Store-and-forward teledermatology versus in-person visits: A comparison in pediatric teledermatology clinic

Hybrid care potential of teledermatology: The importance of linking digital and physical practice and acceptance of online services: A cross-sectional study

Background and Aims

Telemedicine, with Teledermatology, has become a central component of modern medicine. Its importance, especially during the COVID-19 pandemic, underlines its potential to optimize access for dermatological needs. The study aims to assess the potential of teledermatology, understand the importance of linking digital and physical practices, and analyze the adoption of online services based on participants' demographic and experiential factors.

Methods

This cross-sectional survey was conducted among users of the telemedicine platform from July 2022 to March 2023. The platform ("OnlineDoctor") allows users to contact dermatologists for remote dermatological consultations. The survey included questions about the participants' dermatological concerns, their reasons for using teledermatology, their satisfaction with the recommendations and their willingness to continue using telemedicine in the future. Data was collected via the RedCap online platform. Descriptive statistics and regression analyses were carried out.

Results

Overall, 1141 people participated in the study (mean age 44.0 years [SD 14.6], 61.4% women). Results showed that 52.7% of participants with skin conditions had not consulted a dermatologist in the previous year. Shorter waiting times and the lack of face-to-face appointments were the main reasons for using the online platform. In total, 77.6% (n = 885) of participants indicated they would use teledermatology as their first choice if they had an upcoming skin condition. Age, gender, and satisfaction with previous consultations impacted the use of teledermatology as the first choice for future skin conditions.

Conclusion

Teledermatology is characterized by various benefits, including reduced waiting times and improved accessibility to treatment. Nevertheless, the study underscores the importance of a hybrid care approach with direct interaction with the physician. Teledermatology can be transformative in meeting dermatologic needs, mainly when traditional face-to-face consultation is limited. A deep understanding of user preferences and widespread adoption of digital services can pave the way for the successful adoption of teledermatology platforms, improving healthcare accessibility and efficiency.

Impact of dermoscopy-aided pediatric teledermatology program on the accessibility and efficiency of dermatology care at community health centers

BACKGROUND

There are few studies focusing on pediatric teledermatology, and the impact of a large-scale pediatric teledermatology program on the accessibility and efficiency of dermatology care remains unclear. This study evaluated the impact of a state-wide implementation of a store-and-forward teledermatology program augmented by the incorporation of dermoscopy in pediatric patients visiting community health centers.

METHODS

It was a descriptive, retrospective cohort study of 876 pediatric dermatology referrals.

RESULTS

In the traditional referral system, only 60 patients (17.6%) were seen by dermatologists with average waiting times of 75 days due to limited access. In comparison, with an implementation of dermoscopy-aided teledermatology, all 536 teledermatology referrals received dermatological care within 24 h, of which only 64 (12%) patients requires face-to-face (F2F) consultation. Patients referred for F2F consultation via eConsults had a much lower no-show rate as compared to the traditional referral system (39% vs. 71%). Side by side comparison between general population and pediatric population has demonstrated shared features in efficiency and access improvement but revealed specific characteristics of pediatric teledermatology in terms of diagnosis and treatment.

CONCLUSION

Coordinated store-and-forward teledermatology platform with incorporation of dermoscopy between large community care network and dermatology provider can greatly improve access to pediatric dermatology care especially in underserved population. The efficiency of teledermatology in access improvement for pediatric population is comparable with adult population in eConsults. There are also unique features and challenges in pediatric teledermatology that require further research.

Investigation of the effectiveness of teledermatology in the diagnosis of skin lesions in pediatric patients

OBJECTIVE

Teledermatology is the use of communications technology to enable the remote evaluation of skin lesions. Dermatological complaints are common among pediatric patients and should be handled differently than adults. The aim of this study is to group the dermatological lesions of pediatric patients who visited a dermatology outpatient clinic and to investigate in which groups the teledermatology method is more effective.

METHODS

This is a prospective observational study. Images of skin lesions, which were examined face-to-face in a dermatology outpatient clinic, were transmitted to another dermatologist via telecommunication. The diagnoses by the physician who examined patients face-to-face were compared with the diagnoses by the teledermatologist. Informed consent was obtained from the parents or legal representatives of all patients participating in this study.

RESULTS

A total of 93 pediatric patients were evaluated. In our study, the diagnoses by a dermatologist who evaluated patients face-to-face and the diagnoses by a teledermatologist were in agreement with 74.2% of the time. There was 100% agreement between both dermatologists for the diagnosis of acne and scabies. The diagnosis for verruca was consistent with 91.7% of the time, and for atopic dermatitis, it was 72.7%. There was a 25% consistency between both dermatologists on the diagnosis of contact dermatitis. The diagnostic consistency between both physicians was 53% in the erythematous disease group, 89% in the papulopustular group, and 70% in the pigmented group.

CONCLUSION

Teledermatology is a reliable diagnostic method that shortens the waiting time of patients and provides a quick consultation with a dermatologist. When using the teledermatology method, it is important to know which skin lesions or disease groups are more accurately diagnosed.

Efficacy, perception, and utilization of pediatric teledermatology: A systematic review

Background

The use of teledermatology abruptly expanded with the arrival of COVID-19. Here, we review recent studies regarding the efficacy, perception, and utilization of telemedicine in the pediatric population.

Objective

To evaluate the current state of pediatric teledermatology.

Methods

A literature search was performed using the terms "pediatric," "teledermatology," "dermatology," "telemedicine" and "telehealth" in PubMed, Scopus, Embase, and Google Scholar. 44 articles published between 2008 and 2022 were included.

Results

Diagnostic concordance between pediatric teledermatologist and in-person dermatologist ranged from 70.1% to 89%. Conditions treated with pediatric teledermatology were similar to those treated in-person. The rate of in-person follow-up after an initial telemedicine appointment pre and postpandemic was 12% to 51.9% and 13.5% to 28.1%, respectively. Patient satisfaction with teledermatology was between 70% to 98% and provider satisfaction was approximately 95%. The integration of teledermatology can reduce missed appointments and wait times among pediatric patients. However, considerable technological challenges exist, particularly in underserved communities. Globally, teledermatology may expand access to care though limited literature exists regarding its use in pediatric populations.

Conclusion

Telemedicine is effective for the diagnosis and treatment of many dermatological conditions in children, with high patient and provider satisfaction. Implementation of teledermatology can potentially increase access to care both locally and globally, but obstacles to engagement remain.

The role of telehealth in pediatric emergency care

In 2006, the Institute of Medicine published a report titled "Emergency Care for Children: Growing Pains," in which it described pediatric emergency care as uneven at best. Since then, telehealth has emerged as one of the great equalizers in care of children, particularly for those in rural and underresourced communities. Clinicians in these settings may lack pediatric-specific specialization or experience in caring for critically ill or injured children. Telehealth consultation can provide timely and safe management for many medical problems in children and can prevent many unnecessary and often long transport to a pediatric center while avoiding delays in care, especially for time-sensitive and acute interventions. Telehealth is an important component of pediatric readiness of hospitals and is a valuable tool in facilitating health care access in low resourced and critical access areas. This paper provides an overview of meaningful applications of telehealth programs in pediatric emergency medicine, discusses the impact of the COVID-19 pandemic on these services, and highlights challenges in setting up, adopting, and maintaining telehealth services.

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.

Clinical Features of Acne in Primary Care Patients Assessed Through Teledermatology

Introduction/Objectives:

Acne is present in about 90% of teenagers and 12% to 14% of adults. Face and trunk are the most affected areas. Lesions can result in postinflammatory hyperpigmentation and scarring, leading to reduced quality of life. Asynchronous teledermatology has been increasingly used around the world, facilitating patient access to dermatologists. Our objectives were to assess: (1) clinical features of acne patients according to gender, age, severity, site of lesions, excoriation, postinflammatory hyperpigmentation (PIH), and atrophic scar (AS) and (2) how many referrals to in-person consultations with dermatologists could be avoided using asynchronous teledermatology in primary care attention?

Methods:

We analyzed images, demographic and clinical data of 2459 acne patients assisted by teledermatology, with the aim to confirm the diagnoses, to classify acne severity according to grades I to IV, and to search for the presence of postinflammatory hyperpigmentation, atrophic scars, and/or excoriated acne (EA). We compared the clinical and biological data, looking for associations among them.

Results:

Acne severity and age were associated with the most common sequels: postinflammatory hyperpigmentation (mainly on the trunk and in females, P < .0001) and atrophic scars (mainly on the face and in males, P < .0001). We also observed different frequencies according to age and sex: 13 to 24 years in males (P = .0023); and <12 (P = .0023) and 25 to 64 years old (P <.0001) for females; 68% of the patients had no need for in-person dermatologists’ referral, being kept at primary care attention with proper diagnosis and treatment.

Conclusion:

Clinical features of acne and its sequels differ according to gender, age, site, and severity. The new findings of PIH associated with women and AS, with men, may help offer a more personalized management to patients. Teledermatology was suitable for the majority of the acne cases in primary care.

Awareness, acceptability, and satisfaction of teledermatology consultation among social-media users in Nepal

BACKGROUND

Teledermatology refers to the use of telecommunication in consulting one's skin problem to a dermatologist at distance.

AIMS

This study aims to identify the awareness, acceptability, preferred technical tools, willingness to use, comfortability, and satisfaction of teledermatology among social-media users in Nepal.

METHODS

It was an exploratory cross-sectional study performed on 360 social-media users, subjected to web-based interview based on pretested proforma containing questions to address: awareness of telemedicine, type and tools preferred for teledermatology, willingness to use, comfortability, and satisfaction of teledermatology services.

RESULTS

Most of the participants (60.8%) were initially unaware of telemedicine. Despite this, the majority (81.9%) were willing to use the services after being aware, mostly during the follow-up (36.6%). Most of the participants (61.1%) preferred the hybrid model for teleconsultation, while mobile was the preferred technical tool (68.1%) mostly because of its compatibility (84.1%) and portability (56.3%). The majority of the participants felt that teledermatology consultation would be beneficial (77.2%) and they mostly preferred it directly from a dermatologist (85.6%). About two-thirds (64.2%) also believed that teledermatology consultation would eliminate the need for a face-to-face consultation. The majority would be comfortable (68.1%) if their skin lesions are photographed and sent to a dermatologist and would be satisfied (62.5%) with the consultations, through Wi-Fi and mobile data both (55.6%), and via Facebook (97.2%) and Viber (70.8%).

CONCLUSIONS

Despite being unaware of telemedicine, the participants were willing to use teledermatology consultation and thought that they would be comfortable and satisfied with it.

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.

Accuracy and efficiency of telemedicine in atopic dermatitis

Background

Telemedicine provides accurate diagnoses for skin disorders and has gained emphasis. It may be used for the triage and management of common skin diseases in primary care, improving patients’ access and reducing time to treatment.

Objective

To evaluate the proportion of atopic dermatitis patients who could be managed with the support of telemedicine and its accuracy. Second, we aimed to assess the frequency of atopic dermatitis, demographics, clinical features, and therapies dispensed in relation to the disease.

Methods

Retrospective study in a population of 30,976 individuals, assisted by telemedicine. We assessed patients with the diagnosis of atopic dermatitis and evaluated the proportion of cases referred to biopsy, in-person dermatologists, or to be managed by primary care; the treatments suggested; and telemedicine accuracy to diagnose atopic dermatitis.

Results

Atopic dermatitis was diagnosed in 1648 patients (5.3%), the sixth most common dermatosis, with 2058 lesions (3.7%) analyzed. Primary care physicians were able to manage 72% of the atopic dermatitis patients, whereas 28% of them were referred to in-person dermatologists. Accuracy for atopic dermatitis diagnosis was 84.4%.

Conclusion

Telemedicine was an accurate method and helped primary care physicians to treat 72% of the atopic dermatitis lesions, thereby optimizing the availability of in-person appointments with dermatologists for more severe cases.

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.

Teledermatology reduces dermatology referrals and improves access to specialists

BACKGROUND

Teledermatology may be used for triage in primary care to address skin conditions, improving access and reducing time to treat the most severe or surgical cases. We aimed to evaluate the proportion of individuals who could be assessed in primary care using teledermatology, and how this affected the waiting time for an in-person dermatologist appointment.

METHODS

A cross-sectional retrospective study, involving 30,976 individuals and 55,624 skin lesions, was performed from July 2017 to July 2018 We assessed the frequency of diagnoses and referrals to biopsy, to in-person dermatologists, or to primary care, and compared the waiting time for an in-person dermatologist appointment before and after the teledermatology implementation.

FINDINGS

53% of the patients were managed with the primary care physician, 43% were referred to in-person dermatologists and 4% directly to biopsy, leading to a reduction of 78% in the waiting time for in-person appointments when compared to the previous period. The most frequent diseases were: melanocytic nevus, seborrheic keratosis, acne, benign neoplasms, onychomycosis, atopic dermatitis, solar lentigo, melasma, xerosis, and epidermoid cyst, with significant differences according to sex, age and referrals. The most frequent treatment prescribed was emollient.

INTERPRETATION

The use of teledermatology as a triage tool significantly reduced the waiting time for in-person visits, improving health care access and utilizing public resources wisely. Knowledge of sex, age, diagnoses and treatment of common skin conditions can enable public policies for the prevention and orientation of the population, as it can be used to train general physicians to address such cases.

FUNDING

None.

Pediatric dermatology eConsults: Reduced wait times and dermatology office visits

BACKGROUND/OBJECTIVES

Store-and-forward teledermatology provides pediatricians with specialist guidance in managing skin disease. This study evaluates wait times and face-to-face (FTF) dermatology visit avoidance associated with a pediatric dermatology eConsult program at an urban academic medical center.

METHODS

In this retrospective cohort study, electronic medical records were reviewed for patients under age 18 for whom a dermatology eConsult was completed between November 1, 2014, and December 31, 2017. Wait times for eConsult completion and initial FTF dermatology appointments were calculated and compared to average wait times for new patient dermatology office appointments from 2016 to 2017. Recommendations for FTF dermatology visits were assessed, along with FTF visit attendance and potential cost savings.

RESULTS

One hundred eighty pediatric patients with 188 unrelated skin conditions ("cases") were referred to the program. Of 188 cases, FTF dermatology visits were recommended for 60 (31.9%). Actual FTF dermatology visit avoidance was 53.7% of total cases (n = 101 for whom FTF visit was not recommended and no dermatology visit occurred within 90 days after eConsult submission). The program generated potential savings of $24 059 ($9840 out-of-pocket) in 2016 dollars. Average turnaround for eConsult completion was 1.8 calendar days (median: 1 calendar day, target: 2 business days). Average wait time to initial FTF dermatology evaluation was 37.3 calendar days (versus 54.1 days for pediatric patients referred directly to dermatology clinic between 2016 and 2017).

CONCLUSION

Pediatric dermatology eConsults reduce wait times for specialist care, triage cases for in-office evaluation, reduce need for FTF dermatology visits, and offer potential cost savings for payers and patients.

Dermatologists and SARS-CoV-2: the impact of the pandemic on daily practice

Since the first case of 'pneumonia of unknown aetiology' was diagnosed at the Wuhan Jinyintan Hospital in China on 30 December 2019, what was recognized thereafter as 'severe acute respiratory syndrome coronavirus 2' (SARS-CoV-2) has spread over the four continents, causing the respiratory manifestations of coronavirus disease-19 (COVID-19) and satisfying the epidemiological criteria for a label of 'pandemic'. The ongoing SARS-CoV-2 pandemic is having a huge impact on dermatological practice including the marked reduction of face-to-face consultations in favour of teledermatology, the uncertainties concerning the outcome of COVID-19 infection in patients with common inflammatory disorders such as psoriasis or atopic dermatitis receiving immunosuppressive/immunomodulating systemic therapies; the direct involvement of dermatologists in COVID-19 care for patient assistance and new research needs to be addressed. It is not known yet if skin lesions and derangement of the skin barrier could make it easier for SARS-CoV-2 to transmit via indirect contact; it remains to be defined if specific mucosal or skin lesions are associated with SARS-CoV-2 infection, although some unpublished observations indicate the occurrence of a transient varicelliform exanthema during the early phase of the infection. SARS-CoV-2 is a new pathogen for humans that is highly contagious, can spread quickly, and is capable of causing enormous health, economic and societal impacts in any setting. The consequences may continue long after the pandemic resolves, and new management modalities for dermatology may originate from the COVID-19 disaster. Learning from experience may help to cope with future major societal changes.

Diagnostic Concordance in Tertiary (Dermatologists-to-Experts) Teledermoscopy: A Final Diagnosis-Based Study on 290 Cases

Background

Teledermoscopy (TDS) improves diagnostic accuracy and decreases the number of unnecessary consultations.

Objectives

To determine the diagnostic concordance in tertiary (dermatologist-to-experts) TDS with histopathology/follow-up-based diagnosis.

Methods

A descriptive retrospective cohort study including 290 requests.

Results

Perfect diagnostic concordance was found in 202 (69.7%) cases and partial agreement in 29 (10%). Disagreement was found in 59 (20.3%) cases. Perfect concordance on the benign/malignant nature of the lesion was found in 227 (78.3%) cases and disagreement in 63 (21.7%). In onychology, diagnostic concordance was perfect in 43 (76.8%) cases, partial in 7 (12.5%), and there was disagreement in 6 (10.7%). Final concordance on the benign/malignant nature of the lesion was perfect in 48 (85.7%) and there was disagreement in 8 (14.3%) nail cases. For pediatric requests, diagnostic concordance was perfect in 29 (65.9%) cases, partial in 5 (11.4%), and there was disagreement in 10 (22.7%). Final concordance on the benign/malignant nature of the lesion was observed in 34 (77.3%) cases, disagreement in 10 (22.7%).

Conclusions

This study confirms that tertiary TDS improves diagnostic accuracy of pigmented skin lesions. Moreover, it shows encouraging results in unusual conditions such as ungual and pediatric skin tumors. The main limitation was the retrospective nature and the "real-life" setting of our study that could have created a selection bias toward inclusion of the most difficult cases.

Virtual Pediatric Emergency Department Telehealth Network Program: A Case Series

OBJECTIVES

Pediatric patients living in rural, underserved areas have reduced access to medical care. There is a lack of research describing the use of telemedicine (TM) for general pediatric emergency medicine (PEM). In 2013, we established the Child Ready Virtual Pediatric Emergency Department Telehealth Network (CR-VPED), a PEM TM consultation service serving rural hospitals across the state of New Mexico. The aim of this article is to describe our experience for 6 years (2013-2018).

METHODS

We describe the process of establishing the CR-VPED Telehealth Network. We reviewed all the TM consultations completed from June 22, 2013, to September 6, 2018. In our review, we focus on patient demographics, medical complaint, transfer status, type of referring provider, and problems encountered with each TM consultation.

RESULTS

We had a total of 58 PEM TM consultations between June 22, 2013, and September 6, 2018. All consultations occurred at 6 of the 12 established sites. Most TM consultations (71%; 41/58) were with Indian Health Service sites. Among all TM consultations, patients ranged in age from 30 days to 17 years (mean, 54 months; median, 32 months). Only 26% (15/58) of the patients with TM consultations were transferred to the tertiary care hospital. There was a heterogeneous mix of chief complaints and diagnoses. Rash was the most common chief complaint (24%; 14/58). There was a mix of referring providers, with family medicine physicians being most common (31%; 18/58). Common technical issues were not properly recording the encounter into the electronic medical record (12%; 7/58) and difficulty logging into the CR-VPED Telehealth Network (9%; 5/58).

CONCLUSIONS

Previous studies have investigated the use of TM in pediatric acute care, but most studies have focused on critical care or subspecialty care in the office setting. Our experience with CR-VPED has shown that it has been feasible to provide general pediatric emergency care to patients in underserved, rural emergency departments across New Mexico. Patients requiring TM consultation were heterogeneous in age and presentation.

Benefits of Teledermatology for Geriatric Patients: Population-Based Cross-Sectional Study

Background

Teledermatology is a health care tool that has been increasingly used around the world, mostly because dermatology has an emphasis on visual diagnosis. Many studies have shown that access to specialized care improves using teledermatology, which provides accurate diagnosis and reduces the time taken for treatment, with high patient satisfaction. As the population around the world grows old, there will be even more demand for dermatologists in years to come. It is essential to know which are the most prevalent skin conditions in the primary care population and if they can be addressed through teledermatology.

Objective

Our main goal was to evaluate the proportion of lesions in individuals aged 60 years and older that could be managed using teledermatology in conjunction with primary care physicians. Second, we aimed to assess the most frequent skin lesions, the most common treatments provided to patients, and the distribution and causes of referrals made by the teledermatologists.

Methods

This was a retrospective cohort study from July 2017 to July 2018 in São Paulo, Brazil. We included 6633 individuals aged 60 years and older who presented with 12,770 skin lesions. Teledermatologists had three options to refer patients: (1) to undergo biopsy directly, (2) to an in-person dermatologist visit, and (3) back to the primary care physician with the most probable diagnosis and treatment.

Results

Teledermatology managed 66.66% (8408/12614) of dermatoses with the primary care physician without the need for an in-presence visit; 27.10% (3419/12614) were referred to dermatologists, and 6.24% (787/12614) directly to biopsy. The most frequent diseases were seborrheic keratosis, solar lentigo, onychomycosis, melanocytic nevus, benign neoplasms, actinic keratosis, epidermoid cyst, xerosis, leucoderma, and wart, with significant differences between sexes. Malignant tumors increased with age and were the leading cause for biopsies, while infectious skin conditions and pigmentary disorders decreased. Emollient was the most frequent treatment prescribed, in 31.88% (909/2856) of the cases.

Conclusions

Teledermatology helped to treat 67% of the dermatoses of older individuals, addressing cases of minor complexity quickly and conveniently together with the primary care physician, thus optimizing dermatological appointments for the most severe, surgical, or complex diseases. Teledermatology does not aim to replace a face-to-face visit with the dermatologist; however, it might help to democratize dermatological treatment access for patients and decrease health care expenses.

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.

Validity of Infant Face Skin Assessment by Parents at Home

Parents had better to assess their infant's skin daily to prevent the development of any skin problems. However, there are no standard methods for assessing infant skin at home. This study aimed to validate the assessment of infant face skin conditions by parents as compared to using skin barrier function clinical tests. In addition, we evaluated the degree of agreement between parents and physicians/midwives when assessing an infant's skin. A cross-sectional study involving 184 infants aged 3 months was conducted. To evaluate the parents' infant skin assessment, we used the Neonatal Skin Condition Score (NSCS). On the same day, we evaluated the skin barrier function on the infant's forehead and cheek, including transepidermal water loss (TEWL), stratum corneum hydration, skin pH, and sebum secretion. Skin barrier function values were correlated with infant skin condition assessed by parents, especially in cases of TEWL of the cheek, for which a moderate positive correlation was found between parental assessment score (ρ = 0.448). In addition, infant with skin problems based on parental assessment had a significantly higher TEWL, lower SCH, and higher skin pH. However, there was weak agreement between parental and physician/midwife assessment. Thus, there was a relationship between parental assessment and skin barrier function; thus, parents can use at-home assessment to assist with infant skin care. In the future, research focused on developing methods of examining infant skin conditions should consider incorporate parental daily skin assessment.

The majority of skin lesions in pediatric primary care attention could be managed by Teledermatology

Background

Teledermatology is a tool that provides accurate diagnosis and has been gaining more emphasis over time. It can be used for triage in primary care attention to address skin conditions improving access and reducing time to treatment for surgical, severe or even lethal diseases.

Objectives

Our main goal was to evaluate the proportion of pediatric patient’s lesions that could be managed using teledermatology in primary care attention. Secondly, we wanted to assess the ten most frequent skin conditions, the most common treatments and the referrals made by the teledermatologists to biopsy, in-presence dermatologist or kept at primary care attention.

Methods

A cross-sectional retrospective study involving 6,879 individuals and 10,126 lesions was conducted by store-and-forward teledermatology during one year in the city of Sao Paulo, Brazil. If the photographs taken had enough quality, teledermatologist would diagnose, treat and orient each lesion (if possible), and choose one of three options for referral: direct to biopsy, in-presence dermatologist or kept at primary care attention.

Results

Teledermatology managed 62% of the lesions to be kept at primary care attention, 37% were referred to dermatologists and 1% to biopsy, reducing the mean waiting time for an in-presence visit in 78%. In patients 0–2 years old, lesions related to eczema and benign congenital lesions predominated. From 3–12 years old, eczema was still a major cause of complaint, as well as warts and molluscum. From 13–19 years old, acne was the most significant problem, followed by atopic dermatitis, nevi and warts. The most frequent treatment was emollient.

Conclusion

Teletriage addressed 63% of the lesions without the need for an in-presence visit, suggesting that teledermatology can manage common diseases and optimize dermatological appointments for the most serious, surgical or complex skin illnesses, reducing the mean waiting time for them.

Teledermatology for diagnosing skin cancer in adults

BACKGROUND

Early accurate detection of all skin cancer types is essential to guide appropriate management and to improve morbidity and survival. Melanoma and squamous cell carcinoma (SCC) are high-risk skin cancers which have the potential to metastasise and ultimately lead to death, whereas basal cell carcinoma (BCC) is usually localised with potential to infiltrate and damage surrounding tissue. Anxiety around missing early curable cases needs to be balanced against inappropriate referral and unnecessary excision of benign lesions. Teledermatology provides a way for generalist clinicians to access the opinion of a specialist dermatologist for skin lesions that they consider to be suspicious without referring the patients through the normal referral pathway. Teledermatology consultations can be 'store-and-forward' with electronic digital images of a lesion sent to a dermatologist for review at a later time, or can be live and interactive consultations using videoconferencing to connect the patient, referrer and dermatologist in real time.

OBJECTIVES

To determine the diagnostic accuracy of teledermatology for the detection of any skin cancer (melanoma, BCC or cutaneous squamous cell carcinoma (cSCC)) in adults, and to compare its accuracy with that of in-person diagnosis.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, CPCI, Zetoc, Science Citation Index, US National Institutes of Health Ongoing Trials Register, NIHR Clinical Research Network Portfolio Database and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles.

SELECTION CRITERIA

Studies evaluating skin cancer diagnosis for teledermatology alone, or in comparison with face-to-face diagnosis by a specialist clinician, compared with a reference standard of histological confirmation or clinical follow-up and expert opinion. We also included studies evaluating the referral accuracy of teledermatology compared with a reference standard of face-to-face diagnosis by a specialist clinician.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where there were information related to the target condition of any skin cancer missing. Data permitting, we estimated summary sensitivities and specificities using the bivariate hierarchical model. Due to the scarcity of data, we undertook no covariate investigations for this review. For illustrative purposes, we plotted estimates of sensitivity and specificity on coupled forest plots for diagnostic threshold and target condition under consideration.

MAIN RESULTS

The review included 22 studies reporting diagnostic accuracy data for 4057 lesions and 879 malignant cases (16 studies) and referral accuracy data for reported data for 1449 lesions and 270 'positive' cases as determined by the reference standard face-to-face decision (six studies). Methodological quality was variable with poor reporting hindering assessment. The overall risk of bias was high or unclear for participant selection, reference standard, and participant flow and timing in at least half of all studies; the majority were at low risk of bias for the index test. The applicability of study findings were of high or unclear concern for most studies in all domains assessed due to the recruitment of participants from secondary care settings or specialist clinics rather than from primary or community-based settings in which teledermatology is more likely to be used and due to the acquisition of lesion images by dermatologists or in specialist imaging units rather than by primary care clinicians.Seven studies provided data for the primary target condition of any skin cancer (1588 lesions and 638 malignancies). For the correct diagnosis of lesions as malignant using photographic images, summary sensitivity was 94.9% (95% confidence interval (CI) 90.1% to 97.4%) and summary specificity was 84.3% (95% CI 48.5% to 96.8%) (from four studies). Individual study estimates using dermoscopic images or a combination of photographic and dermoscopic images generally suggested similarly high sensitivities with highly variable specificities. Limited comparative data suggested similar diagnostic accuracy between teledermatology assessment and in-person diagnosis by a dermatologist; however, data were too scarce to draw firm conclusions. For the detection of invasive melanoma or atypical intraepidermal melanocytic variants both sensitivities and specificities were more variable. Sensitivities ranged from 59% (95% CI 42% to 74%) to 100% (95% CI 48% to 100%) and specificities from 30% (95% CI 22% to 40%) to 100% (95% CI 93% to 100%), with reported diagnostic thresholds including the correct diagnosis of melanoma, classification of lesions as 'atypical' or 'typical, and the decision to refer or to excise a lesion.Referral accuracy data comparing teledermatology against a face-to-face reference standard suggested good agreement for lesions considered to require some positive action by face-to-face assessment (sensitivities of over 90%). For lesions considered of less concern when assessed face-to-face (e.g. for lesions not recommended for excision or referral), agreement was more variable with teledermatology specificities ranging from 57% (95% CI 39% to 73%) to 100% (95% CI 86% to 100%), suggesting that remote assessment is more likely recommend excision, referral or follow-up compared to in-person decisions.

AUTHORS' CONCLUSIONS

Studies were generally small and heterogeneous and methodological quality was difficult to judge due to poor reporting. Bearing in mind concerns regarding the applicability of study participants and of lesion image acquisition in specialist settings, our results suggest that teledermatology can correctly identify the majority of malignant lesions. Using a more widely defined threshold to identify 'possibly' malignant cases or lesions that should be considered for excision is likely to appropriately triage those lesions requiring face-to-face assessment by a specialist. Despite the increasing use of teledermatology on an international level, the evidence base to support its ability to accurately diagnose lesions and to triage lesions from primary to secondary care is lacking and further prospective and pragmatic evaluation is needed.

A Teledermatology Pilot Programme for the Management of Skin Diseases in Primary Health Care Centres: Experiences from a Resource-Limited Country (Mali, West Africa)

In sub-Saharan Africa, in particular in rural areas, patients have limited access to doctors with specialist skills in skin diseases. To address this issue, a teledermatology pilot programme focused on primary health centres was set up in Mali. This study was aimed at investigating the feasibility of this programme and its impact on the management of skin diseases. The programme was based on the store-and-forward model. Health care providers from 10 primary centres were trained to manage common skin diseases, to capture images of skin lesions, and to use an e-platform to post all cases beyond their expertise for dermatologists in order to obtain diagnosis and treatment recommendations. After training, the cases of 180 patients were posted by trained health workers on the platform. Ninety-six per cent of these patients were properly managed via the responses given by dermatologists. The mean time to receive the expert’s response was 32 h (range: 13 min to 20 days). Analysis of all diseases diagnosed via the platform revealed a wide range of skin disorders. Our initiative hugely improved the management of all skin diseases in the targeted health centres. In developing countries, Internet accessibility and connection quality represent the main challenges when conducting teledermatology programmes.

Teledermatology: A Review and Update

Telemedicine is slowly transforming the way in which healthcare is delivered and has the potential to improve access to subspecialty expertise, reduce healthcare costs, and improve the overall quality of care. While many subspecialty fields within medicine today have either experimented with or begun to implement telemedicine platforms to enable remote consultation and care, dermatology is particularly suited for this care system as skin disorders are uniquely visible to the human eye. Through teledermatology, diagnostic images of skin disorders with accompanying clinical histories can be remotely reviewed by teledermatologists by any number of modalities, such as photographic clinical images or live video teleconferencing. Diagnoses and treatment recommendations can then be rendered and implemented remotely. The evidence to date supports both its diagnostic and treatment accuracy and its cost effectiveness. Administrative, regulatory, privacy, and reimbursement policies surrounding this dynamic field continue to evolve. In this review, we examine the history, evidence, and administrative landscape surrounding teledermatology and discuss current practice guidelines and ongoing controversies.

Diagnostic Accuracy of Pediatric Teledermatology Using Parent-Submitted Photographs: A Randomized Clinical Trial

Importance

Advances in smartphone photography (both quality and image transmission) may improve access to care via direct parent-to-clinician telemedicine. However, the accuracy of diagnoses that are reliant on parent-provided photographs has not been formally compared with diagnoses made in person.

Objective

To assess whether smartphone photographs of pediatric skin conditions taken by parents are of sufficient quality to permit accurate diagnosis.

Design, Setting, and Participants

A prospective study was conducted among 40 patient-parent dyads at a pediatric dermatology clinic at the Children's Hospital of Philadelphia from March 1 to September 30, 2016, to assess concordance between diagnoses made by an independent pediatric dermatologist based on in-person examination and those based on parental photographs. Half of the patient-parent dyads were randomized for a secondary analysis to receive instructions on how best to take photographs with smartphones. Clinicians were blinded to whether parents had received photography instructions.

Exposures

Half of the patient-parent dyads received a simple, 3-step instruction sheet on how best to take photographs using a smartphone (intervention group); the other half did not (control group).

Main Outcomes and Measures

Concordance between photograph-based vs in-person diagnosis in the intervention vs control groups, as quantified using Cohen κ, a measure of interrater agreement that takes into account the possibility of agreement occurring by chance.

Results

Among the 40 patient-parent dyads (22 female children and 18 male children; mean [SD] age, 6.96 [5.23] years), overall concordance between photograph-based vs in-person diagnosis was 83% (95% CI, 71%-94%; κ = 0.81). Diagnostic concordance was 89% (95% CI, 75%-97%; κ = 0.88) in a subgroup of 37 participants with photographs considered of high enough quality to make a diagnosis. No statistically significant effect of photography instructions on concordance was detected (group that received instructions, 85%; group that did not receive instructions, 80%; P = .68). In cases of diagnostic disagreement, appropriate follow-up was suggested.

Conclusions and Relevance

Parent-operated smartphone photography can accurately be used as a method to provide pediatric dermatologic care.

Trial Registration

clinicaltrials.gov Identifier: NCT03246945.

Can You See Me Now? Video Supplementation for Pediatric Teledermatology Cases

BACKGROUND/OBJECTIVES

Digital video is widely available and is used sporadically in clinical settings to evaluate patients, but whether it helps improve clinical management has not been determined. The aim of this study was to assess whether recorded video in addition to still images can improve residents' diagnostic and management accuracy and confidence with pediatric teledermatology cases.

METHODS

Dermatology residents from three programs were assigned alternately to an online survey with 15 pediatric teledermatology cases presented with still images only (still) or still images plus recorded video (mixed). Participants provided free-text diagnoses and management recommendations and rated their confidence and image quality. Responses were scored using a modified script concordance grading key based on reference panelists' responses.

RESULTS

Thirty-one residents participated (response rate 57%). Participants in the mixed group scored significantly higher on management accuracy (87.6 ± 12.9 vs 71.7 ± 14.2; p = 0.003). Both groups performed better on more common conditions than less common conditions. The mixed group outperformed the still group on less common conditions with respect to management recommendations.

CONCLUSION

This novel study suggests that supplemental recorded video may improve the management accuracy of pediatric teledermatology consultations, particularly for complex cases. Residents may benefit from training in recording and interpreting video.

Telemedicine in dermatology: findings and experiences worldwide - a systematic literature review

Telemedicine has become an important element of health care in many countries and profited from the technological progress of the last two decades. Due to the visual character of the dermatological specialty, teledermatology in particular participated in that development and is becoming a major tool in dermatological consultation. The objective of this article was to identify the use of teledermatology across the world based on published original articles. A systematic literature search of the MEDLINE and Embase databases for eligible publications (predefined inclusion and exclusion criteria) and a cross-validation search were conducted. Search results were reviewed systematically. The search resulted in 204 publications meeting the inclusion criteria for analysis. The highest number of published studies on teledermatology was performed in the United States, followed by the United Kingdom, Spain, the Netherlands, Italy and Austria. The majority of dermatological indications for telemedical consultations were not specified or included various kinds of skin diseases, followed by skin cancer and wounds. Research questions predominantly focused on concordance, effectiveness and cost-effectiveness to determine the value. Teledermatology proved to be a reliable consultation tool in the majority of studies. If specified, telemedicine was used in daily dermatological routine for patient management purposes, to consult patients in peripheral locations, or for medical support in nursing homes or home care settings. The application of teledermatology worldwide is highest in North American and European countries, while countries with poor geographical distribution of physicians seem to be under-represented in teledermatological use, as concluded from publication output. Regarding indications, comparison with classic consultation and area of application, most studies were of general nature. For precise determination of the value, systematic studies would be needed. However, teledermatology is already accepted as a valid tool.

Practice Guidelines for Teledermatology

Previous American Telemedicine Association (ATA) Teledermatology Practice Guidelines were issued in 2007. This updated version reflects new knowledge in the field, new technologies, and the need to incorporate teledermatology practice in a variety of settings, including hospitals, urgent care centers, Federally Qualified Health Centers, school-based clinics, public health facilities, and patient homes.

Building a global teledermatology collaboration

Skin disease is common in low-resource countries and is associated with significant morbidity. The disease burden is often heightened by lack of access to adequate diagnosis and treatment. Teledermatology is a growing healthcare delivery modality that allows access to subspecialty care at a distance. This article describes how a low-cost teledermatology program was launched through collaboration between the Medical College of Wisconsin and Hillside Healthcare International. Several factors are required for a teledermatology program to be successful, beginning with a partnership between two entities that targets a locally identified need and is mutually beneficial to invested partners. The program should utilize the expertise of each partner, be based on an agreed upon process with clearly defined objectives, and protect patient privacy. After a program is implemented, adaptation to address challenges and best meet the needs of all parties involved will allow for continued success and sustainability. This process can serve as a model for other programs desiring to establish similar teledermatology partnerships in an academic setting.

Telemedicine Applications for the Pediatric Emergency Medicine: A Review of the Current Literature

OBJECTIVE

The aim of this study was to review current literature relating to telemedicine in pediatric emergency medicine including its clinical applications and challenges associated with its implementation.

METHODS

We reviewed the literature using standard search methods in accordance with preferred reporting items for systematic reviews and meta-analysis. We included the studies done in emergency settings for all age groups and narrowed our search to the articles that are relevant to "impact on quality of care" and "patient outcome." We also described current telemedicine uses, software, hardware, and other requirements needed for pediatric emergency applications.

RESULTS

Telemedicine has a potential role in pediatric emergency medicine for real-time decision making to improve quality of care for children. Logistic and legal challenges exist for pediatric emergency medicine applications similar to its uses in other settings.

CONCLUSIONS

Current frameworks exist in the use of telemedicine for pediatric emergency medicine. Research is still needed to see whether clinical outcomes are improved with pediatric emergency telemedicine solutions. Practical issues regarding training, accessibility, and resource allocation should be explored as pediatric emergency telemedicine evolves.

The Empirical Foundations of Teledermatology: A Review of the Research Evidence

INTRODUCTION

This article presents the scientific evidence for the merit of telemedicine interventions in the diagnosis and management of skin disorders (teledermatology) in the published literature. The impetus for this work derives from the high prevalence of skin disorders, the high cost, the limited availability of dermatologists in certain areas, and the promise of teledermatology to address unmet needs in this area.

MATERIALS AND METHODS

The findings are based on a targeted review of scientific studies published from January 2005 through April 2015. The initial search yielded some 5,020 articles in Google Scholar and 428 in PubMed. A review of the abstracts yielded 71 publications that met the inclusion criteria for this analysis. Evidence is organized according to the following: feasibility and acceptance; intermediate outcomes (use of service, compliance, and diagnostic and treatment concordance and accuracy); outcomes (health improvement and problem resolution); and cost savings. A special section is devoted to studies conducted at the Veterans Health Administration.

RESULTS

Definitions of teledermatology varied across a wide spectrum of skin disorders, technologies, diagnostic tools, provider types, settings, and patient populations. Outcome measures included diagnostic concordance, treatment plans, and health.

CONCLUSIONS

Despite these complexities, sufficient evidence was observed consistently supporting the effectiveness of teledermatology in improving accessibility to specialty care, diagnostic and treatment concordance, and skin care provided by primary care physicians, while also reducing cost. One study reported suboptimal clinical results from teledermatology for patients with pigmented skin lesions. On the other hand, confocal microscopy and advanced dermoscopy improved diagnostic accuracy, especially when rendered by experienced teledermatologists.

Teledermatology

This article provides an overview of teledermatology with an emphasis on the evidence most relevant to referring clinicians, who are often primary care clinicians. Discussion includes the different modalities used for teledermatology and their diagnostic reliability, diagnostic accuracy, impact on in-person dermatology visits, clinical outcomes, and user satisfaction.

[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.

Pediatric teledermatology: a survey of usage, perspectives, and practice

Pediatric dermatology is one of the smallest subspecialties, and expanding the availability of care is of great interest. Teledermatology has been proposed as a way to expand access and improve care delivery, but no current assessment of pediatric teledermatology exists. The objective of the current study was to assess usage and perspectives on pediatric teledermatology. Surveys were distributed electronically to all 226 board-certified U.S. pediatric dermatologists; 44% (100/226) responded. Nearly all respondents (89%) have experience with teledermatology. Formal teledermatology reimbursement success rates have increased to 35%. Respondents were positive about teledermatology's present and future prospects, and 41% want to use teledermatology more often, although they viewed teledermatology as somewhat inferior to in-person care regarding accuracy of diagnosis and appropriation of management plans. Significant differences were found between formal teledermatology users and nonusers in salary structure, practice environment, sex, and region. Substantial increases in pediatric teledermatology have occurred in the last 5 to 10 years, and there remains cause for optimism for teledermatology's future. Concerns about diagnostic confidence and care quality indicate that teledermatology may be best for care of patients with characteristic clinical presentations or management of patients with established diagnoses.

Pediatric teledermatology consultations: relationship between provided data and diagnosis

There is a shortage of pediatric dermatologists. Teledermatology has emerged as a tool to facilitate access to dermatologists. Many questions remain regarding how to optimize consultations in order to provide the best diagnosis and management recommendations. The aim of this retrospective cohort study was to categorize the historical data and judge the adequacy of photographs sent by referring providers to our academic pediatric teledermatology practice at the University of California, San Francisco, and to evaluate the relationship of these data to our ability to render a diagnosis. A diagnosis was rendered in 75% of cases. The only historical data associated with receiving a diagnosis was prior treatment (OR 2.01, CI 1.01, 4, p < 0.05). Appropriate image distance from the target was associated with receiving a diagnosis for rashes (OR 2.69, CI 1.07, 6.8, p = 0.04) and growths (OR 4.16, CI 1.04, 16.6, p = 0.04). A lack of diagnosis was significantly associated with a recommendation for referral for biopsy (OR 0.03, CI 0.01, 0.10, p < 0.0001) or for in-person consultation (OR 0.19, CI 0.05, 0.66, p < 0.001). In conclusion, pediatric teledermatologists are able to make a diagnosis most of the time, regardless of historical information provided or image quality. The rate of diagnosis may be improved with the use of standardized templates for historical information. Similarly, photography training could minimize the need for in-person consultation. Specific information regarding prior treatments could also help in providing useful management recommendations.

Collaborative authoring: a case study of the use of a wiki as a tool to keep systematic reviews up to date

BACKGROUND

Systematic reviews are recognized as the most effective means of summarizing research evidence. However, they are limited by the time and effort required to keep them up to date. Wikis present a unique opportunity to facilitate collaboration among many authors. The purpose of this study was to examine the use of a wiki as an online collaborative tool for the updating of a type of systematic review known as a scoping review.

METHODS

An existing peer-reviewed scoping review on asynchronous telehealth was previously published on an open, publicly available wiki. Log file analysis, user questionnaires and content analysis were used to collect descriptive and evaluative data on the use of the site from 9 June 2009 to 10 April 2010. Blog postings from referring sites were also analyzed.

RESULTS

During the 10-month study period, there were a total of 1222 visits to the site, 3996 page views and 875 unique visitors from around the globe. Five unique visitors (0.6% of the total number of visitors) submitted a total of 6 contributions to the site: 3 contributions were made to the article itself, and 3 to the discussion pages. None of the contributions enhanced the evidence base of the scoping review. The commentary about the project in the blogosphere was positive, tempered with some skepticism.

INTERPRETATIONS

Despite the fact that wikis provide an easy-to-use, free and powerful means to edit information, fewer than 1% of visitors contributed content to the wiki. These results may be a function of limited interest in the topic area, the review methodology itself, lack of familiarity with the wiki, and the incentive structure of academic publishing. Controversial and timely topics in addition to incentives and organizational support for Web 2.0 impact metrics might motivate greater participation in online collaborative efforts to keep scientific knowledge up to date.