Teledermatology: Key factors associated with reducing face-to-face dermatology visits

Image Quality Assessment Using Convolutional Neural Network in Clinical Skin Images

The image quality received for clinical evaluation is often suboptimal. The goal is to develop an image quality analysis tool to assess patient- and primary care physician-derived images using deep learning model. Dataset included patient- and primary care physician-derived images from August 21, 2018 to June 30, 2022 with 4 unique quality labels. VGG16 model was fine tuned with input data, and optimal threshold was determined by Youden's index. Ordinal labels were transformed to binary labels using a majority vote because model distinguishes between 2 categories (good vs bad). At a threshold of 0.587, area under the curve for the test set was 0.885 (95% confidence interval = 0.838-0.933); sensitivity, specificity, positive predictive value, and negative predictive value were 0.829, 0.784, 0.906, and 0.645, respectively. Independent validation of 300 additional images (from patients and primary care physicians) demonstrated area under the curve of 0.864 (95% confidence interval = 0.818-0.909) and area under the curve of 0.902 (95% confidence interval = 0.85-0.95), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value for the 300 images were 0.827, 0.800, 0.959, and 0.450, respectively. We demonstrate a practical approach improving the image quality for clinical workflow. Although users may have to capture additional images, this is offset by the improved workload and efficiency for clinical teams.

The Past, the Present and the Future of Teledermatology: A Narrative Review

Teledermatology may be defined as the application of telemedicine to dermatology. According to published data, teledermatology is more widespread in Europe and North America, probably where resources for health care are greater than in other areas of the world. Indeed, teledermatology requires advanced technology to be efficient, as high image quality is necessary to allow the dermatologist to make correct diagnoses. Thanks to the recent advances in this field, teledermatology is become routinary in daily clinical practice. However, its use has been improved over time, overcoming several challenges. The aim of this narrative review is to retrace the almost 30-year history of teledermatology, to address the new challenges posed by advancing technologies such as artificial intelligence and the implications it may have on healthcare.

Atopic Dermatitis Disease Education

There has been an influx of new educational resources for atopic dermatitis (AD) patients in recent years. The two primary organizations in the United States offering educational materials, online resources, and other forms of support include the National Eczema Association (NEA) and the American Academy of Dermatology (AAD). Educational workshops and interventions have emerged as tools that can deliver comprehensive information on AD, such as symptoms, treatments, and disease management. In regard to these workshops, studies have proven longer interventions to be more effective. Studies have also found multidisciplinary teams, including psychologists, dietitians, and AD specialists, to be more effective in AD treatment and education. Additionally, video-based education was found to be the most effective delivery medium compared to various written modes of education. Given the psychosocial impacts of AD, support groups have been found to improve life quality and decrease disease severity, with age-specific groups offering the greatest benefits. Technology such as social media and smartphones has also improved education. Social media has allowed the rapid exchange of information to wider audiences, but due to its unregulated nature, false information has also been disseminated. Despite this, web-based interventions have still been found to be satisfying, convenient, and effective in increasing treatment awareness. The advent of smartphone applications has provided patients with access to information on AD symptoms and treatment on demand. While the effectiveness of these promising applications hasn't been confirmed by studies, patient provider interactions via smartphone (teledermatology) have been found to be as effective as in-person appointments. This chapter will discuss these different types of emerging resources available to AD patients including educational materials, interventions, support groups, organizational support, and technological resources and their effectiveness.

The Role of Dermoscopy in Provider-to-Provider Store-and-Forward Dermatology eConsults: A Scoping Review of the Recent Literature

Purpose of Review

This scoping review maps recent literature on dermatology provider-to-provider asynchronous store-and-forward (SAF) electronic consult (eConsult) platforms with dermoscopy. It offers a descriptive overview, highlighting benefits and challenges.

Recent Findings

Incorporating dermoscopy into SAF eConsults improves diagnostic accuracy for benign and malignant skin neoplasms. Diagnostic and treatment concordance with traditional face-to-face (FTF) visits is high. SAF eConsults with dermoscopy enhance access to dermatological care by improving triage and reducing wait times for FTF visits. Pediatric patients benefit with improved evaluation of melanocytic and vascular growths. eConsult platforms with dermoscopy serve as a telementoring opportunity for clinicians interested in improving their dermoscopy skills.

Summary

Adding dermoscopy to SAF eConsults is valuable and results in improved diagnostic accuracy and reduced need for FTF visits. Implementation barriers can be overcome through collaboration between primary care and dermatology. Dermoscopy in SAF eConsults has significant potential for managing skin conditions and reducing the burden caused by unnecessary FTF visit and biopsies.

Explainable Image Quality Assessments in Teledermatological Photography

Background and Objectives: Image quality is a crucial factor in the effectiveness and efficiency of teledermatological consultations. However, up to 50% of images sent by patients have quality issues, thus increasing the time to diagnosis and treatment. An automated, easily deployable, explainable method for assessing image quality is necessary to improve the current teledermatological consultation flow. We introduce ImageQX, a convolutional neural network for image quality assessment with a learning mechanism for identifying the most common poor image quality explanations: bad framing, bad lighting, blur, low resolution, and distance issues. Methods: ImageQX was trained on 26,635 photographs and validated on 9,874 photographs, each annotated with image quality labels and poor image quality explanations by up to 12 board-certified dermatologists. The photographic images were taken between 2017 and 2019 using a mobile skin disease tracking application accessible worldwide. Results: Our method achieves expert-level performance for both image quality assessment and poor image quality explanation. For image quality assessment, ImageQX obtains a macro F1-score of 0.73 ± 0.01, which places it within standard deviation of the pairwise inter-rater F1-score of 0.77 ± 0.07. For poor image quality explanations, our method obtains F1-scores of between 0.37 ± 0.01 and 0.70 ± 0.01, similar to the inter-rater pairwise F1-score of between 0.24 ± 0.15 and 0.83 ± 0.06. Moreover, with a size of only 15 MB, ImageQX is easily deployable on mobile devices. Conclusion: With an image quality detection performance similar to that of dermatologists, incorporating ImageQX into the teledermatology flow can enable a better, faster flow for remote consultations.

Implementation and evaluation of a store-and-forward teledermatology workflow in a United States safety-net hospital urgent care emergency center: A retrospective cohort study

Background

Teledermatology (TD) is an important method for increasing access to care in outpatient settings. However, less is known regarding its use in emergency/urgent care centers.

Objective

To evaluate the effect of TD on urgent care emergency center (UCEC) dwell time and postencounter utilization.

Study type and methods

This retrospective cohort study evaluated patients in a safety-net hospital (Parkland Health, Dallas, Texas, USA) UCEC, who (1) received a TD consult in 2018, (2) were referred to dermatology clinic in 2017, or (3) were referred to dermatology clinic in 2018 without a TD consult.

Results

We evaluated 2024 patients from 2017 to 2018. Of the 973 referred to dermatology clinic in 2018, 332 (34%) received TD consultations. Mean dwell time for patients receiving TD was longer versus the 2017 cohort (303 vs 204 minutes, respectively). Patients receiving TD consultation with inflammatory skin conditions had lower odds of dermatology clinic visits compared with those that did not (odds ratio, 0.5; 95% CI, 0.3-0.8). Teledermatology was not associated with differences in repeat UCEC utilization.

Limitations

Single institution study and inability to account for differences in patient complexity.

Conclusion

TD increases dwell time in a safety-net hospital's UCEC but can reduce dermatology clinic utilization for patients with inflammatory skin conditions.

Overview of dermatologic tele-expertise in areas of low physician density: A retrospective study at Le Mans general hospital

BACKGROUND

In areas of low physician density, especially as regards dermatologists in France, there is an increasing interest in tele-expertise. This is particularly the case in the Sarthe department, where the number of physicians continues to decline and access to care was further limited by the COVID 19 epidemic.

STUDY DESIGN

We retrospectively collected data from tele-expertise requests submitted to Le Mans General Hospital by general practitioners via a dedicated platform between May 6, 2019, and April 9, 2021.

RESULTS

Six hundred and forty three requests relating to 90 different diagnoses were recorded during this period. One hundred and thirty four patients (20% of requests) were invited to attend a face-to-face consultation within an average of 29 days.

DISCUSSION

Through the use of tele-expertise at Le Mans Genreal Hospital it was possible to introduce a means of tackling the problem of the lack of dermatologists in the Sarthe department. Rapid responses enabled the number of consultation requests to be reduced, leading to fewer population displacements in the context of the present pandemic.

CONCLUSION

These initial results are encouraging and confirm that tele-expertise seems a satisfactory option to optimize access to care for populations in areas of low physician density.

Teledermatology May Benefit Marginalized Populations: National and Institutional Trends during the COVID-19 Pandemic

INTRODUCTION

Limited data exist regarding demographic-specific teledermatology (TD) utilization during the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to determine TD utilization trends during the pandemic.

METHODS

A retrospective cohort study for national and institutional populations was conducted. Patient encounters in the American Academy of Dermatology's DataDerm registry (DataDerm) were analyzed from 1 April 2020 through 30 June 2021. All dermatological patients seen by Duke University Health Systems (DUHS) were analyzed from 1 March 2020 through 30 April 2021. In-person clinic visits versus TD encounters (national and institutional) and no-show rates (institutional only) were collected for visit type (i.e., TD versus in-person), sex, race, age/generation, and in- versus out-of-state location (national only). TD utilization is defined as the cohort of interest using TD (e.g., females, whites) within a demographic group (i.e., sex, race) as a percentage of total TD users. This was compared with in-person utilization during the identical timeframe.

RESULTS

For US national data, 13,964,816 encounters were analyzed. Sex, race, age, and location each had a significant association with TD utilization (adjusted p < 0.001). For institutional data, 54,400 encounters were analyzed. Sex, race, and age had a significant association with TD utilization (adjusted p < 0.001). Both datasets revealed majority female populations for telehealth visits (DataDerm 66.0%; DUHS 61.7%). Non-white populations accounted for a higher percentage of TD utilizers (DataDerm 15.0%; DUHS 37.3%) when compared with in-person utilizers (DataDerm 11.7%; DUHS 22.3%). Younger patients utilized TD (DataDerm 63.6%; DUHS 62.6%) more than in-person services (DataDerm 26.3%; DUHS 43.8%). Institutional no-show rates between telehealth and in-person visits were lower for Black patients (11.8% versus 19.2%), other non-white races (10.6% versus 13.6%), and younger ages/generations (9.8% versus 12.8%), respectively. TD utilization decreased over time nationally as a percentage of total visits (2.9% versus 0.3%) in 2020 versus 2021, respectively.

CONCLUSIONS AND RELEVANCE

During the COVID-19 pandemic, certain populations (females, younger patients, non-white races) showed higher TD utilization. Understanding TD utilization trends is critical in defining the role of virtual care for improving universal care access, optimizing resources, and informing future healthcare models for all patient populations.

Using teledermatology to prevent and diagnose skin cancer in the rural United States

ABSTRACT

In the United States, skin cancer is a prevalent and sometimes preventable form of cancer that causes a significant disease burden in rural and urban communities. Studies have shown, however, that rural residents are less likely to engage in primary prevention behaviors against skin cancer, and rural populations have higher skin cancer incidence and mortality than urban residents. Teledermatology can be used to address disparities in both skin cancer diagnosis and health education to improve dermatology outcomes in rural communities. This article reviews teledermatology formats, barriers, and benefits to encourage integration of teledermatology modalities into clinical practice.

Evaluation of a pediatric dermatology electronic consult program in a rural state with subanalysis of infantile hemangioma cases

An electronic consultation (e-Consult) store-and-forward teledermatology program was implemented to improve access to dermatologic care in Maine. While initially designed to triage potential skin cancers, we found this program to be heavily used for pediatric patients, especially infants. Our findings suggest e-Consult expedites care for pediatric dermatology patients, particularly those with infantile hemangiomas. The addition of dermoscopy to e-Consult platforms has the potential to expand e-Consult effectiveness.

Telemedicina: validación de un cuestionario para evaluar la experiencia de los profesionales de la salud

Objetivo.

El siguiente trabajo tiene como objetivo desarrollar y validar un cuestionario para evaluar la experiencia de los profesionales de la salud con los sistemas de telemedicina.

Métodos.

A partir de la versión abreviada en español y validada localmente del cuestionario para pacientes desarrollado por Parmanto y col., un grupo de expertos consensuó una versión para evaluar la experiencia de profesionales de la salud que brindan servicios de telemedicina. El comportamiento psicométrico de los ítems se testeó en una primera muestra de 129 profesionales a través de un análisis factorial exploratorio. Luego, se evaluó su comprensibilidad a través de entrevistas cognitivas. Por último, en una nueva muestra de 329 profesionales, se evaluó la validez de constructo del cuestionario mediante un análisis factorial confirmatorio (AFC), y su validez de criterio externo, mediante la evaluación de su puntaje con el de una pregunta de resumen.

Resultados.

Se obtuvo un cuestionario de 12 ítems con una estructura de dos factores con indicadores de ajuste aceptables, documentada mediante AFC. La fiabilidad, la validez convergente y la validez discriminante fueron apropiadas. La validez de criterio externo mostró resultados óptimos.

Conclusiones.

El instrumento obtenido cuenta con propiedades psicométricas adecuadas y contribuirá a la evaluación objetiva de la experiencia de los profesionales que realizan telemedicina.

Access to pediatric dermatology

PURPOSE OF REVIEW

To identify factors that impact accessibility to pediatric dermatology and review healthcare delivery models that improve access and address these barriers.

RECENT FINDINGS

Up to one-third of pediatric primary care visits include a skin-related problem, yet pediatric dermatology subspecialist services are highly inaccessible. Workforce shortages and geographic, sociocultural, and economic barriers perpetuate inaccessibility. Teledermatology expands care, particularly to underserved or geographically remote communities, and reduces healthcare-related costs. Federal legislation to support telehealth services with adequate reimbursement for providers with parity between live, video, and phone visits will dictate the continued feasibility of virtual visits. Innovative care delivery models, such as language-based clinics, multidisciplinary teleconferencing, or embedded dermatology services within primary care are other promising alternatives.

SUMMARY

Despite efforts to expand access, dermatology still ranks among the most underserved pediatric subspecialties. Improving access requires a multipronged approach. Efforts to expand exposure and mentorship within pediatric dermatology, diversify the workforce and clinical curriculum, recruit and retain clinicians in geographically underserved areas, and collaborate with policymakers to ensure adequate reimbursement for teledermatology services are necessary.

Usefulness of Smartphones in Dermatology: A US-Based Review

(1) Background: As smartphones have become more widely used, they have become an appealing tool for health-related functions. For dermatology alone, hundreds of applications (apps) are available to download for both patients and providers. (2) Methods: The Google Play Store and Apple App Store were searched from the United States using dermatology-related terms. Apps were categorized based on description, and the number of reviews, download cost, target audience, and use of AI were recorded. The top apps from each category by number of reviews were reported. Additionally, literature on the benefits and limitations of using smartphones for dermatology were reviewed. (3) Results: A total of 632 apps were included in the study: 395 (62.5%) were marketed towards patients, 203 (32.1%) towards providers, and 34 (5.4%) towards both; 265 (41.9%) were available only on the Google Play Store, 146 (23.1%) only on the Apple App Store, and 221 (35.0%) were available on both; and 595 (94.1%) were free to download and 37 (5.9%) had a cost to download, ranging from USD 0.99 to USD 349.99 (median USD 37.49). A total of 99 apps (15.7%) reported the use of artificial intelligence. (4) Conclusions: Although there are many benefits of using smartphones for dermatology, lack of regulation and high-quality evidence supporting the efficacy and accuracy of apps hinders their potential.

Clinical outcomes and operational impact of a medical photography based teledermatology service with over 8,000 patients in the UK

A new, store-and-forward, fully digitised Teledermatology (TD) pathway was designed and implemented in an urban setting for non-two-week wait routine patients. In total 8,352 new patients had a TD consultation over 37 months. Of these, 4,748 (56.8%) were referred back to their GP, 1,634 (19.6%) were referred directly for a surgical procedure and 1,970 (23.6%) for a face-to-face review with a Dermatologist (F2F). The average waiting time for a TD appointment was 3 vs. 30 weeks for a routine F2F appointment. Between 2019 and 2018, TD referrals rose by 38%, routine dermatology referrals reduced by 16% and cancer referrals increased by 6%. Using medical photographers proved to be effective with only two cases (0.02%) of images being of insufficient quality to form a clinical opinion. Hitherto, savings for the local Commissioning Groups were estimated at £671,218. Last financial year savings (2019-2020) were £284,671. The average cost savings per TD patient appointment was £80.36. Savings in the Trust's overhead costs were £53,587. TD consultants reviewed almost twice the number of patients vs. F2F for the same amount of consultant programmed activities. 95% of surveyed patients would be likely or extremely likely to recommend this service to friends and family.

Coronavirus Disease 2019 and Dermatology Practice Changes

The impact of the COVID-19 pandemic on dermatology practice cannot be overstated. At its peak, the pandemic resulted in the temporary closure of ambulatory sites as resources were reallocated towards pandemic response efforts. Many outpatient clinics have since reopened and are beginning to experience a semblance of pre-pandemic routine, albeit with restrictions in place. We provide an overview of how COVID-19 has affected dermatology practice globally beginning with the rise of teledermatology. A summary of expert recommendations that shape the "new normal" in various domains of dermatology practice, namely, dermatology consultation, procedural dermatology, and phototherapy, is also provided.

Cost-minimization analysis of teledermatology versus conventional care in the Brazilian National Health System

Aims: Cost-minimization analysis (CMA) comparing the teledermatology service of the State of Santa Catarina, Brazil with the provision of conventional care, from the societal perspective. Patients & methods: All costs related to direct patient care were considered in calculation of outpatient costs. The evaluation was performed using the parameters avoided referrals and profile of hospitalizations. The economic analysis was developed through a decision tree. Results: Totally, 40% of 79,411 tests performed could be managed in primary care, avoiding commuting and expanding the patients' access. The CMA showed the teledermatology service had a cost per patient of US$196.04, and the conventional care of US$245.66. Conclusion: In this scenario, teledermatology proved to be a cost-saving alternative to conventional care, reducing commuting costs.

Inter-rater variability in patch test readings and final interpretation using store-forward teledermatology

BACKGROUND

Data regarding teledermatology for patch testing are limited.

OBJECTIVES

Compare patch test readings and final interpretation by two in-person dermatologists (IPDs) with eight teledermatologists (TDs).

METHODS

Patch tested patients had photographs taken of 70 screening series of allergens at 48 hours and second readings. Eight TDs reviewed photos and graded reactions (negative, irritant, doubtful, +, ++, +++) at 48 hours and second readings; in addition, they coded a final interpretation (allergic, indeterminant, irritant, negative) for each reaction. TDs rated overall image quality and confidence level for each patient and patch test reaction, respectively. Percentage of TD-IPD agreement based on clinical significance (success, indeterminate, and failure) was calculated. Primary outcome was agreement at the second reading.

RESULTS

Data were available for 99, 101, and 66 participants at 48 hours, second reading, and final interpretation, respectively. Pooled failure (+/++/+++ vs negative) at second reading was 13.6% (range 7.9%-20.4%). Pooled failure at 48 hours and final interpretation was 5.4% (range 2.9%-6.8%) and 24.6% (range 10.2%-36.8%), respectively. Confidence in readings was statistically correlated with quality of images and disagreement.

CONCLUSION

For patch testing, teledermatology has significant limitations including clinically significant pooled failure percentages of 13.6% for second readings and 24.6% for final interpretation.

Teledermatology in 2020: past, present and future perspectives

Born in 1995, teledermatology (TD) turns 25 years old today. Since then, TD evolved according to patients and physicians needs. The present review aimed to summarize all the efforts and experiences carried out in the field of TD and its subspecialties, the evolution and the future perspectives. A literature search was conducted in PubMed and Google Scholar. The state of the art of the "tele-dermo research" included TD and clinical trials, TD/TDS web platforms, TDS and artificial intelligence studies. Finally, the future perspective of TD/TDS in the era of social distancing was discussed. Using TD in specific situations adds several benefits including time-effectiveness of intervention and reduction in the waiting time for the first visit, reduced travel-costs, reduced sanitary costs, equalization of access from patient to specialistic consult. The communication technologies devices currently available can adequately support the growing needs of tele-assistance. A main limit is the current lack of a common clear European regulation for practicing TD, encompassing privacy issues and data management. The pandemic lockdown of 2020 has highlighted the importance of performing TD for all those patient, elderly and/or fragile, where the alternative would be no care at all. Many efforts are needed to develop efficient workflows and TD programs to facilitate the interplay among the different TD actors, along with practice guidelines or position statements.

Delivering remote consultations: Talking the talk

INTRODUCTION

There is an increasing affinity for remote health consultations (including telephone and virtual platforms), enabling new models of accessing services to evolve. Whilst many key skills are transferable from traditional to remote consultations, there is even greater emphasis on verbal communication skills during these interactions.

PURPOSE

This masterclass considers the communication skills required for delivering remote health care consultations, in particular focussing on: 12 interactional features in an opening sequence of a remote call; active listening; how to offer advice using the Ask-Offer-Ask framework; and subtleties in phrasing and prosody when closing a call that may indicate a level of satisfaction (or otherwise).

IMPLICATIONS

In planning for digitally-enabled services to become mainstream, the differences in communication between remote and face-to-face consultations must be recognised and embraced.

Teledermatology Addressing Disparities in Health Care Access: a Review

Purpose of Review

Dermatologists have been at the forefront of researching telemedicine to expand access to care. The current COVID-19 pandemic has prompted even greater expansion and implementation of teledermatology. This review discusses the research examining the potential impact of teledermatology addressing disparities in care.

Recent Findings

Teledermatology appears to increase access to dermatology given expanded means to deliver care. Specifically, recent studies have found increased access among Medicaid-insured, resource-poor urban and rural, and elderly populations. Teledermatology implementation also facilitates education among providers at different levels of training. Still, as some patients have inconsistent access to the required technology, increased reliance on telemedicine may also potentially increase disparities for some populations.

Summary

Teledermatology may serve to reduce disparities in health care access in many underserved and marginalized communities. Future research should continue to study implementation, especially given the expansion during the COVID-19 pandemic. Ultimately, teledermatology may play an important role in ensuring equitable care access for all.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Ideal Patient for Teleconsultation and Saving Resources

Objectives: The main objectives of the study were to evaluate the level of patients' acceptance of teleconsultation (TC) and to define the ideal patient profile for this type of service. The secondary objectives were to estimate the impact in time and financial resources for the patient in relation to face-to-face medicine. Materials and Methods: This is a prospective, nonprobabilistic, and random sampling study using an uncontrolled selection process consisting of a 19-question survey for health care users in the general population, in which the patients' acceptance of TC was analyzed through the question: "If your doctor suggested that you have a video conference consultation, how attractive would the proposal be for you?" Results: Of the 400 patients, 73.8% were in favor of a TC service. The variables that were associated with the acceptance of TC were health care users who had previously purchased on the internet (odds ratio [OR] = 2.6 confidence interval [CI] 95% 1.31; 5.05) and whether they were willing to assume the economic cost for a TC (OR = 7.8 CI 95% 3.26; 18.6). In terms of face-to-face consultations per year, 50% of the patients spent 5 h (standard deviation [SD] 10.7) going to see the doctor, and on average they requested 8.9 h (SD 16.1) of time off work permission and assumed an economic cost of €29.8 (SD 82.9) on journey time. Conclusion: A high number of health care users accept the use of TC, and this percentage increases in patients who had previously purchased online and were willing to assume an economic cost for this service.

Cost Minimization Analysis of a Teledermatology Triage System in a Managed Care Setting

Importance

Teledermatology (TD) enables remote triage and management of dermatology patients. Previous analyses of TD systems have demonstrated improved access to care but an inconsistent fiscal impact.

Objective

To compare the organizationwide cost of managing newly referred dermatology patients within a TD triage system vs a conventional dermatology care model at the Zuckerberg San Francisco General Hospital and Trauma Center (hereafter referred to as the ZSFG) in California.

Design, Setting, and Participants

A retrospective cost minimization analysis was conducted of 2098 patients referred to the dermatology department at the ZSFG between June 1 and December 31, 2017.

Intervention

Implementation of the TD triage system in January 2015.

Main Outcomes and Measures

The main outcome was mean cost to the health care organization to manage newly referred dermatology patients with or without TD triage. To estimate costs, decision-tree models were constructed to characterize possible care paths with TD triage and within a conventional dermatology care model. Costs associated with primary care visits, dermatology visits, and TD visits were then applied to the decision-tree models to estimate the mean cost of managing patients following each care path for 6 months. The mean cost for each visit type incorporated personnel costs, with the mean cost per TD consultation also incorporating software implementation and maintenance costs. Finally, ZSFG patient data were applied within the models to evaluate branch probabilities, enabling calculation of mean cost per patient within each model.

Results

The analysis captured 2098 patients (1154 men [55.0%]; mean [SD] age, 53.4 [16.8] years), with 1099 (52.4%) having Medi-Cal insurance and 879 (41.9%) identifying as non-White. In the decision-tree model with TD triage, the mean (SD) cost per patient to the health care organization was $559.84 ($319.29). In the decision-tree model for conventional dermatology care, the mean (SD) cost per patient was $699.96 ($390.24). Therefore, the TD model demonstrated a statistically significant mean (SE) cost savings of $140.12 ($11.01) per patient. Given an annual dermatology referral volume of 3150 patients, the analysis estimates an annual savings of $441 378.

Conclusions and Relevance

Implementation of a TD triage system within the dermatology department at the ZSFG was associated with cost savings, suggesting that managed health care settings may experience significant cost savings from using TD to triage and manage patients.

Impact of COVID-19 Pandemic on Dermatology Practice in India

Background:

COVID-19 pandemic has disrupted healthcare systems throughout the globe. It has affected dermatology practice to a great extent. Since most of the consultations (except emergencies) in dermatology are deferred as a precautionary measure, dermatologists have taken the route of virtual appointments in order to continue treating patients in the present lockdown state. However, the concept of telemedicine is quite new for doctors as well as for patients in India.

Material and Methods:

An online questionnaire was circulated among Indian dermatologists which included participant demographics, changes in their practice and teaching during COVID-19, use of virtual or e-health technologies, and attitudes/opinions on their experiences. We also wanted to understand doctor perspectives on their own roles, wellness, and hospital responses to the pandemic.

Results:

A total of 260 responses from qualified dermatologists of different parts of India were received between 1^st and 8^th April 2020 and were analyzed. Two-thirds of the respondents were within 10 years of starting practice. Virtual consultations have increased by almost three-fold during the pandemic, which is a major change noticed in the practice when we compare before and during the pandemic. Earlier the focus of teledermatology (TD) was mainly for follow-up care (85%), whereas during the pandemic, both new and follow-up patients were provided virtual consultations. The number of patients coming to them for a consultation has drastically reduced. Only 2% of the responders are still performing minor procedures with proper care. Almost two-thirds do not have systems in place to train their residents and fellows due to the disruptions caused by the pandemic. The rest of them have started to take the virtual route of teaching through webinars, virtual rounds, and providing access to online journals to continue their teaching. Only 18.6% of dermatologists at work were provided with personal protective equipment. TD has opened new doors to virtual consultation and it was evident that 54.4% of doctors are willing to continue it in the future even after the pandemic is over.

Conclusion:

TD platforms hold great promise to improve access to high-quality dermatologic care in the future. Results from this survey of Indian dermatologists suggest that TD is the future of dermatology as it will be accessed by patients in remote areas and it is a cost-effective move for the patients.

Specialist haematology consultation services in regional Western Australia: Evaluating a model combining telehealth and onsite clinics

BACKGROUND

Models of care that increase specialist medical services to regional or remote patients are being explored worldwide. Many of the models include telehealth (also called telemedicine or video-conferencing consultations) alone or in combination with traditional face-to-face clinics visits.

AIM

This study reports the experience of patients using telehealth consultation and costs associated with delivering the service in a Regional Cancer Centre over a 12 month period.

METHODS

Patients attending a Great Southern haematology clinic between September 2018 and July 2019 were invited to complete a brief questionnaire about their demographic and diagnosis details. Those attending a telehealth clinic were invited to complete a Tele-Haematology Satisfaction Questionnaire and invited to participate in a face-to-face interview regarding their general experiences and thoughts related to telehealth and face-to-face consultations. Occasions of service costs and direct hospital expenses were provided by the central health service's telehealth office.

RESULTS

The use of telehealth alone or as part of a mixed model was acceptable and convenient for most patients. In addition, high levels of satisfaction were reported including improved access to specialist services, reduced travel time, and an ease of use of the telehealth system. The total cost saving was AUD$308 per occasion of service.

CONCLUSIONS

This study demonstrated that the model was effective in providing outpatient services and cost effective to the health service, while being experienced as a satisfactory model by patients. This article is protected by copyright. All rights reserved.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Teledermatology in Belgium: a pilot study

Background: Teledermatology, the application of telemedicine in the field of dermatology, can be a valuable tool to improve the efficiency of care in general practice.Objectives: In this pilot study, we implemented a teledermatology programme in Belgian context to assess the effect on referral rate and to evaluate the acceptability of teledermatology by clinicians and patients.Material and methods: A store-and-forward teledermatology service between 12 general practitioners (GPs) and 3 academic dermatologists was evaluated for a period of 3-6 months. Clinicians and patients were questioned about satisfaction, benefits and barriers.Results: In total, 54 teledermatologic consultations were performed. The referral rate was reduced. Thirty-one teleconsulations were performed instead of physical referral, of which nine patients were actually referred. In 23 cases, performed for a second opinion, two more patients were referred on the dermatologist's advice.All clinicians want to continue working with teledermatology. GPs highlighted the educational benefit, whereas dermatologists were interested in the triage effect and reduced referral rate. Patients indicated that teledermatology would encourage them to consult a GP sooner when experiencing dermatologic problems.Conclusion: Teledermatology proved to be a feasible and acceptable tool for both clinicians and patients. It also shows to be a valuable for triage and reducing unnecessary referrals. Considering the emergent pressure on health care in the next decades, teledermatology following GP selection could be useful for the Belgian health care system and deserves further elaboration in the search for effective tools to strengthen first line health care and streamline referral to secondary care.

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.

Teledermatology and its Current Perspective

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

Mobile consulting (mConsulting) and its potential for providing access to quality healthcare for populations living in low-resource settings of low- and middle-income countries

OBJECTIVE

The poorest populations of the world lack access to quality healthcare. We defined the key components of consulting via mobile technology (mConsulting), explored whether mConsulting can fill gaps in access to quality healthcare for poor and spatially marginalised populations (specifically rural and slum populations) of low- and middle-income countries, and considered the implications of its take-up.

METHODS

We utilised realist methodology. First, we undertook a scoping review of mobile health literature and searched for examples of mConsulting. Second, we formed our programme theories and identified potential benefits and hazards for deployment of mConsulting for poor and spatially marginalised populations. Finally, we tested our programme theories against existing frameworks and identified published evidence on how and why these benefits/hazards are likely to accrue.

RESULTS

We identified the components of mConsulting, including their characteristics and range. We discuss the implications of mConsulting for poor and spatially marginalised populations in terms of competent care, user experience, cost, workforce, technology, and the wider health system.

CONCLUSIONS

For the many dimensions of mConsulting, how it is structured and deployed will make a difference to the benefits and hazards of its use. There is a lack of evidence of the impact of mConsulting in populations that are poor and spatially marginalised, as most research on mConsulting has been undertaken where quality healthcare exists. We suggest that mConsulting could improve access to quality healthcare for these populations and, with attention to how it is deployed, potential hazards for the populations and wider health system could be mitigated.

Cost-effectiveness of Skin Cancer Referral and Consultation Using Teledermoscopy in Australia

Importance

International literature has shown that teledermoscopy referral may be a viable method for skin cancer referral; however, no economic investigations have occurred in Australia.

Objective

To assess the cost-effectiveness of teledermoscopy as a referral mechanism for skin cancer diagnosis and management in Australia.

Design, Setting, and Participants

Cost-effectiveness analysis using a decision-analytic model of Australian primary care, informed by publicly available data.

Interventions

We compared the costs of teledermoscopy referral (electronic referral containing digital dermoscopic images) vs usual care (a written referral letter) for specialist dermatologist review of a suspected skin cancer.

Main Outcomes and Measures

Cost and time in days to clinical resolution, where clinical resolution was defined as diagnosis by a dermatologist or excision by a general practitioner. Probabilistic sensitivity analysis was performed to examine the uncertainty of the main results.

Results

Findings from the decision-analytic model showed that the mean time to clinical resolution was 9 days (range, 1-50 days) with teledermoscopy referral compared with 35 days (range, 0-138 days) with usual care alone (difference, 26 days; 95% credible interval [CrI], 13-38 days). The estimated mean cost difference between teledermoscopy referral (A$318.39) vs usual care (A$263.75) was A$54.64 (95% CrI, A$22.69-A$97.35) per person. The incremental cost per day saved to clinical resolution was A$2.10 (95% CrI, A$0.87-A$5.29).

Conclusions and Relevance

Using teledermoscopy for skin cancer referral and triage in Australia would cost A$54.64 extra per case on average but would result in clinical resolution 26 days sooner than usual care. Implementation recommendations depend on the preferences of the Australian health system decision makers for either lower cost or expedited clinical resolution. Further research around the clinical significance of expedited clinical resolution and its importance for patients could inform implementation recommendations for the Australian setting.

Patients' out-of-pocket expenses analysis of presurgical teledermatology

Background

This study undertakes an economic analysis of presurgical teledermatology from a patient perspective, comparing it with a conventional referral system. Store-and-forward teledermatology allows surgical planning, saving both time and number of visits involving travel, thereby reducing patients' out-of-pocket expenses, i.e. costs that patients incur when traveling to and from health providers for treatment, visits' fees, and opportunity cost of time spent in visits. to The study quantifies the opportunity costs and direct costs of visits for adults waiting for dermatology surgery.

Method

This study uses a retrospective assessment of 123 patients. Patients' out-of-pocket expenses of presurgical teledermatology were analyzed in the setting of a public hospital over 2 years. The teledermatology network covering the area served by the Hospital Garcia da Horta, Portugal, linked the primary care centers of 24 health districts with the hospital's dermatology department. The patients' opportunity cost of visits and direct costs of visits (transport costs, and visits' fee) of each presurgical modality (teledermatology and conventional referral), were simulated from initial primary care visit until surgical intervention. Two groups of patients, those with Squamous Cell Carcinoma and those with Basal Cell Carcinoma, were distinguished in order to compare the patients' out-of-pocket expenses according to the dermatoses.

Results

From a patient perspective, the conventional system was 2.12 times more expensive than presurgical teledermatology. Teledermatology allowed saving €0.74 per patient and per day of delay avoided. This saving was greater in patients with Squamous Cell Carcinoma than in patients with Basal Cell Carcinoma. Although, the probabilistic sensitivity analysis corroborates the results of the base case scenario, only a prospective study can substantiate these results.

Conclusion

In the Portuguese public healthcare system and under specific cost hypotheses, from a patient economic perspective, teledermatology used for presurgical planning and preparation is the dominant strategy in terms of out-of-pocket expenses, outperforming the conventional referral system, especially for patients with severe dermatoses.

Impact of teledermatology on the accessibility and efficiency of dermatology care in an urban safety-net hospital: A pre-post analysis

BACKGROUND

Teledermatology enables dermatologists to remotely triage and evaluate dermatology patients, but previous studies have questioned whether teledermatology is clinically efficient.

OBJECTIVE

To determine whether implementation of a teledermatology system at the Zuckerberg San Francisco General Hospital and Trauma Center has improved the accessibility and efficiency of dermatology care delivery.

METHODS

Retrospective, pre-post analysis of a pre-teledermatology cohort (June 2014-December 2014) compared with a post-teledermatology cohort (June 2017-December 2017).

RESULTS

Our analysis captured 11,586 patients. After implementation of teledermatology, waiting times for new patients decreased significantly (84.6 days vs 6.7 days; P < .001), total cases evaluated per month increased significantly (754 vs 901; P = .008), and number of cases evaluated per dermatologist-hour increased significantly (2.27 vs 2.63; P = .010). In the post-teledermatology period, 61.8% of teledermatology consults were managed without a clinic visit.

LIMITATIONS

We were unable to control for changes in demand for dermatology evaluations between the 2 periods and did not have a control group with which to compare our results.

CONCLUSION

The dermatology service was more accessible and more efficient after implementation of teledermatology, suggesting that capitated health care settings can benefit from implementation of a teledermatology system.

Teledermatology Outcomes in the Providence Veterans Health Administration

Background: As technology evolves, so does the integration of technology into health care delivery. Telemedicine, the use of information technology to provide remote health care, aims to improve patient access to quality care across a wide range of barriers. Introduction: Our objective was to determine whether teleconsultation leverages specialist expertise at one site within the United States' largest integrated health system. We evaluated the Providence Veterans Affairs Medical Center (PVAMC) teledermatology store-and-forward program. Materials and Methods: We evaluated 460 completed teleconsultations using retrospective chart review at the PVAMC in June-August 2016 for 12 postimaging outcomes, with no exclusion criteria. We determined outcomes using Computerized Patient Record System chart reviews. Results: Dermatologists completed 84-99% of all teleconsultations within 1 week after referral. Fifty one percent (51%) of patients required no dermatology clinic visit. Six percent (6%) of all teleconsultations were ultimately diagnosed with a biopsy-proven skin cancer. Sixty nine percent (69%) of referring providers prescribed recommended medications within 7 days. Discussion: We conclude that the PVAMC teledermatology program enables rapid access to dermatologic expertise while avoiding unnecessary clinic appointments. Conclusion: By detecting both weak links, and steps in the chain of care that successful teledermatology requires, our findings can help teledermatology systems within and outside the Veterans Affairs maximize their effectiveness.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Patient satisfaction with dermatology teleconsultation by using MedX

BACKGROUND

The development of telecommunication has strongly affected comprehensive scientific disciplines, including medical sciences.

OBJECTIVE

This study aims to assess the patient satisfaction of the teleconsultation system used for the consultation of dermatological follow-up care.

METHODS

The study was performed cross sectional patient satisfaction survey method conducted between February and April 2017 to determine patient satisfaction using MedX teleconsultation system. The patient sample of the current study was recruited from cosmetic laser clinic, Wanfang and Taipei Medical University hospital. The study was performed on 32 patient (n = 32) participants. All of them were at least university graduate. Consultants and patients were handled using the Android-based MedX mobile application, which is available through an application for Google Android cellular telephones. Its application consists of a demographic information, structured step-by-step questionnaire, essential medical information about each patient, and digital images of skin lesions.

RESULTS

28 patients completed the questionnaire. The mean ± SD age of the patients was 27.25 ± 4.039 years; 78.6% were women. The study shows that respondents have reported a high level (85.8%) of mean overall satisfaction for the teleconsultation service. The usability of the system has highest satisfaction rate of 90.5% among the other subscales especially in terms of data transfer and data displayed. Responses of the patient satisfaction questionnaire were analyzed by age and gender, no statistically significant difference between the variables was found.

CONCLUSION

Patients have shown high satisfaction with teleconsultation service and it is well accepted in the management of cosmetic dermatology service. In the future, MedX application can be integrated into other instant messaging applications such as Line, thus allowing doctors and patients to easily communicate with each other.

Tele-expertise for diagnosis of skin lesions is cost-effective in a prison setting: A retrospective cohort study of 450 patients

CONTEXT

The prevalence of skin diseases among prisoners is higher than in the general population. Diagnosing and treating these lesions require a dermatologic advice. A tele-expertise network in dermatology for prisoners including 8 health facilities in prison and 2 hospital dermatological departments was developed to improve access to dermatologists' expertise in correctional facilities. Our objective was to evaluate the effectiveness and costs of tele-expertise in dermatology for prisoners.

METHODS

We carried out a retrospective cohort study on data collected by the information system of the tele-expertise network. We used the MAST (Model for ASsessment of Telemedicine) model to perform a multidimensional assessment including the proportion of patients with a completed treatment plan for the skin lesions, the proportion of technical problems, the quality of the pictures, the investment and operating costs and the satisfaction of the professionals.

RESULTS

Mean patient age was 34.2 years with 90% men. 511 requests for 450 patients were initiated. The delay from the connection to the tele-expertise software to the validation of the request was inferior to 7 min for 50% of the requests and inferior to 30 min for 85% of the requests. Overall, with tele-expertise, 82% of the patients had a completed treatment plan for the skin lesions, with 2.9% of all patients requiring a later face-to-face appointment or hospitalization, to be compared to a proportion of 35% of patients with a completed treatment plan when tele-expertise was not available. The most frequent lesions were acnea (22%) and atopic dermatitis (18%). The mean cost for one completed treatment plan was €184 by tele-expertise and €315 without tele-expertise. Tele-expertise was well accepted among physicians with all responders (n = 9) willing to continue using it.

CONCLUSION

Tele-expertise is a dominant intervention in comparison to a face-to face consultation taking into account the cost of transportation and the proportion of canceled appointments and is acceptable for physicians.

TRIAL REGISTRATION

NCT02309905.

What do Australian dermatologists expect to be paid for store-and-forward teledermoscopy? A preliminary investigation

Introduction

Determining appropriate remuneration for teledermoscopy service is important because inadequate remuneration can be a barrier to practitioner uptake and participation. This study explores dermatologist remuneration expectations for a single lesion store-and-forward teledermoscopy consultation.

Methods

Fourteen dermatologists participated in telephone interviews during May–June 2017. Questions regarding remuneration focused on a clinical scenario involving teledermoscopy of a single lesion suspected to be skin cancer. The initial scenario was an existing patient, with a provisional diagnosis of benign neoplasm from the images, to be followed-up with routine skin checks, taking three minutes to review. Participants indicated their remuneration expectation by selecting from an ascending array of pre-determined remuneration ranges. The question was repeated a further four times with one aspect of the scenario changed each time; consultation length, source (patient or general practitioner), required follow-up, and a new rather than existing patient. Participants were also asked how appropriate they thought teledermoscopy was for the scenario, and whether they would choose to undertake the consultation presented.

Results

Nine dermatologists selected the AU$61–90 or AU$91–120 remuneration ranges for the initial scenario. When given the opportunity to comment on teledermoscopy service provision in Australia, respondents reflected that it was a valuable, advanced dermatology service, but they would prefer face-to-face consultation with patients where possible to allow for a full body examination.

Discussion

Dermatologists expect to be remunerated in the range of AU$61–120 for a single lesion store-and-forward teledermoscopy consultation when face-to-face examination is not possible.

Unmet digital health service needs in dermatology patients

BACKGROUND

Digital health services are rapidly gaining acceptance in healthcare systems. Dermatology as an image-centric specialty is particularly well suited for telemedical services. However, dermatology patients' demands of electronic services remain largely unexplored.

METHODS

This study investigated patients' views in primary, secondary, and tertiary referral centers. In August 2017, 841 questionnaires were filled in by dermatology patients.

RESULTS

76.34% expressed interest in using digital healthcare services as part of medical consultations. 84.41% of all patients would complete their initial registration form electronically. Fewer patients were comfortable with sending pictures of skin changes to their doctors using email (40.89%) or mobile health applications (40.61%). Specific interest was indicated for arranging appointments online (90.80%) and electronically-placed prescriptions (76.56%), rather than online learning videos (42.03%), and actual online consultations (34.53%). 65.37% of patients would pay for online consultations themselves.

CONCLUSIONS

Taken together, interest in electronic health services is high in dermatology patients. Our data suggest that readily understandable electronic services such as online-arranged appointments and electronic prescriptions are of higher interest to patients than the current type of online consultations. Therefore, the full potential of teledermatology still remains to be tapped by newer, more attractive forms of services closely adapted to patients' demands.

An evaluation of a referral management and triage system for oral surgery referrals from primary care dentists: a mixed-methods study

Background

Oral surgery referrals from dentists are rising and putting increased pressure on finite hospital resources. It has been suggested that primary care specialist services can provide care for selected patients at reduced costs and similar levels of quality and patient satisfaction.

Research questions

Can an electronic referral system with consultant- or peer-led triage effectively divert patients requiring oral surgery into primary care specialist settings safely, and at a reduced cost, without destabilising existing services?

Design

A mixed-methods, interrupted time study (ITS) with adjunct diagnostic test accuracy assessment and health economic evaluation.

Setting

The ITS was conducted in a geographically defined health economy with appropriate hospital services and no pre-existing referral management or primary care oral surgery service. Hospital services included a district general, a foundation trust and a dental hospital.

Participants

Patients, carers, general and specialist dentists, consultants (both surgical and Dental Public Health), hospital managers, commissioners and dental educators contributed to the qualitative component of the work. Referrals from primary care dental practices for oral surgery procedures over a 3-year period were utilised for the quantitative and health economic evaluation.

Interventions

A consultant- then practitioner-led triage system for oral surgery referrals embedded within an electronic referral system for oral surgery with an adjunct primary care service.

Main outcome measures

Diagnostic test accuracy metrics for sensitivity and specificity were calculated. Total referrals, numbers of referrals sent to primary care and the cost per referral are reported for the main intervention. Qualitative findings in relation to patient experience and whole-system impact are described.

Results

In the diagnostic test accuracy study, remote triage was found to be highly specific (mean 88.4, confidence intervals 82.6 and 92.8) but with lower values for sensitivity. The implementation of the referral system and primary care service was uneventful. During consultant triage in the active phases of the study, 45% of referrals were diverted to primary care, and when general practitioner triage was used this dropped to 43%. Only 4% of referrals were sent from specialist primary care to hospital, suggesting highly efficient triage of referrals. A significant per-referral saving of £108.23 [standard error (SE) £11.59] was seen with consultant triage, and £84.13 (SE £11.56) with practitioner triage. Cost savings varied according the differing methods of applying the national tariff. Patients reported similar levels of satisfaction for both settings, and speed of treatment was their over-riding concern.

Conclusions

Implementation of electronic referral management in primary care can lead, when combined with triage, to diversions of appropriate cases to primary care. Cost savings can be realised but are dependent on tariff application by hospitals, with a risk of overestimating where hospitals are using day case tariffs extensively.

Study limitations

The geographical footprint of the study was relatively small and, hence, the impact on services was minimal and could not be fully assessed across all three hospitals.

Future work

The findings suggest that the intervention should be tested in other localities and disciplines, especially those, such as dermatology, that present the opportunity to use imaging to triage.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Patient Satisfaction With an Early Smartphone-Based Cosmetic Surgery Postoperative Follow-Up

BACKGROUND

While prevalent in everyday life, smartphones are also finding increasing use as a medical care adjunct. The use of smartphone technology as a postoperative cosmetic surgery adjunct for care has received little attention in the literature.

OBJECTIVES

The purpose of this effort was to assess the potential efficacy of a smartphone-based cosmetic surgery early postoperative follow-up program. Specifically, could smartphone photography provided by the patient to the plastic surgeon in the first few days after surgery allay patient's concerns, improve the postoperative experience and, possibly, detect early complications?

METHODS

From August 2015 to March 2016 a smartphone-based postoperative protocol was established for patients undergoing cosmetic procedures. At the time of discharge, the plastic surgeon sent a text to the patient with instructions for the patient to forward a postoperative photograph of the operated area within 48 to 72 hours. The plastic surgeon then made a return call/text that same day to review the patient's progress. A postoperative questionnaire evaluated the patients' postoperative experience and satisfaction with the program.

RESULTS

A total of 57 patients were included in the study. Fifty-two patients responded to the survey. A total of 50 (96.2%) patients reported that the process improved the quality of their postoperative experience. The protocol allowed to detect early complications in 3 cases. The physician was able to address and treat the complications the following day prior to the scheduled clinic follow up.

CONCLUSIONS

The smartphone can be effectively utilized by the surgeon to both enhance the patient's postoperative experience and alert the surgeon to early postoperative problems.

LEVEL OF EVIDENCE

4.