinic to enable patients in rural and remote Queensland to access a specialist for dermatology care.

METHODS

Retrospective clinical audit of all patient referrals to the videoconference teledermatology clinic for a two-year period.

RESULTS

A total of 483 consultations for 178 patients were conducted by the teledermatology clinic. Most patients were from remote and very remote regions of Queensland with a mean distance from our metropolitan hospital to the patient's town of residence of 1295 km. The most common reason for referral, as per the referral form, was rash (32%), followed by acne (12%) and dermatitis (11%). Most (78%) referrals came from general practitioners. Around 8% of patients seen in the teledermatology clinic were converted to in-person review; 81% of patients were managed via teledermatology, and 10% of patients did not attend the scheduled teleconsultation.

CONCLUSION

The outpatient teledermatology clinic run through the Telehealth Centre of a metropolitan hospital is an effective way of delivering a general dermatology consultation service to rural and remote patients in a timely manner.

Use of teledermatology by dermatology hospitalists is effective in the diagnosis and management of inpatient disease

Background

Patient outcomes are improved when dermatologists provide inpatient consults. Inpatient access to dermatologists is limited, illustrating an opportunity to utilize teledermatology. Little is known about the ability of dermatologists to accurately diagnose and manage inpatients using teledermatology, particularly utilizing non-dermatologist generated clinical data.

Methods

This prospective study assessed the ability of teledermatology to diagnose and manage 41 dermatology consults from a large urban tertiary care center utilizing internal medicine referral documentation and photos. Twenty-seven dermatology hospitalists were surveyed. Interrater agreement was assessed by the kappa statistic.

Results

There was substantial agreement between in-person and teledermatology assessment of the diagnosis with differential diagnosis (median kappa = 0.83), substantial agreement in laboratory work-up decisions (median kappa = 0.67), almost perfect agreement in imaging decisions (median kappa = 1.0), and moderate agreement in biopsy decisions (median kappa = 0.43). There was almost perfect agreement in treatment (median kappa = 1.0), but no agreement in follow-up planning (median kappa = 0.0). There was no association between raw photo quality and the primary plus differential diagnosis or primary diagnosis alone.

Limitations

Selection bias and single-center nature.

Conclusions

Teledermatology may be effective in the inpatient setting, with concordant diagnosis, evaluation, and management decisions.

Teledermatology in Norway using a mobile phone app

Rashes, ulcers and skin lesions are well suited for telemedicine. We have developed a smartphone app, the first of its kind in Norway, where a referring physician can write a short medical history and take clinical and dermatoscopic photographs with a smartphone, which is then sent to and evaluated by a dermatologist. In the period from June 1st, 2017, to September 1st, 2019, clinical information and photographs of rash and skin lesions from 171 patients were sent by 40 primary care and nursing home physicians via the smartphone app to four dermatologists for diagnosis and therapeutic advice. A wide range of dermatological conditions were diagnosed, most commonly chronic ulcers (17%), eczema (15%) and pigmented lesions (13%). Assessed later by a dermatologist, referral for regular consultations with a specialist was avoided in 119 patients (70%). Sixteen patients (9%) were recommended a regular consultation with a dermatologist; information for prioritization in the specialist healthcare service was then provided. In 36 patients (21%), further measures by the referring physician were recommended. Our experience indicates that many ordinary consultations on rash, ulcers and skin lesions in the specialist healthcare services can be avoided when using the smartphone app.

A review of literature supporting the development of practice guidelines for teledermatology in Australia

Despite the potential of teledermatology to increase access to dermatology services and improve patient care, it is not widely practised in Australia. In an effort to increase uptake of teledermatology, Australian-specific practice guidelines for teledermatology are being developed by the Australasian College of Dermatologist. This paper reports finding from literature reviews that were undertaken to inform the development of these guidelines. Results cover the following sections: Modalities of teledermatology; Patient selection and consent; Imaging; Quality and safety; Privacy and security; Communication; and Documentation and retention. The document educates providers about the benefits and limitations of telehealth while articulating how to enhance patient care and reduce risk when practicing teledermatology.

A Cost-Minimization Analysis of a Medical Record-based, Store and Forward and Provider-to-provider Telemedicine Compared to Usual Care in Catalonia: More Agile and Efficient, Especially for Users

Background: Telemedicine (interconsultation between primary and hospital care teams) has been operating in the counties of Central Catalonia Bages, Moianès and Berguedà since 2011, specializing in teledermatology, teleulcers, teleophthalmology and teleaudiometries. For the period until the end of 2019, a total of 52,198 visits were recorded. Objective: To analyze the differential costs between telemedicine and usual care in a semi-urban environment. Methodology: A cost-minimization evaluation, including direct and indirect costs from a societal perspective, distinguishing healthcare and user’s costs, was carried out over a three-month period. Results: Telemedicine saved € 780,397 over the period analyzed. A differential cost favorable to telemedicine of about € 15 per visit was observed, with the patient being the largest beneficiary of this saving (by 85%) in terms of shorter waiting times and travel costs. From the healthcare system perspective, moving the time spent in a hospital care consultation to primary care is efficient in terms of the total time devoted per patient. In social terms and in this context, telemedicine is more efficient than usual care. Conclusion: Allowing users to save time in terms of consultation and travel is the main driver of interconsultation between primary and hospital care savings in a semi-urban context. The telemedicine service is also economically favorable for the healthcare system, enabling it to provide a more agile service, which also benefits healthcare professionals.

The Role of Teledermatology and Teledermoscopy in the Diagnosis of Actinic Keratosis and Field Cancerization

Actinic keratosis (AK) and field cancerization are increasing health problems insufficiently diagnosed by primary care physicians. The objective of this study was to assess the validity and reliability of teledermatology (TD) and teledermoscopy in the diagnosis of AK and field cancerization in a gatekeeper healthcare model. A prospective diagnostic test evaluation was done to assess the diagnostic concordance, accuracy, and performance parameters and the interobserver and intraobserver concordances of TD and teledermoscopy compared with dermatologists' face-to-face evaluation or histopathology. A total of 636 patients with 1,000 keratotic skin lesions were included. TD diagnostic concordance for AK and field cancerization evaluation was very high and superior to primary care physicians' diagnosis (92.4% vs. 62.4% and 96.7% vs. 51.8%, P < 0.001). TD sensitivity, specificity, and positive and negative predictive values for AK diagnosis and field cancerization were high (range = 82.2-95.0) and better than primary care physicians' diagnosis. Teledermoscopy yielded better results in diagnostic concordance, performance parameters, and AK subtypes. Intraobserver and interobserver agreement was >0.83. TD and, to a greater extent, teledermoscopy may be valid and reliable tools for the diagnosis of AK and field cancerization and may improve diagnosis and correct allocation and management in gatekeeper healthcare systems. It can be an alternative tool to training primary care physicians in direct diagnosis of these lesions.

Is Teledermoscopy Ready to Replace Face-to-Face Examinations for the Early Detection of Skin Cancer? Consumer Views, Technology Acceptance, and Satisfaction with Care

BACKGROUND

Previous cross-sectional research indicates high acceptance of mobile teledermoscopy-enhanced skin self-examination (SSE) by consumers based on the technology acceptance model (TAM) domains: perceived usefulness, ease of use, compatibility, attitude and intention, subjective norms, facilitator, and trust. However, no study has assessed this outcome longitudinally among people who actually used the technology in their own homes.

METHODS

Participants were living in Brisbane, Australia, aged 18 years or older, and at high risk of skin cancer. Participants randomly assigned to the intervention group (n = 98) completed a self-administered questionnaire on mobile teledermoscopy acceptance for skin cancer detection both before use and after performing mobile teledermoscopy-enhanced SSE in their homes. The survey included a 25-item scale assessing seven TAM domains. Item scores ranged from 5 (strongly agree) to 1 (strongly disagree). Participants also answered survey questions on satisfaction with use of teledermoscopy, and a 9-item "thoughts about melanoma" scale that measures cancer worry.

RESULTS

Participants were 19-73 years old, had high skin cancer risk, blue or grey eyes (53.1%), fair or very fair skin (88.8%), and previous skin cancer treatments (61.2%). Participants were more accepting of mobile teledermoscopy at baseline: mean TAM score of 4.15 (SE 0.05); their level of acceptance decreased significantly after teledermoscopy use: mean score 3.94 (SE 0.05; p = 0.001). In linear regression analysis, the decrease in TAM scores was similar across demographic and skin cancer risk categories. Ninety-two percent (n = 90) of participants agreed that mobile teledermoscopy was easy to use. The mean score of the "thoughts about melanoma" scale did not change significantly from baseline to follow-up.

CONCLUSION

Consumers had high TAM scores before they used mobile teledermoscopy within a randomised control trial. At the end of the intervention period, TAM scores decreased, although participants' average score still indicated "agreement" that mobile teledermoscopy was acceptable.

Teledermatology and its Current Perspective

Teledermatology is one of the most important and commonly employed subsets of telemedicine, a special alternative to face-to-face (FTF) doctor--patient consultation that refers to the use of electronic telecommunication tools to facilitate the provision of healthcare between the "seeker" and "provider." It is used for consultation, education, second opinion, and monitoring medical conditions. This article will review basic concepts, the integration of noninvasive imaging technique images, artificial intelligence, and the current ethical and legal issues.

Inpatient eDermatology (Teledermatology) Can Help Meet the Demand for Inpatient Skin Disease

Background: Currently, the number of inpatient dermatology providers cannot meet the overall burden of inpatient skin disease in the United States. Introduction: We seek to determine whether inpatient eDermatology can meet the need for inpatient skin disease in hospitals without access to a dermatology hospitalist. Methods: This retrospective cohort study reviewed inpatient eDermatology consults at the University of Pittsburgh eDermatology Consult Service between July 1, 2014 and June 30, 2018. This included a diverse group of 1,320 patients admitted to 10 different community hospitals. Study data were reviewed for demographics, diagnostic impressions, time to discharge, and diagnostic discordance between referring and consultant physicians. Results: Forty percent of inpatient eDermatology consults were admitted with a primary dermatologic diagnosis. Referring diagnosis most commonly was rash not otherwise specified. eDermatology consulting impressions, conversely, were specific and varied. Ninety-one percent of patients received a consultant impression by the end of day, or within 8 hours. Overall, 89.3% of patients with a referring diagnosis of "cellulitis" were given a different diagnosis by the consultant. Discussion: Although this study lacked concordance data to compare the Inpatient eDermatologist with a live Inpatient Dermatologist, overall, eDermatology consultants were able to provide rapid consult recommendations that aided patient management. Conclusions: Inpatient eDermatology appears to be an effective medium to provide dermatologic care to patients at hospitals without a dermatology presence. This delivery of health care can help prevent misdiagnosis, unnecessary costs, and inappropriate systemic therapies.

Teledermatologia: uma interface entre a atenção primária e atenção especializada em Florianópolis

Introdução: A aplicação do telediagnóstico em dermatologia pode apresentar diversos benefícios como a redução do tempo de espera para consultas com especialistas focais, triagem de doenças graves - principalmente neoplasias - e educação permanente de profissionais. Objetivo: Relatar a experiência da implantação do serviço de teledermatologia no município de Florianópolis - Santa Catarina - e o impacto inicial do processo no acesso e qualificação da assistência aos pacientes com afecções dermatológicas. Métodos: Estudo observacional, transversal e descritivo. Foram utilizados dados do sistema de prontuário eletrônico municipal, base de dados da plataforma Telessaúde-SC e documentos públicos institucionais da Secretaria Municipal de Saúde de Florianópolis entre os anos de 2013 e 2017. Resultados: O serviço de teledermatologia foi implementado no município de Florianópolis em 2015, por meio da adesão ao Sistema Integrado Catarinense de Telemedicina e Telessaúde. O processo de adequação ocorreu por meio da aquisição de equipamentos, adaptações na infraestrutura e capacitações de servidores. No período analisado, verificou-se redução de 52,6% na taxa de encaminhamentos para dermatologia, com expressiva diminuição no tempo de espera para consulta de cerca de 3 anos, em 2013 e 2014, para 20 dias em 2017. Nota-se tendência à qualificação dos encaminhamentos ao serviço, com redução nos laudos emitidos com classificação azul, manejados na APS, e aumento de laudos com classificação amarela, referenciados para dermatologia. Conclusão: A implantação da teledermatologia em Florianópolis representou um grande avanço para o processo de integração entre a Atenção Primária à Saúde e Atenção Especializada, contribuindo para a redução nas filas de espera e na qualificação dos encaminhamentos, com potencial para o aprimoramento da coordenação do cuidado e educação continuada dos profissionais.

Evaluating healthcare practitioners' views on store-and-forward teledermoscopy services for the diagnosis of skin cancer

Objective

The aim of the study is to evaluate healthcare practitioners’ views on and satisfaction with (i) digital image acquisition and storage and (ii) store-and-forward teledermoscopy services for the diagnosis of skin cancer in their clinical practice.

Methods

An online survey was conducted among 59 healthcare practitioners (GPs (n=17), dermatologists (n=22), dermatology registrars (n=18), a dermatology research fellow (n=1) and a plastic surgeon (n=1)) to assess usability of digital image acquisition and storage for when the imaging process is conducted by the healthcare practitioners themselves, or by their patients. The study identifies the enablers and barriers of this emerging mode of medical practice. A thematic analysis was used to extract key themes from open-ended responses, which involved identifying themes and patterns within and across participants.

Results

Thirty-four healthcare practitioners (58%) had previously used a mobile dermatoscope within their practice. Participants most appreciated its use in their practice for lesion monitoring (59%) and record keeping (39%). Challenges reported were the increased time to support the additional workload (45%), technical issues (33%) and cost of equipment (27%). Practitioners were unsure (36%) or did not advocate teledermoscopy for direct-to-consumer use (41%). Only 23% supported the use of direct-to-consumer teledermoscopy.

Conclusion

While most practitioners are receptive to mobile teledermoscopy, there was less support for patient-initiated use, whereby the patient controls the imaging process. As technology improves rapidly it is important to evaluate practitioners’ acceptance and satisfaction of evolving telehealth services, moving forward with models of practice where healthcare practitioners and other healthcare providers will feel comfortable engaging in telehealth services.

Leprosy Diagnosed via Teledermatology in a U. S. Urban Academic Health Center Highlights Potential Benefits and a Pitfall of Existing Telemedicine Services

Purpose: Teledermatology has emerged as an important tool to extend the reach of dermatologists. As utilization of teledermatology services increases, careful attention should be given to the design of the system for consulting dermatologists. Methodology: In this case study, we report how access to a patient's entire medical history in a teledermatology consultation was vital for an accurate diagnosis. Results: This case emphasizes the importance of full access to patients' medical records for improving diagnostic accuracy. We believe that full-access systems will lower the risk of misdiagnosis and will help to maximize the potential of teledermatology.

Recent trends in teledermatology and teledermoscopy

Teledermatology is a useful alternative where specialized dermatological assistance is not available and has been used successfully to support health professionals in a wide range of settings worldwide, in either an asynchronous store-and-forward format or a real-time video conferencing format. Teledermoscopy, which includes dermoscopic images in the teleconsultation, is another addition that improves remote assessments of pigmented lesions. A more recent variant is mobile teledermoscopy, which uses a smartphone to deliver the same type of service.

Teledermoscopy’s greatest strength may be as a triage and monitoring tool, as it can reduce the number of unnecessary referrals, wait times, and the cost of providing and receiving dermatological care. While face-to-face (FTF) care remains the gold standard for diagnosis, drawbacks of not using FTF care as the primary method can be mitigated if teleconsultants are willing to refer to FTF care whenever there is uncertainty. Teledermatology has generally been well accepted by patients and practitioners alike.

Barriers to the large-scale use of teledermatology remain. Assigning medicolegal responsibility and instituting a reimbursement system are critical to promoting widespread use by medical professionals, while privacy and security features and a mechanism to link teleconsultations to patients’ existing health records are essential to maximize patient benefit. Direct-to-consumer services also need attention from regulators to ensure that consumers can enjoy the benefits of telemedicine without the dangers of unregulated or untested platforms.