Mobile teledermatology in the developing world: implications of a feasibility study on 30 Egyptian patients with common skin diseases

Diagnostic reliability in teledermatology: a systematic review and a meta-analysis

OBJECTIVES

To compare teledermatology and face-to-face (F2F) agreement in primary diagnoses of dermatological conditions.

DESIGN

Systematic review and meta-analysis METHODS: MEDLINE, Embase, Cochrane Library (Wiley), CINAHL and medRxiv were searched between January 2010 and May 2022. Observational studies and randomised clinical trials that reported percentage agreement or kappa concordance for primary diagnoses between teledermatology and F2F physicians were included. Titles, abstracts and full-text articles were screened in duplicate. From 7173 citations, 44 articles were included. A random-effects meta-analysis was conducted to estimate pooled estimates. Primary outcome measures were mean percentage and kappa concordance for assessing diagnostic matches between teledermatology and F2F physicians. Secondary outcome measures included the agreement between teledermatologists, F2F dermatologists, and teledermatology and histopathology results.

RESULTS

44 studies were extracted and reviewed. The pooled agreement rate was 68.9%, and kappa concordance was 0.67. When dermatologists conducted F2F and teledermatology consults, the overall diagnostic agreement was significantly higher at 71% compared with 44% for non-specialists. Kappa concordance was 0.69 for teledermatologist versus specialist and 0.52 for non-specialists. Higher diagnostic agreements were also noted with image acquisition training and digital photography. The agreement rate was 76.4% between teledermatologists, 82.4% between F2F physicians and 55.7% between teledermatology and histopathology.

CONCLUSIONS AND RELEVANCE

Teledermatology can be an attractive option particularly in resource-poor settings. Future efforts should be placed on incorporating image acquisition training and access to high-quality imaging technologies.

TRIAL REGISTRATION NUMBER

10.17605/OSF.IO/FJDVG.

Issues in Melanoma Detection: Semisupervised Deep Learning Algorithm Development via a Combination of Human and Artificial Intelligence

BACKGROUND

Automatic skin lesion recognition has shown to be effective in increasing access to reliable dermatology evaluation; however, most existing algorithms rely solely on images. Many diagnostic rules, including the 3-point checklist, are not considered by artificial intelligence algorithms, which comprise human knowledge and reflect the diagnosis process of human experts.

OBJECTIVE

In this paper, we aimed to develop a semisupervised model that can not only integrate the dermoscopic features and scoring rule from the 3-point checklist but also automate the feature-annotation process.

METHODS

We first trained the semisupervised model on a small, annotated data set with disease and dermoscopic feature labels and tried to improve the classification accuracy by integrating the 3-point checklist using ranking loss function. We then used a large, unlabeled data set with only disease label to learn from the trained algorithm to automatically classify skin lesions and features.

RESULTS

After adding the 3-point checklist to our model, its performance for melanoma classification improved from a mean of 0.8867 (SD 0.0191) to 0.8943 (SD 0.0115) under 5-fold cross-validation. The trained semisupervised model can automatically detect 3 dermoscopic features from the 3-point checklist, with best performances of 0.80 (area under the curve [AUC] 0.8380), 0.89 (AUC 0.9036), and 0.76 (AUC 0.8444), in some cases outperforming human annotators.

CONCLUSIONS

Our proposed semisupervised learning framework can help with the automatic diagnosis of skin disease based on its ability to detect dermoscopic features and automate the label-annotation process. The framework can also help combine semantic knowledge with a computer algorithm to arrive at a more accurate and more interpretable diagnostic result, which can be applied to broader use cases.

Evaluation of WhatsApp as a Platform for Teledermatology in Botswana: Retrospective Review and Survey

Background

In emerging market countries in sub-Saharan Africa, access to specialty services such as dermatology is limited. Teledermatology is an innovative solution to address this issue; however, many initiatives have been tried without sustained success. Recently, WhatsApp has been used as a store-and-forward telemedicine communication platform for consultation and education in Botswana.

Objective

This study aims to describe the utilization of WhatsApp for teledermatology and the satisfaction levels of participating providers.

Methods

A 2-part pilot study was conducted. First, a retrospective review was performed of WhatsApp communications received by participating dermatologists in Gaborone, Botswana, from January 2016 to December 2019. Sender information, patient demographics and history, response time, diagnoses made, and follow-up recommendations were collected. Second, a 12-question cross-sectional survey was distributed to health care providers who utilized WhatsApp for teledermatology during this period. Descriptive statistics were then performed.

Results

There were 811 communication threads over the study period. The majority (503/811, 62%) of communications were consultations from providers inquiring about a specific patient, followed by multidisciplinary care coordination communications (90/811, 11%). Our in-depth analysis focused on the former. In 323 (64%) provider consultations, dermatologists responded within 1 hour. A diagnosis was made in 274 (55%) consultations. Dermatologists gave treatment recommendations remotely in 281 (56%) consultations and recommended an in-person dermatology visit in 163 (32%). Of the 150 health care providers surveyed, 23 (15%) responded. All respondents (100%) felt that there was a need for teledermatology and improved teledermatology education in Botswana. Moreover, 17 (74%) respondents strongly felt that the guidance received via WhatsApp was high quality, and 22 (96%) were satisfied with WhatsApp as a platform for teledermatology.

Conclusions

This retrospective review and survey demonstrated that WhatsApp is a quick, well-received, and sustainable method of communication between dermatologists and providers across Botswana. The app may offer a solution to the challenges providers face in accessing specialty referral systems, point-of-care education, and medical decision-making support for complex dermatologic cases in Botswana. The information gained from this pilot study can serve as the basis for future telemedicine studies to improve the implementation of teledermatology in Botswana and other resource-limited countries.

Teledermatology versus Face-to-Face Dermatology: An Analysis of Cost-Effectiveness from Eight Studies from Europe and the United States

(1) Background: The aim of this systematic review was to compare the cost-effectiveness of two follow-up methods (face-to-face and telemedicine) used in dermatology in the last ten years. (2) Methods: A search for articles that included economic analyses was conducted in August 2021 in the databases PubMed, Medline, Scielo and Scopus using the following keywords: "Cost-Benefit Analysis", "Dermatology", "Telemedicine", "Primary Health Care", as well as other search terms and following the PICOS eligibility criteria. (3) Results: Three clinical trials and five observational studies were analyzed, providing information for approximately 16,539 patients (including four cost-minimization or saving analyses, three cost-effectiveness analyses, and one cost-utility analysis) in Europe and the United States. They describe the follow-up procedures in each of the cases and measure and analyze the direct and indirect costs and effectiveness. All the articles indicate that teledermatology lowers costs and proves satisfactory to both patients and professionals. (4) Conclusions: Although it has been found that follow-up via teledermatology can be more efficient than traditional hospital follow-up, more work is needed to establish evaluation protocols and procedures that measure key variables more equally and demonstrate the quality of the evidence of said studies.

A Large Cross-Sectional Survey Study of the Prevalence of Alopecia Areata in the United States

Purpose

Alopecia areata (AA) is an autoimmune disease characterized by the development of non-scarring alopecia. The prevalence is not well known, and estimates vary considerably with no recent estimates in the United States (US). The objective of this study was to define the current AA point prevalence estimate among the general population in the US overall and by severity.

Patients and Methods

We administered an online, cross-sectional survey to a representative sample of the US population. Participants self-screening as positive for AA using the Alopecia Assessment Tool (ALTO) also completed the Severity of Alopecia Tool (SALT) to measure the severity of disease as a percent of scalp hair loss. Self-reported AA participants were invited to upload photographs for adjudication of AA by 3 clinicians.

Results

The average age of participants was 43 years. Approximately half of the participants (49.2%) were male, and the majority were white (77.1%) and not of Hispanic origin (93.2%). Among the 511 self-reported AA participants, 104 (20.4%) uploaded photographs for clinician evaluation. Clinician-adjudicated point prevalence of AA was 0.21% (95% CI: 0.17%, 0.25%) overall, 0.12% (95% CI: 0.09%, 0.15%) for “mild” disease (≤50% SALT score), and 0.09% (95% CI: 0.06%, 0.11%) for “moderate to severe” disease (>50% SALT score) with 0.04% (95% CI: 0.02%, 0.06%) for the alopecia totalis/alopecia universalis (100% SALT score) “moderate to severe” subgroup. The average SALT score was 44.4% overall, 8.8% for “mild”, and 93.4% for “moderate to severe”.

Conclusion

This study suggests that the current AA prevalence in the US is similar to the upper estimates from the 1970s at approximately 0.21% (700,000 persons) with the current prevalence of “moderate to severe” disease at approximately 0.09% (300,000 persons). Given this prevalence and the substantial impact of AA on quality of life, the burden of AA within the US is considerable.

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

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

Novel educational adjuncts for the World Health Organization Basic Emergency Care Course: A prospective cohort study

Introduction

The World Health Organization's (WHO) Basic Emergency Care Course (BEC) is a five day, in-person course covering basic assessment and life-saving interventions. We developed two novel adjuncts for the WHO BEC: a suite of clinical cases (BEC-Cases) to simulate patient care and a mobile phone application (BEC-App) for reference. The purpose was to determine whether the use of these educational adjuncts in a flipped classroom approach improves knowledge acquisition and retention among healthcare workers in a low-resource setting.

Methods

We conducted a prospective, cohort study from October 2017 through February 2018 at two district hospitals in the Pwani Region of Tanzania. Descriptive statistics, Fisher's exact t-tests, and Wilcoxon ranked-sum tests were used to examine whether the use of these adjuncts resulted in improved learner knowledge. Participants were enrolled based on location into two arms; Arm 1 received the BEC course and Arm 2 received the BEC-Cases and BEC-App in addition to the BEC course. Both Arms were tested before and after the BEC course, as well as a 7-month follow-up exam. All participants were invited to focus groups on the course and adjuncts.

Results

A total of 24 participants were included, 12 (50%) of whom were followed to completion. Mean pre-test scores in Arm 1 (50%) were similar to Arm 2 (53%) (p=0.52). Both arms had improved test scores after the BEC Course Arm 1 (74%) and Arm 2 (87%), (p=0.03). At 7-month follow-up, though with significant participant loss to follow up, Arm 1 had a mean follow-up exam score of 66%, and Arm 2, 74%.

Discussion

Implementation of flipped classroom educational adjuncts for the WHO BEC course is feasible and may improve healthcare worker learning in low resource settings. Our focus- group feedback suggest that the course and adjuncts are user friendly and culturally appropriate.

The Promise of Mobile Technologies for the Health Care System in the Developing World: A Systematic Review

Evolution of mobile technologies and their rapid penetration into people's daily lives, especially in the developing countries, have highlighted mobile health, or m-health, as a promising solution to improve health outcomes. Several studies have been conducted that characterize the impact of m-health solutions in resource-limited settings and assess their potential to improve health care. The aim of this review is twofold: 1) to present an overview of the background and significance of m-health and 2) to summarize and discuss the existing evidence for the effectiveness of m-health in the developing world. A systematic search in the literature was performed in Pubmed, Scopus, as well as reference lists, and a broad sample of 98 relevant articles was identified, which were then categorized into five wider m-health categories. Although statistically significant conclusions cannot be drawn since the majority of studies relied on small-scale trials and limited assessment of long-term effects, this review provides a systematic and extensive analysis of the advantages, disadvantages, and challenges of m-health in developing countries in an attempt to determine future research directions of m-health interventions.

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.

Long-Range Diagnosis of and Support for Skin Conditions in Field Settings

Skin diseases are a significant cause of morbidity and mortality worldwide; however, access to dermatology services are critically limited, particularly in low- to middle-income countries (LMIC), where there is an overall shortage of physicians. Implementation of long-range technological support tools has been growing in an effort to provide quality dermatology care to even the most remote settings globally. eHealth strategies can provide realistic healthcare solutions if implemented in a feasible and sensitive way, customizing tools to address the unique needs and resource limitations of the local setting. This article summarizes the various types of telemedicine and mobile health (mHealth) tools and their practical applications and benefits for patient care. The challenges and barriers of teledermatology are discussed, as well as steps to consider when implementing a new teledermatology initiative. eHealth arguably offers one of the most flexible and realistic tools for providing critically needed access to dermatology skills in underserved LMICs.

mHealth Approaches in Managing Skin Cancer: Systematic Review of Evidence-Based Research Using Integrative Mapping

Background

mHealth, which encompasses mobile health technologies and interventions, is rapidly evolving in various medical specialties, and its impact is evident in oncology. In particular, mHealth has established itself as a prominent part of dermatology for cancer screening. Intensified research to seek its use and effectiveness in each phase of the skin cancer continuum is needed in this fast-growing field of teledermatology.

Objective

The purpose of this review was to describe current trends in research addressing the integration of mHealth and its contributions across the skin cancer continuum.

Methods

A systematic review framework was applied to the search using three electronic databases: PubMed, Web of Science, and Embase. We extensively reviewed appropriate studies regarding skin cancer and mobile technology published between 2007 and 2017. Studies of the role and impact of mobile technology in the prevention and management of skin cancer were included. We selected 18 studies adhering to the inclusion and exclusion criteria for analysis.

Results

Of the 18 studies, 5 (28%) evaluated prevention interventions, 6 (33%) assessed diagnostic accuracy, and 7 (39%) pertained to feasibility in the context of mHealth approaches for skin cancer care. These studies portray the potential of mobile teledermatology in the prevention and management of skin cancer. However, not all phases of skin cancer involve mHealth, and not all have been addressed by research.

Conclusions

This review extends our knowledge not only on the contributions of mHealth technologies, but also on their integration in different phases of skin cancer care. To optimize the effectiveness of mHealth in dermatology, larger numbers of robust, evidence-based studies on teledermatology implementations, distributed evenly across the care continuum, should be conducted so that research can be expanded to systematic reviews.

Improving Global Health With Smartphone Technology

The widespread use of smartphones makes them a popular platform for healthcare applications. This article reveals the global trends and overarching goals of mHealth initiatives that seek to enhance healthcare quality, increase access to health services, and improve global health communication. Three main themes emerged from this study: a) the impact of mHealth on international public health, b) overcoming mhealth barriers, and c) emerging mHealth technologies. The costs of developing mHealth apps and handling related data security concerns are the key barriers which need to be addressed to successfully implement global mHealth campaigns. Future directions of mHealth research are discussed, including the integration of new technologies, development of innovative healthcare systems, and overall improvement of global healthcare.

Mobile health solutions in developing countries: a stakeholder perspective

Infrastructural deficiencies, limited access to medical care, and shortage of health care workers are just a few of the barriers to health care in developing countries. mHealth has the potential to overcome at least some of these challenges. To address this, a stakeholder perspective is adopted and an analysis of existing research is undertaken to look at mHealth delivery in developing countries. This study focuses on four key stakeholder groups i.e., health care workers, patients, system developers, and facilitators. A systematic review identifies 108 peer-reviewed articles, which are analysed to determine the extent these articles investigate the different types of stakeholder interactions, and to identify high-level themes emerging within these interactions. This analysis illustrates two key gaps. First, while interactions involving health care workers and/or patients have received significant attention, little research has looked at the role of patient-to-patient interactions. Second, the interactions between system developers and the other stakeholder groups are strikingly under-represented.

On Using a Mobile Application to Support Teledermatology: A Case Study in an Underprivileged Area in Colombia

Background

The use of mobile applications in dermatology to support remote diagnosis is gaining acceptance, particularly in rural areas, where dermatology services are commonly managed by healthcare personnel with no specialty training. Moreover, ontologies—sets of concepts that represent knowledge in a given domain—are increasingly being used to support medical diagnosis. A specific case is ONTODerm: an ontology to aid dermatological diagnosis. However, there is little information on the combined use of mobile applications and ontologies as support solutions in dermatology.

Objective

Assessing the reliability of ONTODerm as a tool to support remote dermatological diagnosis when used together with a mobile dermatological application in underprivileged areas.

Methods

A mobile application that allows characterization of skin lesions was developed, and the information about the lesions was sent to ONTODerm. An exploratory study was conducted in a remote area without access to a dermatologist. A total of 64 dermatological queries were recorded in the application and consulted with ONTODerm. Later, an experienced dermatologist evaluated the characterization and diagnosis of each query to determine the accuracy of the system.

Results

The results showed that the probability of obtaining a correct diagnosis was between 64.4% and 85.6% with a confidence interval of 95%. A higher accuracy rate was obtained when the skin lesion occurred on the face or when its border was categorized as poorly demarcated.

Conclusions

This study demonstrates the implementation of a teledermatology strategy based on mobile applications and domain ontology-driven knowledge base to provide timely assistance to healthcare professionals. This approach was found to be pertinent in the Colombian rural context, particularly in forest regions, where dermatology specialists are not available. The results of this article do not represent a final validation of the proposed approach; they suggest how the ontology can be improved to effectively support medical staff in marginalized regions.

Accuracy of acute burns diagnosis made using smartphones and tablets: a questionnaire-based study among medical experts

BACKGROUND

Remote assistance for burns by medical experts can support nurses and general physicians in emergency care with diagnostic and management advice. Previous studies indicate a high diagnostic accuracy based on images viewed on a computer screen, but whether image-based analysis by experts using handheld devices is accurate remains to be determined.

METHOD

A review of patient data from eight emergency centres in the Western Cape, South Africa, revealed 10 typical cases of burns commonly seen in children and adults. A web-based questionnaire was created with 51 images of burns representing those cases. Burns specialists from two countries (South Africa and Sweden (n = 8 and 7 respectively)) and emergency medicine specialists from South Africa (n = 11) were contacted by email and asked to assess each burn's total body surface area (TBSA) and depth using a smartphone or tablet. The accuracy and inter-rater reliability of the assessments were measured using intraclass correlation coefficients (ICC), both for all cases aggregated and for paediatric and adult burn cases separately. Eight participants repeated the questionnaire on a computer and intra-rater reliability was calculated.

RESULTS

The assessments of TBSA are of high accuracy all specialists aggregated (ICC = 0.82 overall and 0.81 for both child and adult cases separately) and remain high for all three participant groups separately. The burn depth assessments have low accuracy all specialists aggregated, with ICCs of 0.53 overall, 0.61 for child and 0.46 for adult cases. The most accurate assessments of depth are among South African burns specialists (reaching acceptable for child cases); the other two groups' ICCs are low in all instances. Computer-based assessments were similar to those made on handheld devices.

CONCLUSION

As was the case for computer-based studies, burns images viewed on handheld devices may be a suitable means of seeking expert advice even with limited additional information when it comes to burn size but less so in the case of burn depth. Familiarity with the type of cases presented could facilitate image-based diagnosis of depth.

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.

Global Burden of Skin Disease: Inequities and Innovations

PURPOSE OF REVIEW

We review the current understanding of the burden of dermatological disease through the lens of the Global Burden of Disease project, evaluate the impact of skin disease on quality of life in a global context, explore socioeconomic implications, and finally summarize interventions towards improving quality of dermatologic care in resource-poor settings.

RECENT FINDINGS

The Global Burden of Disease project has shown that skin diseases continue to be the 4th leading cause of nonfatal disease burden world-wide. However, research efforts and funding do not match with the relative disability of skin diseases. International and national efforts, such as the WHO List of Essential Medicines, are critical towards reducing the socioeconomic burden of skin diseases and increasing access to care. Recent innovations such as teledermatology, point-of-care diagnostic tools, and task-shifting help to provide dermatological care to underserved regions in a cost-effective manner.

SUMMARY

Skin diseases cause significant non-fatal disability worldwide, especially in resource-poor regions. Greater impetus to study the burden of skin disease in low resource settings and policy efforts towards delivering high quality care are essential in improving the burden of skin diseases.

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.

A systematic review of satisfaction with teledermatology

Background The two most commonly used modalities of teledermatology (TD) are store-and-forward (SF) and live-interactive (LI) TD. Existing studies have not compared these tools with respect to patient and provider satisfaction. Objective To systematically review all published studies of patient and provider satisfaction with SF and LI TD. Methods PubMed, EMBASE, and Cochrane databases were systematically searched for studies on provider or patient satisfaction with SF or LI TD between January 2000 and June 2016. Results Forty eligible studies were identified: 32 with SF TD, 10 with LI TD, and 2 evaluating both. With SF TD, 96% of studies assessing patient satisfaction and 82% of studies assessing provider satisfaction demonstrated satisfaction ( n = 24 and 17, respectively). With LI TD, 89% of studies assessing patient satisfaction and all studies assessing provider satisfaction revealed satisfaction (n = 9 and 6, respectively). Conclusion Patients and providers are satisfied with both SF and LI TD. Studies assessing satisfaction with LI have not been conducted in recent years, and have only been conducted in limited geographic patient populations. Further research assessing satisfaction with TD will help address any dissatisfaction with its uses and allow for increased support and funding of future programmes.

mHealth based interventions for the assessment and treatment of psychotic disorders: a systematic review

The relative burden of mental health disorders is increasing globally, in terms of prevalence and disability. There is limited data available to guide treatment choices for clinicians in low resourced settings, with mHealth technologies being a potentially beneficial avenue to bridging the large mental health treatment gap globally. The aim of the review was to search the literature systematically for studies of mHealth interventions for psychosis globally, and to examine whether mHealth for psychosis has been investigated. A systematic literature search was completed in Embase, Medline, PsychINFO and Evidence Based Medicine Reviews databases from inception to May 2016. Only studies with a randomised controlled trial design that investigated an mHealth intervention for psychosis were included. A total of 5690 records were identified with 7 studies meeting the inclusion criteria. The majority of included studies, were conducted across Europe and the United Sates with one being conducted in China. The 7 included studies examined different parameters, such as Experiential Sampling Methodology (ESM), medication adherence, cognitive impairment, social functioning and suicidal ideation in veterans with schizophrenia. Considering the increasing access to mobile devices globally, mHealth may potentially increase access to appropriate mental health care. The results of this review show promise in bridging the global mental health treatment gap, by enabling individuals to receive treatment via their mobile phones, particularly for those individuals who live in remote or rural areas, areas of high deprivation and for those from low resourced settings.

mHealth Interventions in Low and Middle-Income Countries: A Systematic Review

The purpose of this review was to determine whether mHealth interventions were effective in low- and middle-income countries in order to create a baseline for the evidence to support mHealth in developing countries. Studies were identified by searching Medline on 02 October 2014 for articles published in the English language between January 2000 and September 2014. Inclusion criteria were: 1) written in English, 2) completion of an mHealth intervention in a low or middle-income country, 3) measurement of patient outcomes, and 4) participants 18 years of age or older. 7,920 titles were reviewed and 7 were determined eligible based on inclusion criteria. Interventions included a cluster randomized trial, mixed methods study, retrospective comparison of an opt-in text message program, a two-arm proof of concept, single arm trial, a randomized trial, and a single subject design. Five out of seven of the studies showed significant difference between the control and intervention. Currently there is little evidence on mHealth interventions in developing countries, and existing studies are very diverse; however initial studies show changes in clinical outcomes, adherence, and health communication, including improved communication with providers, decrease in travel time, ability to receive expert advice, changes in clinical outcomes, and new forms of cost-effective education. While this initial review is promising, more evidence is needed to support and direct system-level resource investment.

A systematic review of randomized controlled trials of mHealth interventions against non-communicable diseases in developing countries

Background

The reasons of deaths in developing countries are shifting from communicable diseases towards non-communicable diseases (NCDs). At the same time the number of health care interventions using mobile phones (mHealth interventions) is growing rapidly. We review studies assessing the health-related impacts of mHealth on NCDs in low- and middle-income countries (LAMICs).

Methods

A systematic literature search of three major databases was performed in order to identify randomized controlled trials (RCTs) of mHealth interventions. Identified studies were reviewed concerning key characteristics of the trial and the intervention; and the relationship between intervention characteristics and outcomes was qualitatively assessed.

Results

The search algorithms retrieved 994 titles. 8 RCTs were included in the review, including a total of 4375 participants. Trials took place mostly in urban areas, tested different interventions (ranging from health promotion over appointment reminders and medication adjustments to clinical decision support systems), and included patients with different diseases (diabetes, asthma, hypertension). Except for one study all showed rather positive effects of mHealth interventions on reported outcome measures.

Furthermore, our results suggest that particular types of mHealth interventions that were found to have positive effects on patients with communicable diseases and for improving maternal care are likely to be effective also for NCDs.

Conclusions

Despite rather positive results of included RCTs, a firm conclusion about the effectiveness of mHealth interventions against NCDs is not yet possible because of the limited number of studies, the heterogeneity of evaluated mHealth interventions and the wide variety of reported outcome measures. More research is needed to better understand the specific effects of different types of mHealth interventions on different types of patients with NCDs in LaMICs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3226-3) contains supplementary material, which is available to authorized users.

Can teledermatology be a useful diagnostic tool in dermatology practice in remote areas? An Egyptian experience with 600 patients

Introduction

The paucity of studies evaluating teledermatology (TD) in developing countries was the impetus behind conducting this work. We aimed to evaluate the feasibility and reliability of TD in remote areas where medical facilities and consultant dermatologists are not available, through measurement of diagnostic concordance rates between face-to-face diagnosis and store-and-forward (SAF) TD diagnosis.

Methods

A total of 600 patients with dermatological ailments who attended Abshway Hospital were recruited into the study, examined by an on-site dermatology resident, and offered a diagnosis. The clinical images and patients’ history were collected and transferred (through the Dropbox application) to two remote consultant dermatologists. The reliability of the three physicians’ agreement rates was assessed.

Results

Diagnostic agreement rates between the face-to-face dermatologist and the two teledermatologists were 86.7% and 87% respectively. Of the cases, 97% had complete or partial agreement and 81.3% of cases showed complete agreement between the three physicians. The reliability of the three physicians’ agreement rates was assessed statistically using Cohen’s kappa coefficient (κ) and this showed a range of 0.46–0.52.

Conclusion

This study might aid in enhancing the utilization of this tool in our country, especially in remote areas with a lack of a proper dermatological service. The simplicity and low cost of the adopted technique might facilitate its use over large sectors. It opens the door for gaining the benefit of this technology in other aspects such as teaching and monitoring health care providers.

A survey of direct-to-consumer teledermatology services available to US patients: Explosive growth, opportunities and controversy

Introduction

Direct-to-consumer (DTC) teledermatology is radically changing the way patients obtain dermatological care. Now, with a few clicks, patients can obtain dermatological consultations and prescription medications without a prior physician-patient relationship. To analyse all DTC teledermatology services available to US patients.

Methods

We performed Internet searches to identify DTC teledermatology services available through Internet webpages or through smartphone applications. For each service, the scope of care provided, cost, wait times, prescription policies and other relevant information were recorded.

Results

Twenty-two DTC teledermatology services are available to US patients in 45 states. Six (27%) services offer care from international physicians. Sixteen (73%) services allow patients to seek care for any reason, while six (27%) limit care to acne or anti-aging. The median reported response time for DTC teledermatology services is 48 hours from the time of patient request. The median consultation fee for companies providing care from US board-certified physicians is US$59. Across all services, consultation fees range from US$1.59 to US$250.

Conclusions

DTC teledermatology services are readily available to patients in most states. These services may reduce the cost of patient visits, expand access to care and increase patient convenience. However, the presence of services staffed by physicians who are not US board-certified, as well as the use of incautious language regarding prescription medications, is concerning.

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.

Impact of store-and-forward (SAF) teledermatology on outpatient dermatologic care: A prospective study in an underserved urban primary care setting

BACKGROUND

The clinical value of teledermatology in the primary care setting remains relatively unknown.

OBJECTIVE

We sought to determine the impact of teledermatology on outpatient diagnosis, management, and access to dermatologic care in a resource-poor primary care setting.

METHODS

We performed a prospective study of store-and-forward teledermatology consults submitted between January and November 2013 from 11 underserved clinics in Philadelphia to the University of Pennsylvania using mobile devices and the Internet. We assessed diagnostic and management concordance between primary care providers and dermatologists, time to consult completion, anticipated level of dermatology input in the absence of teledermatology, and number of consults managed with teledermatology alone.

RESULTS

The study included 196 consults encompassing 206 dermatologic conditions. Diagnoses and management plans of primary care providers and dermatologists were fully concordant for 22% and 23% of conditions, respectively. The median time to consult completion was 14 (interquartile range 3-28) hours. At least 61% of consults would not otherwise have received dermatology input, and 77% of consults were managed with teledermatology alone.

LIMITATIONS

Lack of a diagnostic gold standard, limited patient follow-up, and uncertain generalizability are limitations.

CONCLUSION

Teledermatology is an innovative and impactful modality for delivering dermatologic care to outpatients in resource-poor primary care settings.

Teledermatology as a means to improve access to inpatient dermatology care

Many hospitals have limited inpatient dermatology consultation access. Most dermatologists are outpatient-based and may find the distance and time to complete inpatient consultations prohibitive. Teledermatology may improve access to inpatient dermatology care by reducing barriers of distance and time. We conducted a prospective two-phase pilot study at two academic hospitals comparing time needed to complete inpatient consultations after resident dermatologists initially evaluated patients, called average handling time (AHT), and time needed to respond to the primary team, called time to response (TTR), with and without teledermatology with surveys to capture changes in dermatologist opinion on teledermatology. Teledermatology was only used in the study phase, and patients were seen in-person in both study phases. Teledermatology alone sufficiently answered consultations in 10 of 25 study consultations. The mean AHT in the study phase (sAHT) was 26.9 min compared to the baseline phase (bAHT) of 43.5 min, a 16.6 min reduction ( p = 0.004). The 10 study cases where teledermatology alone was sufficient had mean study TTR (sTTR) of 273.3 min compared to a baseline TTR (bTTR) of 405.7 min, a 132.4 min reduction ( p = 0.032). Teledermatology reduces the time required for an attending dermatologist to respond and the time required for a primary team to receive a response for an inpatient dermatology consultation in a subset of cases. These findings suggest teledermatology can be used as a tool to improve access to inpatient dermatology care.

mHealth Education Applications Along the Cancer Continuum

The majority of adults worldwide own a mobile phone, including those in under-resourced communities. Mobile health (mhealth) education technologies present a promising mechanism for improving cancer prevention, treatment, and follow-up. The purpose of this study was to summarize the literature related to mobile phone (mhealth) applications for patient education specific to cancer and identify current recommendations from randomized studies. In particular, we were interested in identifying mobile phone applications along the cancer continuum, from cancer prevention to survivorship. The authors identified 28 articles reporting on mobile applications for patients related to cancer. Articles were identified in all categories along the cancer continuum, including health professional involvement in application development. Of these, six involved direct patient education, and eight focused on improving patient/professional communication and patient self-management. However, only six of the studies were randomized interventions. The potential for mobile applications to help overcome the "health care gap" has not yet been realized in the studies from the USA that were reviewed for this paper. However, early recommendations are emerging that support the use of mHealth communications to change behaviors for cancer prevention, early detection, and symptom management and improved patient-provider communication. Recommendations include short messages, use of multiple modalities as patient characteristics dictate comfort with mHealth communication, and the inclusion of patients and health professionals to develop and test applications. Tailoring mHealth to particular cultures, languages, and ethnic groups may also represent a unique possibility to provide accessible information and education at minimal cost for under-resourced communities and individuals.

A review of m-health in medical imaging

OBJECTIVE

The increasing capabilities of camera-equipped mobile phones have led to a growing body of evidence regarding their use in medical imaging across a broad range of medical specialties. This article reviews the current evidence for the use of mobile health (m-health) in medical imaging.

MATERIALS AND METHODS

We performed a structured review of the published literature regarding m-health in medical imaging using the Medline, PubMed, and Web of Science databases (January 2002-August 2013). The two authors independently extracted data regarding type of specialty, purpose, and study design of publications.

RESULTS

In total, 235 articles were identified. The majority of studies were case reports or noncomparative product validation studies. The greatest volume of publications originated in the fields of radiology (21%), dermatology (15%), laboratory techniques (15%), and plastic surgery (12%). Among these studies, m-health was used as diagnostic aids, for patient monitoring, and to improve communication between health practitioners. With the growing use of mobile phones for medical imaging, considerations need to be given to informed consent, privacy, image storage and transfer, and guidelines for healthcare workers and patients.

CONCLUSIONS

There are several novel uses of mobile devices for medical imaging that show promise across a variety of areas and subspecialties of healthcare. Currently, studies are mostly exploratory in nature. To validate these devices, studies with higher methodological rigor are required.

Feasibility and cost of a medical student proxy-based mobile teledermatology consult service with Kisoro, Uganda, and Lake Atitlán, Guatemala

BACKGROUND

The expansion of mobile technology and coverage has unveiled new means for delivering medical care to isolated and resource-poor communities. Teledermatology, or dermatology consultation from a distance using technology, is gaining greater acceptance among physicians and patients.

OBJECTIVES

To evaluate feasibility and cost of a smartphone-based teledermatology consult service utilizing a designated medical student proxy to facilitate all consults on site, and to evaluate the service's effect upon diagnosis and management.

METHODS

An IRB-approved smartphone-based teledermatology consult service was established to serve two rural communities in the developing world: Kisoro, Uganda, and Lake Atitlán, Guatemala. Fourth-year medical students were recruited as proxies for each site, responding to consults by local doctors and transmitting photographs and clinical information via a smartphone application to a dermatology resident and attending in the USA over an encrypted website. At the Ugandan site, when indicated, the medical student performed skin biopsies under supervision, and rotating Montefiore residents transported specimens back to the USA.

RESULTS

From October 2011 to August 2012, 93 cases were evaluated by the consult service (57 from Uganda and 36 from Guatemala). Initial diagnoses changed completely in 55.9% (52 of 93) of cases, and management changes were recommended in 89.2% (83 of 93) of cases. The estimated total cost of supplies and technology was 42.01 USD per consult and 64.24 USD per biopsy (including processing). Given fixed upfront costs, the cost per consult decreased with each additional case.

CONCLUSION

Smartphone-based systems for teledermatology consultation using a medical student proxy are feasible for delivery of care in the developing world at relatively little cost. Optimization and sustainability of this system requires and deserves further investigation in larger studies.

Digital photography in skin cancer screening by mobile units in remote areas of Brazil

BACKGROUND

Non-melanoma skin cancer (NMSC) is one of the most common neoplasms in the world. Despite the low mortality rates, NMSC can still cause severe sequelae when diagnosed at advanced stages. Malignant melanoma, the third most common type of skin cancer, has more aggressive behavior and a worse prognosis. Teledermatology provides a new tool for monitoring skin cancer, especially in countries with a large area and unequal population distribution. This study sought to evaluate the performance of digital photography in skin cancer diagnosis in remote areas of Brazil.

METHODS

A physician in a Mobile Prevention Unit (MPU) took four hundred sixteen digital images of suspicious lesions between April 2010 and July 2011. All of the photographs were electronically sent to two oncologists at Barretos Cancer Hospital who blindly evaluated the images and provided a diagnosis (benign or malignant). The absolute agreement rates between the diagnoses made by direct visual inspection (by the MPU physician) and through the use of digital imaging (by the two oncologists) were calculated. The oncologists' accuracy in predicting skin cancer using digital imaging was assessed by means of overall accuracy (correct classification rate), sensitivity, specificity and predictive value (positive and negative). A skin biopsy was considered the gold standard.

RESULTS

Oncologist #1 classified 59 lesions as benign with the digital images, while oncologist #2 classified 27 lesions as benign using the same images. The absolute agreement rates with direct visual inspection were 85.8% for oncologist #1 (95% CI: 77.1-95.2) and 93.5% for oncologist #2 (95% CI: 84.5-100.0). The overall accuracy of the two oncologists did not differ significantly.

CONCLUSIONS

Given the high sensitivity and PPV, Teledermatology seems to be a suitable tool for skin cancer screening by MPU in remote areas of Brazil.

Assessing the impact of mHealth interventions in low- and middle-income countries--what has been shown to work?

BACKGROUND

Low-cost mobile devices, such as mobile phones, tablets, and personal digital assistants, which can access voice and data services, have revolutionised access to information and communication technology worldwide. These devices have a major impact on many aspects of people's lives, from business and education to health. This paper reviews the current evidence on the specific impacts of mobile technologies on tangible health outcomes (mHealth) in low- and middle-income countries (LMICs), from the perspectives of various stakeholders.

DESIGN

Comprehensive literature searches were undertaken using key medical subject heading search terms on PubMed, Google Scholar, and grey literature sources. Analysis of 676 publications retrieved from the search was undertaken based on key inclusion criteria, resulting in a set of 76 papers for detailed review. The impacts of mHealth interventions reported in these papers were categorised into common mHealth applications.

RESULTS

There is a growing evidence base for the efficacy of mHealth interventions in LMICs, particularly in improving treatment adherence, appointment compliance, data gathering, and developing support networks for health workers. However, the quantity and quality of the evidence is still limited in many respects.

CONCLUSIONS

Over all application areas, there remains a need to take small pilot studies to full scale, enabling more rigorous experimental and quasi-experimental studies to be undertaken in order to strengthen the evidence base.

Reliability and validity of mobile teledermatology in human immunodeficiency virus-positive patients in Botswana: a pilot study

IMPORTANCE

Mobile teledermatology may increase access to care.

OBJECTIVE

To determine whether mobile teledermatology in human immunodeficiency virus (HIV)-positive patients in Gaborone, Botswana, was reliable and produced valid assessments compared with face-to-face dermatologic consultations.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study conducted in outpatient clinics and public inpatient settings in Botswana for 76 HIV-positive patients 18 years and older with a skin or mucosal condition that had not been evaluated by a dermatologist.

MAIN OUTCOMES AND MEASURES

We calculated the κ coefficient for diagnosis, diagnostic category, and management for test-retest and interrater reliability. We also determined sensitivity and specificity for each diagnosis.

RESULTS

The κ coefficient for test-retest reliability ranged from 0.47 (95% CI, 0.35 to 0.59) to 0.78 (0.67 to 0.88) for the primary diagnosis, 0.29 (0.18 to 0.42) to 0.73 (0.61 to 0.84) for diagnostic category, and 0.17 (-0.01 to 0.36) to 0.54 (0.38 to 0.70) for management. The κ coefficient for interrater reliability ranged from 0.41 (95% CI, 0.31 to 0.52) to 0.51 (0.41 to 0.61) for the primary diagnosis, 0.22 (0.14 to 0.31) to 0.43 (0.34 to 0.53) for diagnostic category, and 0.08 (0.02 to 0.15) to 0.12 (0.01 to 0.23) for management. Sensitivity and specificity for the top 10 diagnoses varied from 0 to 0.88 and 0.84 to 1.00, respectively.

CONCLUSIONS AND RELEVANCE

Our results suggest that while the use of mobile teledermatology technology in HIV-positive patients in Botswana has significant potential for improving access to care, additional work is needed to improve the reliability and validity of this technology on a larger scale in this population.

Tele-nuclear medicine

This article presents a description of tele-nuclear medicine and, after outlining its history, a wide, representative range of its applications. Tele-nuclear medicine has benefited greatly from technological progress, which for several decades has provided greater data transfer rates and storage capacity at steadily decreasing cost. Differences in the practice of nuclear medicine between developed and developing countries arise mainly from disparities in their available infrastructure, funding and education levels of personnel involved. Consequently there are different emphases in their tele-nuclear medicine, which are elaborated. It is concluded that tele-nuclear medicine is important for all countries, but the emphasis on its application may differ between developed and developing nations, with an emphasis on distance learning in the latter.

Mobile teledermatology: a promising future in clinical practice

BACKGROUND

As a product of electronic health, teledermatology is a cost-effective means of improving access to care, facilitating specialist consultations, and supporting patient self-management. Even so, use of traditional teledermatology services is limited by infrastructure and costs in the form of digital cameras, computers, and Internet access.

METHODS

Considering the significant improvement in smartphone camera resolution and the rapidly increasing number of physicians using smartphones, we explored the use of smartphones as reliable, effective clinical tools in store-and-forward teledermatology. We describe the technical specifications of modern smartphone cameras, the widespread use of smartphones by physicians, and the advantages of smartphones over traditional camera and Internet teledermatology, and we propose recommendations as to how mobile teledermatology may be more effectively used in modern dermatologic practice.

Mobile teledermatology--patient satisfaction, diagnostic and management concordance, and factors affecting patient refusal to participate in Saudi Arabia

We evaluated the use of a 4G smart phone for mobile teledermatology. A dermatologist took pictures of skin images with a mobile phone (8 Mpixel camera resolution) and made a face-to-face diagnosis. The images were transmitted to a second dermatologist who viewed them on a similar mobile phone and made an independent diagnosis for comparison. Images were taken and transmitted only after receiving informed consent from the patients. A total of 166 consecutive patients were included in the study (97 male and 69 female). A questionnaire to assess patient satisfaction was administered to each patient. Most of the responders were highly satisfied with teledermatology. However, 23 patients (14%) refused photography of the skin lesions (21 female and 2 males). The main reasons for refusal to be photographed were stated as social or religious. The broad categorical diagnostic and management concordance (i.e. when considering at least one of the diagnoses to be similar) was 95%. Specific diagnostic concordance varied according to the disease. The average kappa coefficient was 0.66 for diagnostic concordance and 0.82 for management concordance. Refusal to be photographed--a problem not limited to teledermatology--needs to be considered when designing teledermatology protocols for larger scale implementation in areas like the Middle East.

Evaluation criteria for mobile teledermatology applications and comparison of major mobile teledermatology applications

BACKGROUND

Mobile teledermatology applications have enabled increased patient access to dermatologic care. For groups interested in starting a mobile teledermatology program, selection of the appropriate application can be challenging. Having pretested evaluation criteria allows for efficient, systematic assessment of mobile teledermatology applications and identification of features important for comparison. The primary aim of this study is to determine a framework for evaluation of mobile teledermatology applications and to compare two major mobile teledermatology applications available in the United States using the proposed criteria.

MATERIALS AND METHODS

We incorporated previous teledermatology application evaluation criteria and developed new evaluation criteria to reflect matters specific to the mobile platform. Through a systematic search, we identified two publicly available mobile teledermatology applications in the United States and applied the evaluation criteria.

RESULTS

The 13-point evaluation criteria encompass three major domains: (1) technical specifications, (2) user experience and workflow, and (3) integration and scalability. The evaluation criteria provided an effective way of assessing the two mobile teledermatology applications. Both AccessDerm version 1.0 (Vignet Corp., McLean, VA) and ClickMedix version 1.3 (ClickMedix LLC, Rockville, MD) were capable of managing consultations. These applications adopted different approaches to balancing image quality versus data transmission, managing follow-up patients, and enabling dialogue between providers.

CONCLUSIONS

Mobile teledermatology provides convenient and scalable means of providing specialty care. The creation of mobile application evaluation criteria offers a useful guide for assessing future mobile applications.