Lessons learned after a three-year store and forward teledermatology experience using internet: Strengths and limitations

Barriers and Facilitators to Teledermatology and Tele-Eye Care in Department of Veterans Affairs Provider Settings: Qualitative Content Analysis

BACKGROUND

Veterans Affairs health care systems have been early adopters of asynchronous telemedicine to provide access to timely and high-quality specialty care services in primary care settings for veterans living in rural areas. Scant research has examined how to expand primary care team members' engagement in telespecialty care.

OBJECTIVE

This qualitative study aimed to explore implementation process barriers and facilitators to using asynchronous telespecialty care (teledermatology and tele-eye care services).

METHODS

In total, 30 participants including primary care providers, nurses, telehealth clinical technicians, medical and program support assistants, and administrators from 2 community-based outpatient clinics were interviewed. Semistructured interviews were conducted using an interview guide, digitally recorded, and transcribed. Interview transcripts were analyzed using a qualitative content analysis summative approach. Two coders reviewed transcripts independently. Discrepancies were resolved by consensus discussion.

RESULTS

In total, 3 themes were identified from participants' experiences: positive perception of telespecialty care, concerns and challenges of implementation, and suggestions for service refinement. Participants voiced that the telemedicine visits saved commute and waiting times and provided veterans in rural areas more access to timely medical care. The mentioned concerns were technical challenges and equipment failure, staffing shortages to cover both in-person and telehealth visit needs, overbooked schedules leading to delayed referrals, the need for a more standardized operation protocol, and more hands-on training with formative feedback among supporting staff. Participants also faced challenges with appointment cancellations and struggled to find ways to efficiently manage both telehealth and in-person visits to streamline patient flow. Nonetheless, most participants feel motivated and confident in implementing telespecialty care going forward.

CONCLUSIONS

This study provided important insights into the positive perceptions and ongoing challenges in telespecialty care implementation. Feedback from primary care teams is needed to improve telespecialty care service delivery for rural veterans.

Store-and-forward (asynchronous) doctor-to-dermatologist non-skin cancer specific teledermatology services in Australia: A scoping review

Store-and-forward teledermatology (SAFT) has become increasingly popular as a means to increase access to specialist care and address healthcare disparities such as those experienced by rural communities. A contemporary systematic overview of the Australian SAFT services and outcomes for all dermatological conditions is missing. This scoping review provides an overview of Australian SAFT models. Twelve studies were identified through web databases, grey literature sites and reference lists of eligible articles. Eligibility criteria included studies evaluating doctor-to-dermatologist Australian SAFT services provided to Australians for all skin conditions but excluded the studies that solely focused on skin cancers. Data on study design, setting, population, SAFT model, referral characteristics, patient, and general practitioner perspectives, diagnostic concordance, and measured outcomes such as follow up, investigation and waiting time were extracted. Quality of the included studies was assessed using CASP tools. Synthesis reveals that SAFT can be used for patients with any dermatological condition, provides more accurate diagnostics compared to cases without dermatologist input, may reduce waiting times for dermatological expertise, and users generally had positive experiences with SAFT. Although results are positive, this review reveals the heterogenous nature of the literature on SAFT in Australia and a need to establish a uniform approach to assessing the outcomes and impacts of such services.

Descriptive and Concordance Data for Asynchronous Teledermatology Consultations for Dermatitis: A Retrospective Study

Background: Implementation of teledermatology for assessing dermatitis patients provides comparable diagnostic and management outcomes to in-person visits, but studies on consumer to physician asynchronous teledermatology (eDerm) consults submitted by patients in large dermatitis cohorts are limited. The objective of this study was to retrospectively assess associations of eDerm consults with diagnostic accuracy, management, and follow-up in a large cohort of dermatitis patients. Methods: One thousand forty-five eDerm encounters between April 1, 2020, and October 29, 2021, recorded in the University of Pittsburgh Medical Center Health System Epic electronic medical record were reviewed. Descriptive statistics and concordance were analyzed using chi-square. Results: Asynchronous teledermatology modified/changed treatment in 97.6% of cases and had the same diagnosis between teledermatology and in-person follow-up in 78.3% of cases. Patients following up in the time line requested were more likely to follow-up in person (61.2% vs. 43.8%) than those who did not. Patients with intertriginous dermatitis (p = 0.003), preexisting conditions (p = 0.002), who required follow-ups (<0.0001), and moderate-high severity scores of 4-7 (p = 0.019) were more likely to follow up in the time line requested. Limitations: Lack of similar in-person visit data did not allow us to compare descriptive and concordance data between eDerm and clinic visits. Conclusions: eDerm offers a quick accessible solution to provide comparable dermatologic care for patients with dermatitis.

Store-and-Forward Images in Teledermatology: Narrative Literature Review

Background

Store-and-forward (SAF) teledermatology uses electronically stored information, including patient photographs and demographic information, for clinical decision-making asynchronous to the patient encounter. The integration of SAF teledermatology into clinical practice has been increasing in recent years, especially during the COVID-19 pandemic. Despite this growth, data regarding the outcomes of SAF teledermatology are limited. A key distinction among current literature involves comparing the quality and utility of images obtained by patients and trained clinicians, as these metrics may vary by the clinical expertise of the photographer.

Objective

This narrative literature review aimed to characterize the outcomes of SAF teledermatology through the lens of patient- versus clinician-initiated photography and highlight important future directions for and challenges of the field.

Methods

A literature search of peer-reviewed research was performed between February and April 2021. Key search terms included patient-initiated, patient-submitted, clinician-initiated, clinician-submitted, store-and-forward, asynchronous, remote, image, photograph, and teledermatology. Only studies published after 2001 in English were included. In total, 47 studies were identified from the PubMed electronic database and Google Scholar after omitting duplicate articles.

Results

Image quality and diagnostic concordance are generally lower and more variable with patient-submitted images, which may impact their decision-making utility. SAF teledermatology can improve the efficiency of and access to care when photographs are taken by either clinicians or patients. The clinical outcomes of clinician-submitted images are comparable to those of in-person visits in the few studies that have investigated these outcomes. Coinciding with the onset of the COVID-19 pandemic, asynchronous teledermatology helped minimize unnecessary in-person visits in the outpatient setting, as many uncomplicated conditions could be adequately managed remotely via images captured by patients and referring clinicians. For the inpatient setting, SAF teledermatology minimized unnecessary contact during dermatology consultations, although current studies are limited by the heterogeneity of their outcomes.

Conclusions

In general, photographs taken by trained clinicians are higher quality and have better and more relevant diagnostic and clinical outcomes. SAF teledermatology helped clinicians avoid unnecessary physical contact with patients in the outpatient and inpatient settings during the COVID-19 pandemic. Asynchronous teledermatology will likely play a greater role in the future as SAF images become integrated into synchronous teledermatology workflows. However, the obstacles summarized in this review should be addressed before its widespread implementation into clinical practice.

Evaluation of electronic consults for outpatient pediatric patients with dermatologic complaints

BACKGROUND

Although dermatologic complaints are frequently encountered by pediatricians, access to pediatric dermatologists remains limited. Teledermatology has been proposed to expand access to dermatologic care for children. We report our experience with a physician-to-physician store-and-forward teledermatology service (eConsults), focusing on patient and consult characteristics and their relationship with teledermatologist confidence and follow-up recommendations as well as clinical outcomes.

METHODS

We reviewed electronic health records of all pediatric patients referred through eConsults at the Massachusetts General Hospital from 1/13/2020 to 7/17/2020. We assessed pediatrician and parental receptiveness with a confidential survey.

RESULTS

A total of 302 referrals (median patient age 4.6 years (IQR 0.6-12); 54% female) and 310 cases were completed in 1.8 days on average (SD = 1.2). Teledermatologists rated their confidence as definite and moderate in 51.3% and 39.4% cases, respectively. Teledermatologists felt comfortable managing rashes remotely, but patients with alopecia, pigmented and vascular lesions, and warts frequently required formal dermatology evaluation. Among patients seen subsequently, full concordance was seen for 70.1% of diagnoses and 74.4% of management recommendations. All responding pediatricians were satisfied with the service, and 97.5% felt that the parents were receptive to it.

CONCLUSIONS

Our study supports the growing evidence that store-and-forward teledermatology can quickly and effectively provide the access to pediatric dermatologic care and is well received by pediatricians and parents. To maximize cost-effectiveness of store-and-forward teledermatology, dermatologists should work with referring providers to improve the quality of submitted photographs and patient history as well as advise in-person referrals for cases likely to require further follow-up.

Evaluation of High-Efficiency Image Coding algorithm for dermatology images in teledermatology

BACKGROUND

Currently, teledermatology assumes a progressively greater role in the modern healthcare system, especially in consultation, diagnosis, or examining lesions and skin cancers. One of the major challenges facing teledermatology systems is determining the optimal image compression method to efficiently reduce the space needed for electronic storage and data transmission.

OBJECTIVE

To the objective and subjective assessment of HEIC compression method on dermatological color images and benchmarking the performance of High-Efficiency Image Coding (HEIC) with different algorithms to a feasibility study of the method for teledermatology.

METHODS

Twenty-five clinical and five skin histopathology images were taken in department of dermatology, Imam Reza Hospital, Mashhad, Iran. For each image, a set of 24 compressed images with different compression rates, which is composed of eight JPEG, eight JPEG2000, and eight HEIC images, has been prepared. Compressed and original images were shown simultaneously to three dermatologists and one dermatopathologist with different experiences. Each dermatologist scored quality and suitability of compressed images for diagnostic, as well as educational/scientific purposes. An objective evaluation was performed by calculating the mean "distance" of pixel colors and peak signal-to-noise ratio (PSNR).

RESULTS

All compression rates for HEIC were objectively better than JPEG and JPEG2000, particularly at PSNR. Moreover, mean "color distance" per pixel for compressed images using HEIC was lower than others. The subjective image quality assessment also confirms the results of objective evaluation. In both educational and clinical diagnostic applications, HEIC compressed images have the highest score.

CONCLUSION

In consideration of objective and subjective evaluation, the HEIC algorithm represents an optimal performance in dermatology images compression compared with JPEG and JPEG2000.

Assessing the Diagnostic Accuracy of Teledermatology Consultations at a Local Veterans Affairs Dermatology Clinic

With the advances in health information technology and the need for increased access to specialized health care, the advent of telemedicine was designed to bring care to individuals at a distance. Telemedicine decreases barriers to health care and brings medical specialists to underserved areas and populations. We have seen a tremendous increase in the need and utilization of telemedicine during the COVID-19 pandemic due to the lockdowns and social distancing efforts. Virtual care continues to be extended to patients to maintain their health care needs when in-person clinic appointments are not feasible or ideal such as seen during a pandemic. Telemedicine is an additional tool that has proven vital to our healthcare system. To provide optimal care, a strong technological infrastructure must be in place. Once in practice, positive outcomes have been noted for patients and healthcare providers as diagnosis, treatment, and appropriate triage can be made virtually and at the patients' convenience. To ensure high-quality care is provided through the Veterans Affairs teledermatology consultation service, we investigated the concordance of teledermatology diagnoses with clinical examination findings through a retrospective chart review covering a one-year time period. Our study found a concordance of 75.3% between the teledermatology diagnoses and the in-person clinical diagnoses. The main limitation we found to virtual examination is the inability to perform total body skin examinations. We found that 60.2% of patients had additional diagnoses when examined in person, with 8.4% of patients having an additional malignant diagnosis. These findings highlight the need for in-person examinations when feasible to ensure that no other diagnoses go undiscovered if not captured on the submitted images for teledermatology consultation. Despite the limitations posed by photographic examination, teledermatology can be used as a reliable method for diagnosis when a conventional in-person examination is not readily available or ideal, such as during a pandemic, and can serve as a powerful triaging tool.

Factors Contributing to Diagnostic Discordance Between Store-and-Forward Teledermatology Consultations and In-Person Visits: Case Series

BACKGROUND

Use of asynchronous store-and-forward (SAF) teledermatology can improve access to timely and cost-effective dermatologic care and has increased during the COVID-19 pandemic. Previous research has found high diagnostic concordance rates between SAF teledermatology and face-to-face clinical diagnosis, but to our knowledge, none have used specific cases to illustrate factors contributing to diagnostic discordance.

OBJECTIVE

To identify and illustrate characteristics that may have contributed to diagnostic discordance between store-and-forward teledermatology and in-person clinical diagnosis in a series of patients.

METHODS

We identified 7 cases of diagnostic discordance between teledermatology and in-person visits where the favored diagnosis of the in-person dermatologist was not included in the differential diagnosis formulated by the teledermatologist. Cases were identified from a previously published retrospective chart review of 340 SAF teledermatology consultations, which was previously performed at an academic community health care system in the greater Boston area, Massachusetts, from January 1, 2014, through December 31, 2017. Of 99 patients who completed an in-person dermatology appointment after their teledermatology consultation, 7 had diagnostic disagreement between the teledermatologist and in-person dermatologist where the diagnosis in the in-person consultation was not included in the differential diagnosis in the original teledermatology consult. These 7 cases were examined by 2 author reviewers to identify factors that may have contributed to diagnostic discordance.

RESULTS

Factors contributing to diagnostic discordance between SAF teledermatology consultations and in-person visits included poor image quality, inadequate history or diagnostic workup, inability to evaluate textural characteristics, diagnostic uncertainty due to atypical presentations, and evolution in appearance of skin conditions over time.

CONCLUSIONS

We identified multiple factors that contributed to diagnostic discordance. Recognition and mitigation of these factors, when possible, may help to improve diagnostic accuracy and reduce the likelihood of misdiagnosis. Continuing education of referring providers and implementation of standardized guidelines for referrals may also be helpful in reducing the risk of misdiagnosis due to inherent limitations of teledermatology services.

Pediatric teledermatology: A review of the literature

Skin complaints are common among pediatric patients, yet as of 2020, fewer than 400 board-certified pediatric dermatologists currently practice in the United States. Pediatric teledermatology may address barriers to dermatologic care in children, assisting with distant geographic locations and long wait times. A review of the literature was conducted to synthesize important features of teledermatology for pediatric dermatologists. We summarize types of telemedicine platforms, common dermatologic conditions seen by pediatric teledermatologists, diagnostic accuracy and concordance, and guidelines from the American Academy of Dermatology and the American Telemedicine Association regarding teledermatology. This report highlights the utility of pediatric telemedicine in both the outpatient and inpatient dermatology setting to increase access to high-quality dermatologic care.

Part II: Accuracy of Teledermatology in Skin Neoplasms

Teledermatology has been proving to be of great help for delivering healthcare, especially now, during the SARS-CoV-2 pandemic. It is crucial to assess how accurate this method can be for evaluating different dermatoses. Such knowledge can contribute to the dermatologists' decision of whether to adhere to teledermatology or not. Our objective was to determine the accuracy of teledermatology in the 10 most frequent skin neoplasms in our population, comparing telediagnosis to histopathological report and in-person dermatologists' diagnosis. A retrospective cohort study was conducted in São Paulo, Brazil, where a store-and-forward teledermatology project was implemented under primary-care attention to triage surgical, more complex, or severe dermatoses. A total of 30,976 patients presenting 55,012 lesions took part in the project. Thirteen teledermatologists who participated in the project had three options to refer the patients: send them directly to biopsy, to the in-person dermatologist, or back to the general physician with the most probable diagnosis and management. In the groups referred to the in-person dermatologist and biopsy, we looked for the 10 most frequent International Statistical Classification of Diseases and Related Health Problems-10 (ICD-10) of skin neoplasms, which resulted in 289 histopathologic reports and 803 in-person dermatologists' diagnosis. We were able to compare the ICD-10 codes filled by teledermatologists, in-person dermatologists, and from histopathological reports. The proportion of complete, partial, and no agreement rates between the in-person dermatologist's, histopathologic report, and the teledermatologist's diagnosis was assessed. We also calculated Cohen's kappa, for complete and complete plus partial agreement. The mean complete agreement rate comparing telediagnosis to histopathological report was 54% (157/289; kappa = 0.087), being the highest for malign lesions; to in-person dermatologists was 61% (487/803; kappa = 0.213), highest for benign lesions. When accuracy of telediagnosis for either malign or benign lesions was evaluated, the agreement rate with histopathology was 70% (kappa = 0.529) and with in-person dermatologist, 81% (kappa = 0.582). This study supports that teledermatology for skin neoplasms has moderate accuracy. This result reassures that it can be a proper option for patient care, especially when the goal is to differentiate benign from malign lesions.

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

Purpose of Review

Telemedicine use in dermatology, termed “teledermatology”, offers a cost-effective model to improve healthcare efficiency and access. Only a minority of dermatology practices has integrated teledermatology into their practice prior to COVID-19. A thorough understanding of the barriers and facilitators may promote teledermatology adoption. Implementation science frameworks offer theoretically driven ways to assess factors affecting teledermatology implementation. This review uses a comprehensive implementation science framework to summarize barriers and facilitators of teledermatology implementation and appraises the quality of existing research.

Recent Findings

Technological characteristics of teledermatology (e.g., user-friendliness) and factors within the outer setting (e.g., reimbursement and legal considerations) were the most commonly reported barriers. No existing studies use a comprehensive implementation framework to identify factors influencing teledermatology implementation. Many included studies have a risk of bias in at least two of the five study quality indices evaluated.

Summary

This systematic review is the first study to summarize the existing teledermatology implementation literature into well-defined constructs from a comprehensive implementation science framework. Findings suggest future studies would benefit from the use of an implementation framework to reduce study bias, improve result comprehensiveness, facilitate comparisons across studies, and produce evidence-based resolutions to implementation barriers. Tools, resources, and recommendations to facilitate the use of an implementation framework in future studies are provided.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13671-020-00323-0.

Part I: Accuracy of Teledermatology in Inflammatory Dermatoses

Teledermatology is assuming a progressively greater role as a healthcare delivery method, especially now, during this pandemic time. It is important to know how accurate this tool is for different skin diseases. Most of the studies have focused on skin neoplasms or general dermatology. Studies based on a large number of inflammatory dermatoses have not yet been performed. Such knowledge can help dermatologists to decide whether endorsing this method or not. Our objective was to determine the accuracy of teledermatology in inflammatory dermatoses in a robust number of cases. A retrospective cohort study was conducted in São Paulo, Brazil, from July 2017–18, where a store-and-forward Teledermatology project was implemented under primary-care attention to triage surgical, more complex, or severe dermatoses. A total of 30,976 patients presenting 55,012 lesions took part in the project. Thirteen participating teledermatologists had three options to refer the patients: directly to biopsy, to the in-person dermatologist or back to the general physician with most probable diagnosis and management. In the group referred to the in-person dermatologist, we looked for the 20 most frequent International Classification of Diseases and Related Health Problems- 10th revision (ICD-10) of inflammatory dermatoses, which resulted in 739 patients and 739 lesions. As patients had been triaged by teledermatology previously, we were able to compare ICD-10 codes filled both by teledermatogists and by in-person dermatologists. The proportion of complete, partial, and no agreement rates between the in-person dermatologist's and the teledermatologist's diagnoses was used for accuracy. We also calculated Cohen's kappa, a statistical measure of inter-rater agreement, for complete agreement. The mean complete agreement rate for all twenty dermatoses was 78% (31–100%) and kappa = 0.743; partial agreement 8%; and no agreement 14%, presenting variability according to the disease. Our study showed that teledermatology for inflammatory dermatoses has a high accuracy. This result reassures that it can be a proper option for patient care.

Reorganising dermatology care: predictors of the substitution of secondary care with primary care

Background

The substitution of healthcare is a way to control rising healthcare costs. The Primary Care Plus (PC+) intervention of the Dutch ‘Blue Care’ pioneer site aims to achieve this feat by facilitating consultations with medical specialists in the primary care setting. One of the specialties involved is dermatology. This study explores referral decisions following dermatology care in PC+ and the influence of predictive patient and consultation characteristics on this decision.

Methods

This retrospective study used clinical data of patients who received dermatology care in PC+ between January 2015 and March 2017. The referral decision following PC+, (i.e., referral back to the general practitioner (GP) or referral to outpatient hospital care) was the primary outcome. Stepwise logistic regression modelling was used to describe variations in the referral decisions following PC+, with patient age and gender, number of PC+ consultations, patient diagnosis and treatment specialist as the predicting factors.

Results

A total of 2952 patients visited PC+ for dermatology care. Of those patients with a registered referral, 80.2% (N = 2254) were referred back to the GP, and 19.8% (N = 558) were referred to outpatient hospital care. In the multivariable model, only the treating specialist and patient’s diagnosis independently influenced the referral decisions following PC+.

Conclusion

The aim of PC+ is to reduce the number of referrals to outpatient hospital care. According to the results, the treating specialist and patient diagnosis influence referral decisions. Therefore, the results of this study can be used to discuss and improve specialist and patient profiles for PC+ to further optimise the effectiveness of the initiative.

Pilot evaluation of sensitive data segmentation technology for privacy

BACKGROUND

Consent2Share (C2S) is an open source software created by the Office of the National Coordinator Data Segmentation for Privacy initiative to support electronic health record (EHR) granular segmentation. To date, there are no published formal evaluations of Consent2Share.

METHOD

Structured data (e.g. medications) codified using standard clinical terminologies (e.g. RxNorm) was extracted from the EHR of 36 patients with behavioral health conditions from study sites. EHRs were available through a health information exchange and two sites. The EHR data was already classified into data types (e.g. procedures and services). Both Consent2Share and health providers classified EHR data based on value sets (e.g. mental health) and sensitivity (e.g. not sensitive. Descriptive statistics and Chi-square analysis were used to compare differences between data categorizations.

RESULTS

From the resulting 1,080 medical records items, 584 were distinct. Significant differences were found between sensitivity classifications by Consent2Share and providers (χ2 (2, N = 584) = 114.74, p = <0.0001). Sensitivity comparisons led to 56.0 % of agreements, 31.2 % disagreements, and 12.8 % partial agreements. Most (97.8 %) disagreements resulted from information classified as not sensitive by Consent2Share, but sensitive by provider (e.g. behavioral health prevention education service). In terms of data types, most disagreements (57.1 %) focused on procedures and services information (e.g. ligation of fallopian tube). When considering value sets, most disagreements focused on genetic data (100.0 %), followed by sexual and reproductive health (88.9 %).

CONCLUSIONS

There is a need to further validate Consent2Share before broad use in health care settings. The outcomes from this pilot study will help guide improvements in segmentation logic of tools like Consent2Share and may set the stage for a new generation of personalized consent engines.

Teledermatology in paediatrics: Health-care impact on the early treatment of infantile haemangiomas

INTRODUCTION

Teledermatology can solve diagnostic and therapeutic problems in paediatrics, for example in infantile haemangiomas (IHs) requiring early treatment with propranolol. This study aims to assess the impact of teledermatology following its implementation in a health area of Spain, specifically analysing its effectiveness in reducing the age of first propranolol treatment for IH.

METHODS

This was a descriptive study of paediatric teledermatology from 2015 to 2018, studying age, sex, diagnosis, time and mode of resolution. All IHs referred via teledermatology were analysed, and age at propranolol initiation was compared to the period prior to implementation (2008-2014). We also analysed IHs according to referral pathways (teledermatology vs. conventional pathways).

RESULTS

We included 432 consultations (47.7% boys). The main diagnoses were IH, erythematous-desquamative diseases and infections. Concordance in diagnosis between paediatricians and dermatologists was good, and 48.12% of cases consulted via teledermatology were resolved remotely. Response time was 2.81 days on average. Children younger than two months of age showed the highest proportion of in-person visits. In 2015-2018, children with IHs began treatment with propranolol at a mean age of 4.5 months (1.9 months in those referred via teledermatology vs. 5.6 months in those using conventional referral pathways). In 2008-2014, the mean age at referral was 7.1 months. These differences were significant.

DISCUSSION

Teledermatology is a fast and effective tool to resolve paediatric cases, enabling a significant decrease in the age of treatment in infants with IH.

Improved patient access and outcomes with the integration of an eConsult program (teledermatology) within a large academic medical center

BACKGROUND

Insurance, racial, and socioeconomic health disparities continue to pose significant challenges for access to dermatologic care. Studies applying teledermatology to increase access to underinsured individuals and ethnic minorities are limited.

OBJECTIVE

To determine how the implementation of a teledermatology program affects access to health care and patient outcomes.

METHODS

A cross-sectional evaluation was performed of all ambulatory dermatology referrals and electronic dermatology consultations (eConsults) at Ohio State University within a 25-month period.

RESULTS

Compared with ambulatory referrals, eConsults served more nonwhite patients (612 of 1698 [36.0%] vs 4040 of 16,073 [25.1%]; P < .001) and more Medicaid enrollees (459 of 1698 patients [27.0%] vs 3266 of 16,073 [20.3%]; P < .001). In addition, ambulatory referral patients were significantly less likely to attend their scheduled appointment compared with eConsult patients, as either "no-shows" (246 of 2526 [9.7%] vs 3 of 62 [4.8%]) or cancellations (742 of 2526 [29.4%] vs 8 of 62 [12.9%]; P = .003). There were fewer median days to extirpation for eConsult patients compared with ambulatory referral patients (interquartile range; 80.7 ± 79.8 vs 116.9 ± 86.6 days; P = .004).

CONCLUSION

Integrating dermatologic care through a telemedicine system can result in improved access for underserved patients through improved efficiency outcomes.

[Teledermatology between two French hospitals: Two years of experience]

BACKGROUND

Teledermatology is currently booming. Due to the shortage of dermatologists in hospitals access to dermatological consultations is very limited in some hospitals. We present our experience of collaboration between an expert center, the dermatology department of the Victor-Dupouy Hospital Centre in Argenteuil, and all medical structures under the André-Mignot Hospital in Versailles (CHV), including 2 prison medical centers (UCSA), traditional departments and emergency department.

PATIENTS AND METHODS

Teledermatology, developed in the form of tele-expertise, began at the UCSA in November 2013. This expertise was then extended in June 2014 to the Internal Medicine department of CHV, and in December 2014 to all departments, including the emergency department. The rules and ethics of teledermatology were strictly adhered to. While UCSA could file all expertise dossiers, only urgent or difficult cases could be filed by other CHV departments.

RESULTS

In 26 months, 347 expertise requests were filed: 231 by prisons and 116 by the other departments of the CHV. No patients refused teledermatology. The quality of information and photographs was considered good or excellent in over 95% of cases. A response was given within 3hours in more than 50% of cases and in all cases within 24hours (on working days). Analysis of diseases diagnosed illustrates the wide variety of conditions encountered in dermatology, with different structures having their own specific features.

CONCLUSION

Our example illustrates the possibility of developing such an inter-hospital platform. However, it does not yet cater for requests made by patients to dermatologists, by dermatologists to dermatologists, or by dermatologists to the hospital teledermatology department. Acceptability was considered excellent by patients (with no refusals), physicians at the CHV, and the expert center.

Towards reinforcing telemedicine adoption amongst clinicians in Nigeria

Telemedicine systems have been considered as a necessary measure to alleviate the shortfall in skilled medical specialists in developing countries. However, the obvious challenge is whether clinicians are willing to use this technological innovation, which has aided medical practice globally. One factor which has received little academic attention is the provision of suitable encouragement for clinicians to adopt telemedicine, in the form of rewards, motivation or incentives. A further consideration for telemedicine usage in developing countries, especially sub-Saharan Africa and Nigeria in particular, are to the severe shortage of available practising clinicians. The researchers therefore explore the need to positively reinforce the adoption of telemedicine amongst clinicians in Nigeria, and also offer a rationale for this using the UTAUT model. Data were collected using a structured paper-based questionnaire, with 252 physicians and nurses from six government hospitals in Ondo state, Nigeria. The study applied SmartPLS 2.0 for analysis to determine the relationship between six variables. Demographic moderating variables, age, gender and profession, were included. The results indicate that performance expectancy (p<0.05), effort expectancy (p<0.05), facilitating condition (p<0.01) and reinforcement factor (p<0.001) have significant effects on clinicians' behavioural intention to use telemedicine systems, as predicted using the extended UTAUT model. Our results showed that the use of telemedicine by clinicians in the Nigerian context is perceived as a dual responsibility which requires suitable reinforcement. In addition, performance expectancy, effort expectancy, facilitating condition and reinforcement determinants are influential factors in the use of telemedicine services for remote-patient clinical diagnosis and management by the Nigerian clinicians.

Patient and practitioner satisfaction with tele-dermatology including Australia's indigenous population: A systematic review of the literature

Background

Australia’s health disparity, combined with evolving technologies, has evoked increasing interest and funding in health services that could address inequities. One such emerging service is tele-medicine.

Objective

The purpose of this report is to discuss and evaluate the current literature regarding patient and practitioner satisfaction with tele-medicine, and more specifically tele-dermatology.

Methods

We searched for literature relevant to tele-dermatology use among Australia’s indigenous population. We synthesized the literature in our report and identified elements of tele-dermatology not yet researched.

Results

Most significantly, all available research is currently based on descriptive studies and there is no validated tool to assess the efficacy of tele-dermatology.

Limitations

No published research currently exists on the use of tele-dermatology among Australia’s indigenous population.

Conclusion

A review of the literature shows that tele-dermatology is considered a valuable service, particularly to patients living in rural areas who might not otherwise have access to specialist care.

Teleconsultation and Clinical Decision Making: a Systematic Review

BACKGROUND

The goal of teleconsultation is to omit geographical and functional distance between two or more geographically separated health care providers. The purpose of present study is to review and analyze physician-physician teleconsultations.

METHOD

The PubMed electronic database was searched. The primary search was done on January 2015 and was updated on December 2015. A fetch and tag plan was designed by the researchers using an online Zotero library.

RESULTS

174 full-text articles of 1702 records met inclusion criteria. Teleconsultation for pediatric patients accounts for 14.36 percent of accepted articles. Surgery and general medicine were the most prevalent medical fields in the adults and pediatrics, respectively. Most teleconsultations were inland experiences (no=135), and the USA, Italy and Australia were the three top countries in this group. Non-specialists health care providers/centers were the dominant group who requested teleconsultation (no=130). Real time, store and forward, and hybrid technologies were used in 50, 31, and 16.7 percent of articles, respectively. The teleconsultation were reported to result in change in treatment plan, referral or evacuation rate, change in diagnosis, educational effects, and rapid decision making. Use of structured or semi-structured template had been noticed only in a very few articles.

CONCLUSION

The present study focused on the recent ten years of published articles on physician-physician teleconsultations. Our findings showed that although there are positive impacts of teleconsultation as improving patient management, still have gaps that need to be repaired.

Electronic consultation systems: worldwide prevalence and their impact on patient care-a systematic review

BACKGROUND

Many health organizations are exploring the potential of electronic consultation (eConsult) services to address excessive wait times for specialist care.

OBJECTIVE

To understand the effectiveness, population impact and costs associated with implementation of eConsult services.

METHODS

We conducted a systematic review using a narrative synthesis approach. We searched Medline and Embase from inception to August 2014 (English/French). Included studies focused on communication between primary care providers and specialist physicians through an asynchronous, directed communication over a secure electronic medium. We assessed study quality with a modified version of the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. We synthesized the results using the Triple Aim framework.

RESULTS

A total of 36 studies were included. Most were set in the USA and focused on single-specialty services (most commonly dermatology). Population health outcomes included patient populations, adoption/utilization and provider attitudes. Providers cited timely advice from specialists, good medical care, confirmation of diagnoses and educational benefits. No clinical outcomes were reported. Patient experience of care was generally positive, with quick specialist response times (4.6 hours to 3.9 days), avoided referrals (12-84%) and satisfaction ranging from 78% to 93%. System costs were reported in only seven studies using different outcome measures and settings, limiting comparability.

CONCLUSION

Though eConsult systems are highly acceptable for patients and providers and deliver improved access to specialist advice, gaps remain regarding eConsult's impact on population health and system costs. To achieve optimized health system performance, eConsult services must include specialty services as determined by community needs and further explore cost-effectiveness.

Outpatient services and primary care: scoping review, substudies and international comparisons

Aim

This study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.

Findings from the scoping review

Evidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.

Findings from the substudies

Because of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.

Conclusions

For many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.

Funding

The NIHR Health Services and Delivery Research programme.

Discriminating Between Patients With Parkinson's and Neurological Diseases Using Cepstral Analysis

In this paper, we wanted to discriminate between two groups of patients (patients who suffer from Parkinson's disease and patients who suffer from other neurological disorders). We collected a variety of voice samples from 50 subjects using different recording devices in different conditions. Subsequently, we analyzed and extracted features from these samples using three different Cepstral techniques; Mel frequency cepstral coefficients (MFCC), perceptual linear prediction (PLP), and ReAlitive SpecTrAl PLP (RASTA-PLP). For classification we used leave one subject out validation scheme along with five different supervised learning classifiers. The best obtained result was 90% using the first 11 coefficients of the PLP and linear SVM kernels.

Holistic approach to design and implementation of a medical teleconsultation workspace

While there are many state-of-the-art approaches to introducing telemedical services in the area of medical imaging, it is hard to point to studies which would address all relevant aspects in a complete and comprehensive manner. In this paper we describe our approach to design and implementation of a universal platform for imaging medicine which is based on our longstanding experience in this area. We claim it is holistic, because, contrary to most of the available studies it addresses all aspects related to creation and utilization of a medical teleconsultation workspace. We present an extensive analysis of requirements, including possible usage scenarios, user needs, organizational and security issues and infrastructure components. We enumerate and analyze multiple usage scenarios related to medical imaging data in treatment, research and educational applications - with typical teleconsultations treated as just one of many possible options. Certain phases common to all these scenarios have been identified, with the resulting classification distinguishing several modes of operation (local vs. remote, collaborative vs. non-interactive etc.). On this basis we propose a system architecture which addresses all of the identified requirements, applying two key concepts: Service Oriented Architecture (SOA) and Virtual Organizations (VO). The SOA paradigm allows us to decompose the functionality of the system into several distinct building blocks, ensuring flexibility and reliability. The VO paradigm defines the cooperation model for all participating healthcare institutions. Our approach is validated by an ICT platform called TeleDICOM II which implements the proposed architecture. All of its main elements are described in detail and cross-checked against the listed requirements. A case study presents the role and usage of the platform in a specific scenario. Finally, our platform is compared with similar systems described into-date studies and available on the market.

[Teledermatology in Paediatrics. Observations in daily clinical practice]

INTRODUCTION

Teledermatology is a technique that is increasingly being developed. There are many studies that assess this discipline in the general population, but few studies analyse the paediatric population exclusively. The aims of this study are to describe the distribution of diseases consulted through teledermatology, the use of this technique to avoid face-to-face consultations, and the agreement between virtual and face-to-face diagnoses, in the paediatric population.

MATERIAL AND METHODS

The work consisted of an observational and retrospective study of the virtual consultations made between May 2011 and January 2015 through a store-and-forward teledermatology programme, involving patients from 0 to 15 years. We collected demographic data, as well as the diagnoses made by the paediatrician who made the virtual consultation, and by the dermatologists who assessed the virtual and the face-to-face consultations, the indication given by the dermatologist who assessed the virtual consultation (discharge or referral), reason for referral, and diagnostic agreement rate.

RESULTS

A total of 183 virtual consultations were analysed. The most frequent diagnoses were inflammatory diseases (39%), benign pigmented lesions (23%), and infectious diseases (20%). Almost half of the virtual consultations (48%) were referred for a face-to-face diagnosis. Diagnostic agreement between the dermatologist who evaluated the virtual consultation and the dermatologist who evaluated the face-to-face consultation was 89%, and 66% between the paediatrician who made the virtual consultation and the dermatologist who assessed it.

CONCLUSIONS

Virtual consultations have a similar disease distribution to conventional (face-to-face) referrals. Approximately half of the virtual consultations do not require a subsequent face-to-face visit. The agreement rate between the diagnoses given by both dermatologists (virtual and face-to-face diagnoses) is high.

Using TV white space spectrum to practise telemedicine: A promising technology to enhance broadband internet connectivity within healthcare facilities in rural regions of developing countries

The following correspondence provides an overview of TV White Space (TVWS) technology, regulations, and potential applications to the health care sector. This report also introduces "Project Kgolagano," a Botswana-based initiative representing the first endeavour to utilize TVWS internet connection for practising telemedicine. TV "white space" refers to the previously unused, wasted spectrum within TV radiofrequency channels that can now be leveraged to obtain broadband internet access. TVWS represents a less costly, faster, and farther-reaching internet connection that is a promising option for connecting the previously unconnected populations of remote and underserved areas. The Botswana-University of Pennsylvania Partnership, Microsoft, Botswana Innovation Hub, Vista Life Sciences, and Global Broadband Solutions have partnered together to bring TVWS wireless broadband access to healthcare facilities in poorly connected regions of Botswana (Lobatse, Francistown, Maun, Gaborone) in order to improve healthcare delivery and facilitate telemedicine in dermatology, cervical cancer screening, and family medicine (HIV/AIDS, TB, general adult and pediatric medicine).