A Framework-Driven Systematic Review of the Barriers and Facilitators to Teledermatology Implementation

An Exploration of Dutch Dermatologists' Experience and Satisfaction With Teledermatology: Sociotechnical and Complex Adaptive System Perspective

BACKGROUND

Despite the global upscale of teledermatology during the COVID-19 pandemic, persistent barriers, such as the poor anamnesis and photo quality, hinder its effective use in practice. Understanding Dutch dermatologists' experiences and satisfaction with using the teledermatology system in the Dutch health care system is needed. A holistic evaluation may provide valuable insight to understand how barriers interrelate which is deemed necessary for the innovation of teledermatology in practice.

OBJECTIVE

Guided by a complex adaptive system perspective, this study aims to understand Dutch dermatologists' experience and satisfaction with their training, support communication, interaction, and usage of a teledermatology platform of a Dutch digital hospital during the COVID-19 pandemic, uncovering insights to improve teledermatology services for the future.

METHODS

A web-based questionnaire was sent in December 2021 to Dutch dermatologists who (1) had an active teledermatology platform account, and (2) responded to a teledermatology consultation between October 1, 2019, and September 30, 2021. The questionnaire consisted of the validated Store-and-Forward Telemedicine Service User-satisfaction Questionnaire (SAF-TSUQ) questionnaire, and new questions regarding; demographics of teledermatologists, the use of teledermatology during the COVID-19 pandemic, the performance of teledermatology by general practitioners (GP), and the role of dermatologists in the teledermatology process. The open-ended questions were analyzed by a grounded theory approach guided by a sociotechnical model and complemented by a complex adaptive system perspective. A panel discussion with 3 dermatologists was performed to provide additional insight into the responses to the questionnaire.

RESULTS

We obtained responses from 25 out of the 249 (10%) invited dermatologists. Overall, dermatologists had a positive experience with teledermatology. Interestingly, teledermatology use frequency remained unaffected by the COVID-19 pandemic. However, the insufficient quality and incompleteness of the clinical content (photos and anamneses information) of the teledermatology consultation impacted the efficiency of the teledermatology workflow. Dermatologists expressed the need for improvement to avoid time-consuming processes or physical referrals. The panel discussion enriched and confirmed the responses, suggesting solutions like mandatory fields for the GPs for a complete anamnesis.

CONCLUSIONS

Dutch Dermatologists view teledermatology as a valuable tool to provide access to dermatology care. However, improvements regarding the quality and completeness of the provided clinical content are necessary for the effectiveness and efficiency of the complex teledermatology system in Dutch health care. This could increase both the dermatologists' satisfaction and the quality of teledermatology services. Managing trade-offs, such as time investments versus image quality, is crucial for teledermatology implementation and should be assessed from a complexity perspective to understand trade-offs and prevent unintended consequences.

Does the Diagnostic Accuracy and Rates of Face-to-Face Visits Occurring Shortly after an Asynchronized Teledermatology Consultation Justify Its Implementation? An 18-Month Cohort Study

INTRODUCTION

In 2019, Maccabi Health Services (MHS) rolled out the store-and-forward "Dermadetect" teledermatology consultation (TC) application. Study goal was to analyze MHS records of TCs (August 2019-February 2021) for the rate and reasons for face-to-face consultations (FTFC) occurring shortly after a TC with emphasis on FTFCs resulting in a different diagnosis for the same indication.

METHODS

The records of FTFCs held up shortly after TCs were reviewed and classified into cases marked as unsuited for teledermatology, cases in which the indication differed, and cases with the same indication, which were analyzed for concordance of diagnoses.

RESULTS

Dermadetect was used by 12,815 MHS beneficiaries. In 30% of cases, following FTFC occurred within the subsequent 5 months, and 901 of them occurred in the subsequent 2 weeks and were analyzed. Thirty percent were not suited for teledermatology, 15% were held for a different indication, and 55% occurred for the same indication. The diagnosis concordance between the TC and recurrent FTFC for the same indication was 97.4%, with full concordance at 68.1% and partial concordance at 29.3%. Overall, 13 patients (1.4%) of the 901 patients using the application only once had a subsequent FTFC within 2 weeks and received a different diagnosis than the one given in the TC.

CONCLUSIONS

When considering the implementation of store-and-forward TC's, a 30% rate of following FTFC's during the next 5 months should be considered when planning the reimbursement model. Diagnosis discordance may be disregarded due to its low rates.

Implementation evaluation of a teledermatology virtual clinic at an academic medical center

BACKGROUND

Teledermatology (TD) is an evidence-based practice that may increase access to dermatologic care. We sought to use the Exploration, Preparation, Implementation, and Sustainment (EPIS) and the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to evaluate implementation of TD at Duke.

METHODS

The EPIS and RE-AIM frameworks were deployed to design and implement a TD program that leveraged the strengths of the Duke University Health System and addressed previously reported barriers to implementation of store-and-forward and synchronous TD models. In the resultant hybrid TD model, trained primary care providers (PCPs) sent e-comm referrals with clinical and dermatoscopic images to dermatology. These e-consults were reviewed asynchronously and patients were scheduled for a synchronous video visit with dermatology within days. Dermatologists managed the patient plan. This hybrid TD model was piloted at four primary care clinics. Pertinent outcomes from a TD-adapted RE-AIM framework were tracked using electronic health record data. Patient satisfaction was assessed using a post-video visit survey (n = 18). Implementation barriers and facilitators were also collected through provider surveys (n = 24 PCPs, n = 10 dermatologists, n = 10 dermatology residents).

RESULTS

At four PCP clinics throughout 9/1/2021-4/30/2022, there were 218 TD referrals. Video visits occurred on average 7.5 ± 0.5 days after referral and 18/18 patients completing the post-visit survey were satisfied. Adoption varied between clinics, with one placing 22% of all dermatology referrals as TD and another placing 2%. The primary PCP barriers to TD were time burdens, lack of fit in clinic flow, and discomfort with image taking. Top-endorsed potential facilitating interventions included allowing for rash referrals without dermoscopy and assurance for clinical evaluation within 3 days.

CONCLUSIONS

The use of implementation science frameworks allowed for identification of system and contextual strengths which informed the hybrid TD pilot. Barriers and facilitating interventions will provide guidance for expansion and ongoing maintenance of TD.

Implementation Evaluation of a Teledermatology Virtual Clinic at an Academic Medical Center

Background

Teledermatology (TD) is an evidence-based practice that may increase access to dermatologic care. We sought to evaluate implementation of TD at four Duke primary care practices.

Methods

We implemented a hybrid TD program where trained primary care providers (PCPs) sent referrals with clinical and dermatoscopic images to dermatology. Patients were seen by dermatologists over video visit within days, and dermatologists managed the patient plan. We evaluated implementation using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework using electronic health record data. Implementation barriers and facilitators were collected through surveys (n = 24 PCPs, n = 10 dermatologists, n = 10 dermatology residents).

Results

At four PCP clinics throughout 9/1/2021-4/30/2022 there were 218 TD referrals. Video visits occurred on average 7.5 days after referral and 18/18 patients completing the post-visit survey were satisfied. Adoption varied between clinics, with one placing 22% of all dermatology referrals as TD and another placing 2%. The primary PCP barriers to TD were time burdens, lack of fit in clinic flow, and discomfort with image taking. Top-endorsed potential facilitating interventions included allowing for rash referrals without dermoscopy and assurance for clinical evaluation within 3 days.

Conclusions

Addressing TD process fit into PCP clinic flow and reducing time burdens may increase PCP uptake of TD.

Diagnostic and treatment concordance in primary care participants and dermatologists utilizing Extension for Community Health Outcomes (ECHO)

INTRODUCTION

Suboptimal access to dermatologic care is dependent on patient location and insurance type. Although there have been attempts to address access issues, barriers to providing excellent dermatologic care to all patients at the right time still exist. The objective of this study was to investigate the clinical impact of Dermatology Extension for Community Healthcare Outcomes (ECHO) project participation on primary care providers' diagnostic and treatment tendencies and accuracy.

METHODS

This was a retrospective cohort study constructed using Dermatology Extension for Community Healthcare Outcomes case and recommendation data from November 2015 to June 2021. The University of Missouri-based Dermatology Extension for Community Healthcare Outcomes specialty hub team offers regularly scheduled live interactive tele-mentoring sessions for primary care providers who practice in rural and underserved areas. 524 patient cases presented by 25 primary care providers were included in the analysis. Of those, 449 cases were included in diagnostic concordance, and 451 in treatment concordance analysis.

RESULTS

Less than 40% of all diagnoses were fully concordant with an expert panel. Over 33% of patients were misdiagnosed, and over 26% received partially correct diagnosis. Only 16% of all treatment recommendations were fully concordant with an expert panel.

DISCUSSION

Diagnostic and treatment accuracy of participants is low, and Dermatology Extension for Community Healthcare Outcomes platform ensured patients received correct diagnosis and treatment quickly. Although tele-dermatology models are effective, they continue to be underutilized. Dermatologists in practice and training should be encouraged to adopt innovative clinical educational models, like Dermatology ECHO, to expand access to dermatologic expertise for the most marginalized populations.

Artificial Intelligence Implementation in Healthcare: A Theory-Based Scoping Review of Barriers and Facilitators

There is a large proliferation of complex data-driven artificial intelligence (AI) applications in many aspects of our daily lives, but their implementation in healthcare is still limited. This scoping review takes a theoretical approach to examine the barriers and facilitators based on empirical data from existing implementations. We searched the major databases of relevant scientific publications for articles related to AI in clinical settings, published between 2015 and 2021. Based on the theoretical constructs of the Consolidated Framework for Implementation Research (CFIR), we used a deductive, followed by an inductive, approach to extract facilitators and barriers. After screening 2784 studies, 19 studies were included in this review. Most of the cited facilitators were related to engagement with and management of the implementation process, while the most cited barriers dealt with the intervention's generalizability and interoperability with existing systems, as well as the inner settings' data quality and availability. We noted per-study imbalances related to the reporting of the theoretic domains. Our findings suggest a greater need for implementation science expertise in AI implementation projects, to improve both the implementation process and the quality of scientific reporting.

Navigating patients with atopic dermatitis or chronic spontaneous urticaria during the COVID-19 pandemic

A rapid spread of different strains of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented pandemic. Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, the medical body has encountered major obstacles concerning disease management at different levels. Even though patients infected with this virus mainly present with respiratory symptoms, it has been associated with a plethora of well-documented cutaneous manifestations in the literature. However, little investigations have been conducted concerning COVID-19 and its impact on skin disorders mediated by type 2 inflammation leaving multiple dermatologists and other specialists perplexed by the lack of clinical guidelines or pathways. This review focuses on the effects of this pandemic in patients with skin disorders mediated by type 2 inflammation, specifically atopic dermatitis and chronic spontaneous urticaria. In addition, it will provide clinicians a guide on treatment and vaccination considerations for this stated set of patients.

Eleven years of teledermoscopy in the Netherlands: A retrospective quality and performance analysis of 18,738 consultations

INTRODUCTION

Teledermoscopy supports and enhances the early detection of skin lesions by general practitioners in primary practice through remote consultation with dermatologists. Teledermoscopy has been a regular health service in Dutch primary care since February 2009. Teledermoscopy quality and performance outcomes on Dutch general practitioner primary care 11 years after its implementation were assessed.

METHODS

Dutch primary care teledermoscopy consultation data was retrospectively analysed on timestamps and responses on non-mandatory evaluation questions posed to the general practitioner and teledermatologist during the teledermoscopy consultation process. Anonymized data (February 2009-February 2020) was extracted from a Dutch teledermoscopy service database. The timestamps and evaluation questions data were subject to the teledermoscopy quality and performance outcomes. A limited cost evaluation was performed.

RESULTS

A total of 18,738 teledermoscopy consultations were sent by 1341 general practitioners (February 2009-February 2020). For 3908 (31.9%) teledermoscopy consultations, the general practitioner requested second opinion advice which led to 712 (18.2%) extra teledermoscopy referrals of patients who would not have been referred without teledermoscopy, including skin cancer teledermoscopy diagnoses. The general practitioner followed the teledermatologists' advice on patient referral for 8813 (88.5%) patients, reported 97.3% of the teledermoscopy consultations as helpful and 95.1% as instructive, referred 68.0% less patients with teledermoscopy availability, referred overall 59.4% less patients, and needed 5.4 minutes (median) for sending a teledermoscopy consultation. Teledermatologist's median answer and response time was 2 minutes and 2.4 hours, respectively. The estimated cost reduction was €144.18 ($164.65) (50.2%) per teledermoscopy patient.

DISCUSSION

Teledermoscopy is a useful service in general practitioner practice for requesting dermatologist advice in primary care settings to support the detection of skin lesion at an early stage and at lower costs. Teledermoscopy could also decrease the burden of secondary dermatology care since general practitioners reported that they did not refer the majority of patients to a dermatologist after the teledermoscopy consultation compared to their initial referral decision. General practitioners reported the teledermoscopy system as helpful and instructive which could contribute to enhancement of their dermatological knowledge.

The process of telepractice implementation during the COVID-19 pandemic: a narrative inquiry of preschool speech-language pathologists and assistants from one center in Canada

BACKGROUND

Many professional services were pressed to adopt telepractice in response to the global coronavirus SARS-CoV-2 (COVID-19) pandemic. The need to adopt a new service delivery approach quickly created different implementation challenges. This study explored the lived experiences of frontline clinicians who successfully transitioned their in-person speech-language therapy services to telepractice through an implementation science lens.

METHODS

The study was conducted in partnership with one publicly funded program in Ontario, Canada that offers services to preschoolers with speech, language and communication disorders. Sixteen frontline speech-language pathologists and assistants at this organization shared their lived experience transitioning to telepractice during the pandemic during videoconference interviews. A narrative inquiry approach was used to analyze interview transcripts to identify the processes (or steps) this program took to implement telepractice and to understand the facilitators and barriers to telepractice implementation during the pandemic.

RESULTS

The following six stages were identified from clinicians' narratives: abrupt lockdown; weeks of uncertainty; telepractice emerged as an option; preparation for telepractice; telepractice trials; and finally, full implementation of telepractice. The stages of events offered significant insights into how government public health measures influenced clinicians' decisions and their processes of adopting telepractice. In terms of barriers, clinicians reported a lack of knowledge, skills and experience with telepractice and a lack of technological support. The organization's learning climate and team approach to transitioning services were identified as the main facilitator of implementation.

CONCLUSIONS

Findings suggest a need for better coordination of public health measures and professional services, which would have eased clinicians' stress and facilitated an earlier transition to telepractice. Fostering an organization's learning climate may improve organization's resilience in response to emergency situations.

A Narrative Review of Factors Historically Influencing Telehealth Use across Six Medical Specialties in the United States

Prior to the COVID-19 pandemic, studies in the US have identified wide variations in telehealth use across medical specialties. This is an intriguing problem, because the US has historically lacked a standardized set of telehealth coverage and reimbursement policies, which has posed a barrier to telehealth use across all specialties. Although all medical specialties in the US have been affected by these macro (policy-level) barriers, some specialties have been able to integrate telehealth use into mainstream practice, while others are just gaining momentum with telehealth during COVID-19. Although the temporary removal of policy (coverage) restrictions during the pandemic has accelerated telehealth use, uncertainties remain regarding future telehealth sustainability. Since macro (policy-level) factors by themselves do not serve to explain the variation in telehealth use across specialties, it would be important to examine meso (organizational-level) and micro (individual-level) factors historically influencing telehealth use across specialties, to understand underlying reasons for variation and identify implications for widespread sustainability. This paper draws upon the existing literature to develop a conceptual framework on macro-meso-micro factors influencing telehealth use within a medical specialty. The framework is then used to guide a narrative review of the telehealth literature across six medical specialties, including three specialties with lower telehealth use (allergy-immunology, family medicine, gastroenterology) and three with higher telehealth use (psychiatry, cardiology, radiology) in the US, in order to synthesize themes and gain insights into barriers and facilitators to telehealth use. In doing so, this review addresses a gap in the literature and provides a foundation for future research. Importantly, it helps to identify implications for ensuring widespread sustainability of telehealth use in the post-pandemic future.