Teledermatology: From historical perspective to emerging techniques of the modern era

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Solutions for Addressing the Dermatologist Shortage in Rural Canada: A Review of the Literature

In Canada, there is a maldistribution of dermatologists, with as many as 5.6 dermatologists per 100,000 population in urban areas and as low as 0.6 per 100,000 in rural areas. Considering trends of dermatologists to work in group practices in urban areas, and the low number of rural dermatologists, one solution may be to incentivize dermatologists to practice rurally. Several solutions using the following themes are discussed: dermatology program-specific incentives, dermatology practice-specific incentives, and other indirect incentives. The low number of dermatologists in rural areas in Canada is concerning and has negative consequences for access to care for patients in rural areas, ultimately resulting in worse patient outcomes. Future research is needed to evaluate the impact of these initiatives and assess future access to dermatological care.

The role of teledermatology in Mohs micrographic surgery: a review

This paper explores the role of teledermatology (TD) in Mohs micrographic surgery (MMS) at various stages of patient care. The study aims to assess the benefits, limitations, and patient experiences surrounding TD integration into MMS practices. We conducted a PubMed search using keywords related to TD and MMS, categorizing selected articles into pre-operative, intra-operative, and post-operative stages of MMS. TD reduced waiting times (26.10 days for TD compared to 60.57 days for face-to-face [FTF]) and consultation failure rates (6% for TD vs. 17% for FTF) for MMS preoperative consultations. It also shortened time to treatment by two weeks and led to notable travel savings (162.7 min, 144.5 miles, and $60.00 per person). Telepathology facilitated communication and decision-making during MMS, improving accuracy and efficiency, especially in challenging cases requiring collaboration where physical presence of another surgeon or pathologist is not feasible. Telepathology definitively diagnosed benign lesions and malignant tumors in 81.8% of cases (18/22). Additionally, there was a 95% agreement between conventional light microscopy diagnosis and telepathology in tumors (19/20), and 100% agreement for all 20 Mohs frozen section consultations. For post-operative follow-up, telephone follow-up (TFU) and text messaging proved effective, cost-efficient alternatives with high patient satisfaction (94% in New Zealand and 96% in the U.K.) and early complication identification. This study underscores TD's multifaceted benefits in MMS: enhanced patient experience preoperatively, improved communication during surgery, and cost-effective postoperative follow-up. Limitations include the financial expense and technical issues that can arise with TD (connectivity problems, delays in video/audio transmission, etc.). Further studies are needed to explore emerging TD modalities in post-operative patient management. The integration of TD into MMS signifies a progressive step in dermatological care, offering convenient, cost-effective, and better solutions with the potential to enhance patient experiences and outcomes.

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

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

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.

Teledermatology Evaluation and Feedback Systems: A Tool for Improving Care

Chile is a country where teledermatology has been growing exponentially since the implementation of a single national asynchronous teledermatology platform for the public system in December 2018. To ensure the quality of care in teledermatology systems, it is crucial to evaluate the fulfillment of basic specifiers such as ICD-Diagnosis, therapeutic suggestions, and diagnostic suggestions, among others. This article aims to evaluate the teledermatology system of the Chilean public health service by analyzing 243 randomly extracted consultations, representative of the 20,716 electronic consultations performed during 2020. Compliance with basic specifiers is evaluated. From these, fulfillment of core teledermatology functions, such as diagnostic and therapeutic suggestions, is observed in most consultations. There are statistically significant relationships between the patient's destination (primary health center [PHC] or face-to-face referral), pharmacological prescription, coverage of the drug prescribed by the public system, and the education received by the consulting physician. If the consultation is resolved in the PHC, there is a higher chance for pharmacological prescription, prescribing mostly drugs that are covered by the government. This is less likely to occur when patients are referred for face-to-face evaluation. A targeted evaluation of education, pharmacological prescriptions, and their applicability is key to improving the quality of teledermatology systems.

A Call to Action: Evidence for the Military Integration of Teledermoscopy in a Pandemic Era

Skin disease remains a common complaint among deployed service members. To mitigate the limited supply of dermatologists in the U.S. Military Health System, teledermatology has been harnessed as a specialist extender platform, allowing for online consultations in remote deployed settings. Operational teledermatology has played a critical role in reductions of medical evacuations with significant cost-savings. When direct in-person lesion visualization is unattainable, teledermoscopy can be harnessed as an effective diagnostic tool to distinguish suspicious skin lesions. Teledermoscopy has the versatile capacity for streamlined incorporation into the existing asynchronous telemedicine platforms utilized worldwide among deployed U.S. military healthcare providers. In terms of clinical utility, teledermoscopy offers a unique and timely opportunity to improve diagnostic accuracy, early detection rates, and prognostic courses for dermatological conditions. Such improvements will further reduce medical evacuations and separations, thereby improving mission readiness and combat effectiveness. As mission goals are safeguarded, associated operational budget costs are also preserved. This innovative, cost-effective technology merits integration into the U.S. Military Health System (MHS).

Expanding access to substance use services and mental health care for people with HIV in Alabama, a technology readiness assessment using a mixed methods approach

BACKGROUND

Alabama is one of seven priority states for the National Ending the HIV Epidemic Initiative due to a large rural burden of disease. Mental health (MH) and substance use disorders (SUD) represent obstacles to HIV care in rural areas lacking Medicaid expansion and infrastructure. Evidence-informed technologies, such as telehealth, may enhance SUD and MH services but remain understudied in rural regions.

METHODS

We conducted a readiness assessment using a mixed methods approach to explore opportunities for enhanced SUD and MH screening using electronic patient reported outcomes (ePROs) and telehealth at five Ryan White HIV/AIDS Program-funded clinics in AL. Clinic providers and staff from each site (N = 16) completed the Organizational Readiness to Implement Change (ORIC) assessment and interviews regarding existing services and readiness to change. People with HIV from each site (PLH, N = 18) completed surveys on the acceptability and accessibility of technology for healthcare.

RESULTS

Surveys and interviews revealed that all clinics screen for depression annually by use of the Patient Health Questionnaire-9 (PHQ9). SUD screening is less frequent and unstandardized. Telehealth is available at all sites, with three of the five sites beginning services due to the COVID-19 pandemic; however, telehealth for MH and SUD services is not standardized across sites. Results demonstrate an overall readiness to adopt standardized screenings and expand telehealth services beyond HIV services at clinics. There were several concerns including Wi-Fi access, staff capacity, and patients' technological literacy. A sample of 18 people with HIV (PWH), ages 18 to 65 years, participated in surveys; all demonstrated adequate technology literacy. A majority had accessed telehealth and were not concerned about it being too complicated or limiting communication. There were some concerns around lack of in-person interaction and lack of a physical exam and high-quality care with telehealth.

CONCLUSION

This study of PWH and the clinics that serve them reveals opportunities to expand SUD and MH services in rural regions using technology. Areas for improvement include implementing routine SUD screening, expanding telehealth while maintaining opportunities for in-person interaction, and using standardized ePROs that are completed by patients, in order to minimize stigma and bias.

Dermatology workforce over a decade in Saudi Arabia: demographics, distributions, and future challenges

BACKGROUND

The dermatology workforce is an important topic, as many countries are facing an undersupply of dermatologists, while some are expecting a surplus. Therefore, we conducted this study to identify the current dermatology workforce demographics in Saudi Arabia (SA) and the changes in such demographics over the last 10 years to identify future workforce-related challenges.

METHODS

This study was conducted in SA, and it included all the practicing dermatologists in the country over the last decade (2010-2020). The number of practicing dermatologists, their gender, their nationality, and dermatology residency candidates and graduates were obtained from the Saudi Commission for Health Specialties (SCFHS). The geographic distribution of dermatologists was obtained from the Ministry of Health Statistical Yearbook 2018.

RESULTS

As of September 2020, there were 2678 practicing dermatologists in SA at a ratio of 7.82 dermatologists per 100 000 people. Of the 2678 dermatologists, only 24.8% were Saudis. The Saudi dermatologist ratio has been almost constant over 10 years, ranging from 1.3 to 1.9 per 100 000 people. Of all Saudi dermatologists, 42% were female. The number of residents who graduated from the residency program was not consistent for each year and ranged from 4 to 25. The number of dermatologists varied by region, with 9.2 in Riyadh and 3.4 in Najran per 100 000 people.

CONCLUSIONS

The results of our study revealed that a quarter of dermatologists in SA are Saudis. In addition, the number of non-Saudi dermatologists has increased in the last 10 years, while the number of Saudi dermatologists to the population has remained almost constant. There is also a geographic maldistribution of dermatologists, with urban areas having a higher number of dermatologists than rural areas. We encourage local studies that can elucidate the factors influencing the workforce, such as the dermatologist appointment waiting time, dermatologists' working hours, and the geographic maldistribution of dermatologists in the country.

On the timing and probability of Presurgical Teledermatology: how it becomes the dominant strategy

Health level fluctuations make the outcome of any treatment option uncertain, so that decision-makers might have to wait for more information before optimally choosing treatments, especially when time spent in treatment cannot be fully recovered later in terms of health outcome. To examine whether or not, and when decision-makers should use presurgical teledermatology, a dynamic stochastic model is applied to patients waiting for dermatology surgical intervention. The theoretical model suggests that health uncertainty discourages using teledermatology. As teledermatology becomes less cost competitive, the uncertainty becomes more dominant. The results of the model were then tested empirically with the teledermatology network covering the area served by one Portuguese regional hospital, which links the primary care centers of 24 health districts with the hospital's dermatology department via the corporate intranet of the Portuguese healthcare system. Under uncertainty and irreversibility, presurgical teledermatology becomes the dominant strategy for younger patients and with lower probability of developing skin cancer.

The Role in Teledermoscopy of an Inexpensive and Easy-to-Use Smartphone Device for the Classification of Three Types of Skin Lesions Using Convolutional Neural Networks

Background. The use of teledermatology has spread over the last years, especially during the recent SARS-Cov-2 pandemic. Teledermoscopy, an extension of teledermatology, consists of consulting dermoscopic images, also transmitted through smartphones, to remotely diagnose skin tumors or other dermatological diseases. The purpose of this work was to verify the diagnostic validity of images acquired with an inexpensive smartphone microscope (Nurugo^TM), employing convolutional neural networks (CNN) to classify malignant melanoma (MM), melanocytic nevus (MN), and seborrheic keratosis (SK). Methods. The CNN, trained with 600 dermatoscopic images from the ISIC (International Skin Imaging Collaboration) archive, was tested on three test sets: ISIC images, images acquired with the Nurugo^TM, and images acquired with a conventional dermatoscope. Results. The results obtained, although with some limitations due to the smartphone device and small data set, were encouraging, showing comparable results to the clinical dermatoscope and up to 80% accuracy (out of 10 images, two were misclassified) using the Nurugo^TM demonstrating how an amateur device can be used with reasonable levels of diagnostic accuracy. Conclusion. Considering the low cost and the ease of use, the Nurugo^TM device could be a useful tool for general practitioners (GPs) to perform the first triage of skin lesions, aiding the selection of lesions that require a face-to-face consultation with dermatologists.

The utility of teledermatology in the evaluation of skin lesions

INTRODUCTION

Past studies have shown mixed results about the accuracy of store-and-forward (SAF) teledermatology in the evaluation of skin lesions. The objective of this study is to determine the accuracy of SAF teledermatology in the diagnosis of skin lesions and biopsy decision compared to in-person clinical evaluation.

METHODS

Histories and photographs of skin lesions gathered at clinic visits were sent as SAF consults to teledermatologists, whose diagnoses and biopsy decisions were recorded and compared statistically to the clinic data.Results and Discussion: We enrolled 206 patients with 308 lesions in the study. The study population was composed of 50% males (n = 104), and most patients were white (n = 179, 87%) and not Hispanic/Latino (n = 167, 81%). There was good concordance for biopsy decision between the clinic dermatologist (CD) and teledermatologist (TD) (Cohen's kappa (κ) = 0.51), which did not significantly differ when melanocytic lesions were excluded (κ = 0.54). The sensitivity and specificity of teledermatology based on biopsy decision was 0.71 and 0.85, respectively. Overall concordance in first diagnosis between the CD and TD was good (κ = 0.60). While there was no difference between CD and TD in proportion of correct diagnoses compared to histopathology, two skin cancers presentations were missed by TD. Study limitations included sample size, enrolment bias and differing amounts of teledermatologist case experience. Teledermatology has good concordance in diagnosis and biopsy decision when compared to clinic dermatology. Teledermatology may be utilized in the evaluation of skin lesions to expand access to dermatologic care.

Value of Teledermoscopy in Primary Healthcare Centers: Preliminary Results of the TELESPOT Project in Belgium

INTRODUCTION

Teledermoscopy using smartphone-based applications is becoming more and more important in a setting of increasing frequency of skin cancer and difficult access to specialized care. The TELESPOT project aimed to provide rapid diagnosis and speed up patient flow between primary healthcare centers and a tertiary care center in Belgium. The aim of the present study is to describe the development of an in-house smartphone-based dermoscopy application, evaluate its real-life value in a series of primary healthcare centers, and present preliminary diagnostic data.

METHODS

Modified Likert scales were used to assess patient and general practitioner (GP) satisfaction rates for the system. Furthermore, a total of 105 photographic and dermoscopic images were acquired in a series of 80 patients at participating centers.

RESULTS

Overall, patient and GP satisfaction levels were 89% and 94%, respectively. High-priority management was recommended in 7.6% of cases (8/105: 3 basal cell carcinoma, 1 primary cutaneous B-cell lymphoma, 1 Spitz melanocytic nevus, 1 congenital nevus, 1 in situ melanoma, and 1 invasive melanoma, proven by histology).

CONCLUSIONS

The primary healthcare centers were highly satisfied with the TELESPOT project in terms of user-friendliness, efficacy, and reliability as well as in providing a reinforced image of first-line medicine efforts in combating skin cancer.

Metrology and sensors as dermo-cosmetic technology opportunities for a change of paradigm

OBJECTIVE

Metrology and measures are changing the way patients and consumers behave and help find new, more effective solutions.

METHODS

This Review and Prospective Paper identifies applications in the field of dermatology and beauty tech.

RESULTS

The review of skincare as well as dermatological applications and analysis provides a comprehensive picture of the dynamics in the process of impacting the complete value chain in the field of dermo-cosmetics, as well as the opportunities offered by a strict approach around new and innovative measures, especially in the field of better patient/consumer knowledge, understanding, and personalized solution offering. It identifies the new business models or opportunities for the cosmetic industry.

CONCLUSION

Adapting metrology and measures to skincare is a significant opportunity to change the way things are done today.

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

Background

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

Objectives

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

Methods

A descriptive retrospective cohort study including 290 requests.

Results

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

Conclusions

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

Teledermatology: idea, benefits and risks of modern age - a systematic review based on melanoma

Telemedicine may be described as a modern technology supporting health care at a distance. Dermatology, as a visually-dependent specialty, is particularly suited for this kind of the health care model. This has been proven in a number of recent studies, which emphasized feasibility and reliability of teledermatology. Many patients in the world still do not have access to appropriate dermatological care, while skin cancers morbidity is on an upward trend. Technological development has enabled clinicians to care for diverse patient populations in need of skin expertise without increasing their overhead costs. Teledermatology has been used for various purposes: health care workers can use this technology to provide clinical services to patients, to monitor patient health, to consult with other health care providers and to provide patients with access to educational resources. It seems that teledermatology might be the answer to numerous issues concerning diagnosing, screening and managing cancers as well as pigmented skin lesions.

Automatic Extraction of Dermatological Parameters from Nevi Using an Inexpensive Smartphone Microscope: A Proof of Concept

The evolution of smartphone technology has made their use more common in dermatological applications. Here we studied the feasibility of using an inexpensive smartphone microscope for the extraction of dermatological parameters and compared the results obtained with a portable dermoscope, commonly used in clinical practice. Forty-two skin lesions were imaged with both devices and visually analyzed by an expert dermatologist. The presence of a reticular pattern was observed in 22 dermoscopic images, but only in 10 smartphone images. The proposed paradigm segments the image and extracts texture features which are used to train and validate a neural network to classify the presence of a reticular pattern. Using 5-fold cross-validation, an accuracy of 100% and 95% was obtained with the dermoscopic and smartphone images, respectively. This approach can be useful for general practitioners and as a triage tool for skin lesion analysis.

Comparison of Dermatologist Density Between Urban and Rural Counties in the United States

Importance

As the US population continues to increase and age, there is an unmet need for dermatologic care; therefore, it is important to identify and understand the characteristics and patterns of the dermatologist workforce.

Objective

To analyze the longitudinal dermatologist density and urban-rural disparities using a standardized classification scheme.

Design, Setting, and Participants

This study analyzed county-level data for 1995 to 2013 from the Area Health Resources File to evaluate the longitudinal trends and demographic and environmental factors associated with the geographic distribution of dermatologists.

Main Outcomes and Measures

Active US dermatologist and physician density.

Results

In this study of nationwide data on dermatologists, dermatologist density increased by 21% from 3.02 per 100 000 people to 3.65 per 100 000 people from 1995 to 2013; the gap between the density of dermatologists in urban and other areas increased from 2.63 to 3.06 in nonmetropolitan areas and from 3.41 to 4.03 in rural areas. The ratio of dermatologists older than 55 years to younger than 55 years increased 75% in nonmetropolitan and rural areas (from 0.32 to 0.56) and 170% in metropolitan areas (from 0.34 to 0.93). Dermatologists tended to be located in well-resourced, urban communities.

Conclusions and Relevance

Our findings suggest that substantial disparities in the geographic distribution of dermatologists exist and have been increasing with time. Correcting the workforce disparity is important for patient care.

Evaluation of Barriers to Telehealth Programs and Dermatological Care for American Indian Individuals in Rural Communities

Importance

Understanding geographic and financial barriers to health care is an important step toward creating more accessible health care systems. Yet, the barriers to dermatological care access for American Indian populations in rural areas have not been studied extensively.

Objective

To evaluate the driving distances and insurance coverage for dermatological care and the current availability of teledermatological programs within the Indian Health Service (IHS) or tribal hospitals system.

Design, Setting, and Participants

This mixed-methods study was conducted from May 7, 2018, to September 1, 2018, and did not take place in any IHS or tribal health care facility in the continental United States. The study design involved a geographic analysis and a cross-sectional telephone survey with brick-and-mortar dermatology clinics (n = 27) and teledermatological programs (n = 49). Brick-and-mortar clinics were selected for their proximity to a rural IHS or tribal hospital.

Main Outcomes and Measures

Mean driving distance from rural IHS or tribal hospital to nearest dermatology clinic, number of dermatology clinics within a 35-mile or 90-mile radius of IHS or tribal hospitals, insurance and referral types accepted by dermatology clinics, and number of teledermatological programs collaborating with IHS or tribal hospitals or health centers.

Results

In total, 27 brick-and-mortar dermatology clinics and 49 teledermatological programs were identified and contacted for the survey. The median (interquartile range [IQR]) driving distance between rural IHS or tribal hospitals and the nearest dermatology clinic was 68 (30-104) miles. Of the 27 dermatology clinics in closest proximity to rural IHS or tribal hospitals (median [IQR] driving distance, 82.4 [31-114] miles), 25 (93%) responded to the survey, 6 (22%) did not accept patients with Medicaid, and 6 (22%) did not accept IHS referrals for patients without insurance. Of the 49 teledermatological programs, 45 (92%) responded and 14 (29%) were no longer active. Ten (20%) teledermatology programs were currently partnering (n = 6), previously partnered (n = 2), or were setting up services (n = 2) with an IHS or tribal site. Only 9% (n = 27) of the 303 rural IHS or facility in the continental United States reported receiving teledermatological services.

Conclusions and Relevance

Substantial geographic and insurance coverage barriers to dermatological care exist for American Indian individuals in rural communities; teledermatological innovations could represent an important step toward minimizing the disparities in dermatological care access and outcomes.

Recent trends in teledermatology and teledermoscopy

Teledermatology is a useful alternative where specialized dermatological assistance is not available and has been used successfully to support health professionals in a wide range of settings worldwide, in either an asynchronous store-and-forward format or a real-time video conferencing format. Teledermoscopy, which includes dermoscopic images in the teleconsultation, is another addition that improves remote assessments of pigmented lesions. A more recent variant is mobile teledermoscopy, which uses a smartphone to deliver the same type of service.

Teledermoscopy’s greatest strength may be as a triage and monitoring tool, as it can reduce the number of unnecessary referrals, wait times, and the cost of providing and receiving dermatological care. While face-to-face (FTF) care remains the gold standard for diagnosis, drawbacks of not using FTF care as the primary method can be mitigated if teleconsultants are willing to refer to FTF care whenever there is uncertainty. Teledermatology has generally been well accepted by patients and practitioners alike.

Barriers to the large-scale use of teledermatology remain. Assigning medicolegal responsibility and instituting a reimbursement system are critical to promoting widespread use by medical professionals, while privacy and security features and a mechanism to link teleconsultations to patients’ existing health records are essential to maximize patient benefit. Direct-to-consumer services also need attention from regulators to ensure that consumers can enjoy the benefits of telemedicine without the dangers of unregulated or untested platforms.

Teledermatology and teledermatopathology as educational tools for international dermatology: a virtual grand rounds pilot curriculum

BACKGROUND

Teledermatology may improve dermatologic care access in underserved areas and expand the clinical experience of dermatologists-in-training. The potential for teledermatology to supplement global health curricula in dermatology residency education has not been explored.

METHODS

An international virtual grand rounds (VGR) curriculum was created based on teledermatology cases from Kabul, Afghanistan. The learning objectives included understanding the diagnosis and management of skin diseases in unfamiliar resource-limited settings and highlighting socioeconomic, cross-cultural, and ethical issues. A 17-item, Likert scale questionnaire was used to assess the effectiveness of the curriculum, including specific Accreditation Council for Graduate Medical Education (ACGME) competencies, as well as interest in global health and teledermatology.

RESULTS

The survey was completed by 85 of 118 VGR attendees (72% response rate). Most respondents considered the curriculum valuable to their education (mean 4.5 on a 5-point Likert scale; standard deviation, 0.5), learned more about diagnosis and treatment of skin diseases in international settings (4.5; 0.6) and in the US (4.1; 0.8), and learned more about socioeconomic, cultural, and ethical issues in skin health (4.6; 0.5). The majority also reported being more interested in global dermatology (4.1; 0.8) and would recommend VGR to a colleague (4.5; 0.6).

CONCLUSION

This pilot curriculum provided an innovative platform to enhance undergraduate and graduate medical education in international dermatology. International teledermatology education may be used to address multiple ACGME core competencies and increase resident awareness of sociocultural determinants of skin health.

Uses of Mobile Device Digital Photography of Dermatologic Conditions in Primary Care

BACKGROUND

PhotoExam is a mobile app that incorporates digital photographs into the electronic health record (EHR) using iPhone operating system (iOS, Apple Inc)-based mobile devices.

OBJECTIVE

The aim of this study was to describe usage patterns of PhotoExam in primary care and to assess clinician-level factors that influence the use of the PhotoExam app for teledermatology (TD) purposes.

METHODS

Retrospective record review of primary care patients who had one or more photos taken with the PhotoExam app between February 16, 2015 to February 29, 2016 were reviewed for 30-day outcomes for rates of dermatology consult request, mode of dermatology consultation (curbside phone consult, eConsult, and in-person consult), specialty and training level of clinician using the app, performance of skin biopsy, and final pathological diagnosis (benign vs malignant).

RESULTS

During the study period, there were 1139 photo sessions on 1059 unique patients. Of the 1139 sessions, 395 (34.68%) sessions documented dermatologist input in the EHR via dermatology curbside consultation, eConsult, and in-person dermatology consult. Clinicians utilized curbside phone consults preferentially over eConsults for TD. By clinician type, nurse practitioners (NPs) and physician assistants (PAs) were more likely to utilize the PhotoExam for TD as compared with physicians. By specialty type, pediatric clinicians were more likely to utilize the PhotoExam for TD as compared with family medicine and internal medicine clinicians. A total of 108 (9.5%) photo sessions had a biopsy performed of the photographed site. Of these, 46 biopsies (42.6%) were performed by a primary care clinician, and 27 (25.0%) biopsies were interpreted as a malignancy. Of the 27 biopsies that revealed malignant findings, 6 (22%) had a TD consultation before biopsy, and 10 (37%) of these biopsies were obtained by primary care clinicians.

CONCLUSIONS

Clinicians primarily used the PhotoExam for non-TD purposes. Nurse practitioners and PAs utilized the app for TD purposes more than physicians. Primary care clinicians requested curbside dermatology consults more frequently than dermatology eConsults.

Barriers and Facilitators to eHealth Use in Daily Practice: Perspectives of Patients and Professionals in Dermatology

BACKGROUND

The number of eHealth interventions in the management of chronic diseases such as atopic dermatitis (AD) is growing. Despite promising results, the implementation and use of these interventions is limited.

OBJECTIVES

This study aimed to assess opinions of the most important stakeholders influencing the implementation and use of eHealth services in daily dermatology practice.

METHODS

The perspectives of health care professionals and patients towards the implementation and use of eHealth services in daily practice were assessed by using a mixed method design. A cross-sectional survey based on the eHealth implementation toolkit (eHit) was conducted to explore factors influencing the adoption of eHealth interventions offering the possibility of e-consultations, Web-based monitoring, and Web-based self-management training among dermatologists and dermatology nurses. The perspectives of patients with atopic dermatitis (AD) regarding the use of eHealth services were discussed in an online focus group.

RESULTS

Health care professionals (n=99) and patients (n=9) acknowledged the value of eHealth services and were willing to use these digital tools in daily dermatology practice. Key identified barriers (statements with <50% of the participants scoring totally agree or agree) in the implementation and adoption of eHealth interventions included concerns about the availability (12/99, 12%) and allocation (14/99, 14%) of resources, financial aspects (26/99, 26%), reliability, security, and confidentially of the intervention itself (29/99, 29%), and the lack of education and training (6/99, 6%).

CONCLUSIONS

Health care professionals and patients acknowledge the benefits arising from the implementation and use of eHealth services in daily dermatology practice. However, some important barriers were identified that might be useful in addressing the implementation strategy in order to enhance the implementation success of eHealth interventions in dermatology.

Teledermatology: An updated overview of clinical applications and reimbursement policies

Telemedicine is an emerging field in healthcare that provides services from different medical specialties to patients all around the world. One of the specialties in telemedicine, teledermatology, has grown exponentially as a cost-effective way to implement dermatological healthcare to underserved areas and populations. This article reviews the literature that pertains to the cost-effectiveness, reliability, public access, patient satisfaction, and reimbursement policies of teledermatology. Teledermatology was found to be cost-effective and reliable in reducing in-person visits and time away from work, and allows for the faster delivery of care. However, reimbursement policies for teledermatology services are rather new and vary significantly from state to state. As public interest in and access to teledermatology continue to grow, the future of teledermatology depends on the development of new technology as well as quality improvement strategies and the evolution of sustainable reimbursement policies.

Telediagnosis with Confocal Microscopy: A Reality or a Dream?

Reflectance confocal microscopy (RCM) is becoming more popular among dermatologists aiming to improve their bedside diagnostic accuracy and reduce unnecessary removal of benign cutaneous lesions. With increased interest in the field, limitation of experts, and dedicated training programs, telemedicine application to RCM (teleconfocal) helps to connect patients with experts at a distance. Diagnostic accuracy of store-and-forward telemedicine review of RCM images, patient safety, and cost-effectiveness are important considerations for proper acceptance and usage of the technology in the medical community.

What drives attitude towards telemedicine among families of pediatric patients? A survey

BACKGROUND

Telemedicine has been recognized as a way to improve accessibility, quality, and efficiency of care. In view of the introduction of new telemedicine services, we conducted a survey through a self-administered questionnaire among families of children attending the Bambino Gesù Children's Hospital IRCCS, a tertiary care children's hospital located in Rome, Italy.

METHODS

We investigated sociodemographic data, clinical information, technological profile, attitude towards telemedicine, perceived advantages of telemedicine, fears regarding telemedicine, willingness to use a smartphone app providing telemedicine services and willingness to use a televisit service. Through logistic regression, we explored the effect of sociodemographic and clinical variables and technological profile on willingness of using a telemedicine app and a televisit service.

RESULTS

We enrolled a total of 751 families. Most patients had a high technological profile, 81% had at least one account on a social network. Whatsapp was the most popular messaging service (76%). Seventy-two percent of patients would use an app for telemedicine services and 65% would perform a televisit. Owning a tablet was associated with both outcome variables - respectively: OR 2.216, 95% CI 1.358-3.616 (app) and OR 2.117, 95% CI 1.415-3.168 (televisit). Kind of hospitalization, diagnosis of a chronic disease, disease severity and distance from the health care center were not associated with the outcome variables.

CONCLUSION

Families of pediatric patients with different clinical problems are keen to embark in telemedicine programs, independently from severity of disease or chronicity, and of distance from the hospital.

Internet-based skin cancer screening using clinical images alone or in conjunction with dermoscopic images: A randomized teledermoscopy trial

BACKGROUND

Teledermoscopy involves the use of dermoscopic images for remote consultation and decision-making in skin cancer screening.

OBJECTIVE

We sought to analyze the potential benefits gained from the addition of dermoscopic images to an internet-based skin cancer screening system.

METHODS

A randomized clinical trial assessed the diagnostic performance and cost-effectiveness of clinical teleconsultations (CTC) and clinical with dermoscopic teleconsultations.

RESULTS

A total of 454 patients were enrolled in the trial (n_CTC = 226, n_{clinical with dermoscopic teleconsultation} = 228). Teledermoscopy improved sensitivity and specificity (92.86% and 96.24%, respectively) compared with CTC (86.57% and 72.33%, respectively). Correct decisions were made in 94.30% of patients through clinical with dermoscopic teleconsultations and in 79.20% in CTC (P < .001). The only variable associated with an increased likelihood of correct diagnosis was management using teledermoscopy (odds ratio 4.04; 95% confidence interval 2.02-8.09; P < .0001). The cost-effectiveness analysis showed teledermoscopy as the dominant strategy, with a lower cost-effectiveness ratio (65.13 vs 80.84).

LIMITATIONS

Potentially, a limitation is the establishment of an experienced dermatologist as the gold standard for the in-person evaluation.

CONCLUSIONS

The addition of dermoscopic images significantly improves the results of an internet-based skin cancer screening system, compared with screening systems based on clinical images alone.

Variation in dermatologist visits by sociodemographic characteristics

BACKGROUND

Access to dermatologists is an ongoing concern for Medicaid enrollees. Understanding current use is a key step toward designing and implementing policies to improve access.

OBJECTIVE

We sought to quantify how often Medicaid enrollees visit dermatologists and receive treatment for skin-related conditions compared with patients with other coverage or without health insurance.

METHODS

We conducted a retrospective cross-sectional analysis of multiyear federal survey data (Medical Expenditure Panel Survey). The sample included Medical Expenditure Panel Survey respondents younger than 65 years from 2008 to 2012.

RESULTS

In unadjusted comparisons, we found that 1.4% of Medicaid enrollees had an ambulatory visit to a dermatologist annually, compared with 1.2% of uninsured individuals and 5.5% of individuals with private coverage. In adjusted models, we found that health insurance source, age, sex, race/ethnicity, and geography are associated with the likelihood of having visits to a dermatologist. Compared with individuals with private coverage, Medicaid enrollees are less likely to receive a diagnosis for a skin condition by any provider and are less than half as likely to have skin-related diagnoses made by dermatologists.

LIMITATIONS

We have relatively few Medical Expenditure Panel Survey respondents for a subset of specific diagnoses.

CONCLUSIONS

Our findings emphasize the need for efforts to reduce disparities in access to dermatologists.

Aerospace Dermatology

Evolutionarily, man is a terrestrial mammal, adapted to land. Aviation and now space/microgravity environment, hence, pose new challenges to our physiology. Exposure to these changes affects the human body in acute and chronic settings. Since skin reflects our mental and physical well-being, any change/side effects of this environment shall be detected on the skin. Aerospace industry offers a unique environment with a blend of all possible occupational disorders, encompassing all systems of the body, particularly the skin. Aerospace dermatologists in the near future shall be called upon for their expertise as we continue to push human physiological boundaries with faster and more powerful military aircraft and look to colonize space stations and other planets. Microgravity living shall push dermatology into its next big leap-space, the final frontier. This article discusses the physiological effects of this environment on skin, effect of common dermatoses in aerospace environment, effect of microgravity on skin, and occupational hazards of this industry.

Improving Diagnostic Accuracy of Dermoscopically Equivocal Pink Cutaneous Lesions with Reflectance Confocal Microscopy in Telemedicine Settings: Double Reader Concordance Evaluation of 316 Cases

BACKGROUND

Solitary pink lesions in differential diagnosis with hypopigmented/amelanotic melanoma present a diagnostic challenge in daily practice and are regularly referred for second expert opinion. Reflectance confocal microscopy (RCM) has been shown to improve diagnostic accuracy of dermoscopically equivocal pink lesions. No studies have been performed to evaluate the effect of adding a second expert reader and automatic removal of lesions with discordant management recommendations and its potential effect on diagnostic sensitivity and final management of these lesions in retrospective or telemedicine settings.

OBJECTIVE

To improve diagnostic accuracy and reduce potential mismanagement of dermoscopically equivocal pink cutaneous lesions by implementing double reader concordance evaluation of RCM images.

METHODS

316 dermoscopically equivocal pink lesions with dermoscopy-RCM image sets were evaluated retrospectively. Accuracy of three readers was evaluated by single reader evaluation of dermoscopy only and dermoscopy-RCM image sets and finally by double reader evaluation of dermoscopy-RCM image sets. Lesions with discordant diagnosis between two readers were automatically recommended for excision.

RESULTS

Dermoscopy only evaluation resulted in an overall sensitivity of 95.9% and specificity of 33.6%, with 1 of 12 amelanotic melanomas mismanaged. Dermoscopy-RCM image set single reader evaluation resulted in an overall sensitivity of 93.9% and overall specificity of 54.2%, with 1 of 12 melanomas mismanaged. Dermoscopy-RCM image set double reader concordance evaluation resulted in an overall sensitivity of 98.3% and specificity of 42.7%, with no amelanotic melanoma mismanagement.

CONCLUSION

Evaluation of dermoscopy-RCM image sets of equivocal pink lesions by a single reader in telemedicine settings is limited by the potential for misdiagnosis of dangerous malignant lesions. Double reader concordance evaluation with automatic referral of lesions for removal in the case of discordant diagnosis improves the diagnostic sensitivity in this subset of lesions and reduce potential misdiagnosis in settings where a second expert opinion may be employed.

Smartphone patient monitoring post-laser resurfacing

BACKGROUND/OBJECTIVES

Patients should be monitored post-laser resurfacing for reassurance and the early detection of adverse events. Smartphone monitoring in the post-laser resurfacing setting is an efficient and convenient tool that is well accepted by patients and dermatologists. The objective was to identify the benefits and barriers of, and patient attitudes towards, smartphone monitoring in the post-laser resurfacing setting.

METHODS

A retrospective audit of 123 laser resurfacing patients was undertaken to determine the characteristics of this population. A web-based survey was used to determine patients' attitudes towards smartphone monitoring.

RESULTS

The commonest indications for laser resurfacing were acne scarring and photoageing rejuvenation. 88% of patients either had no adverse outcomes or expected post-laser resurfacing side-effects such as erythema. 12% developed adverse effects requiring intervention. The survey showed that all patients who had used the smartphone monitoring service felt it was a positive initiative for post-laser patients. Of note, most patients not using the smartphone review service were simply unaware of its existence. Biases may have been introduced as staff were less likely to promote the review service to patients undergoing lower intensity procedures.

CONCLUSIONS

Smartphone monitoring post-laser resurfacing is an efficient and convenient alternative to face-to-face review for both patients and dermatologists. As technology improves and patients' expectations increase we expect more patients will request teledermatology reviews in order to easily and rapidly access medical advice.

Two Decades of Teledermatology: Current Status and Integration in National Healthcare Systems

Teledermatology, originating in 1995, has been one of the first telemedicine services to see the light of day. Two decades of teledermatology research is summarized in this review. A literature search was conducted in PubMed. Search terms included “teledermatology,” “teledermoscopy,” “tele wound care,” “telederm*,” “(dermatology OR dermoscopy OR wound care OR skin) AND (telemedicine OR ehealth or mhealth OR telecare OR teledermatology OR teledermoscopy).” Inclusion criteria were (i) Dutch or English written papers and (ii) publication year from 2011 to present or (iii) (systematic) reviews with publication year before 2011. One hundred fourteen publications and 14 (systematic) reviews were included for full text reading. Focus of this review is on the following outcomes: (i) actors (primary, secondary, tertiary), (ii) purposes (consultation, triage, follow-up, education) and subspecialties (tele-wound care, burn care, teledermoscopy (teledermatoscopy), teledermatopathology, and mobile teledermatology), (iii) delivery modalities and technologies (store and forward, real-time interactive, and hybrid modalities using web-based systems, email, mobile phones, tablets, or videoconferencing equipment), (iv) business models, (v) integration of teledermatology into national healthcare systems, (vi) preconditions and requirements for implementation (security, ethical issues, responsibility, reimbursement, user satisfaction, technique, and technology standards), and (vii) added value.

To conclude, teledermatology is an efficient and effective healthcare service compared to in-person care. Teledermatology reduces patients’ travel time and waiting time, avoids (unnecessary) dermatologic visits, and improves access of care to underserved patients.

The growth of a skin emergency teledermatology service from 2008 to 2014

OBJECTIVE

To conduct an audit of the Skin Emergency Telemedicine Service at Princess Alexandra Hospital in Brisbane from January to December 2014, and determine whether there has been any change in the number, type and location of referrals.

METHODS

Retrospective analyses of referrals to the teledermatology service were conducted and compared with the 2012 audit. Main outcomes assessed included the number of referrals, referral site location, telediagnosis categories, image characteristics and response times.

RESULTS

In 2014, 318 cases were referred to the teledermatology service. The highest number of cases (n = 140) were referred from Princess Alexandra Hospital and Queen Elizabeth II Jubilee Hospital emergency departments. However, referrals to the teledermatology service came from as far as 1600 km distant from Brisbane. The most common provisional telediagnoses were dermatitis or eczema, skin infection or drug eruption. Over half of all referrals (62%) received a response within 3 h and a further 20% were responded to within 3-6 h. Almost half all referring doctors (48%) attached very large image files (> 500 kb) to their referral.

CONCLUSIONS

The Skin Emergency Telemedicine Service has proved to be a successful, sustainable and valuable addition to the specialist dermatology services provided across Queensland. With adequate funding and resources and appropriate attention to ethical and legal considerations, our service could significantly change the management of Queenslanders with acute skin conditions.

The acceptance of mobile teledermoscopy by primary care nurse practitioners in the state of Arizona

PURPOSE

To conduct a pilot survey to assess acceptance of mobile teledermoscopy (MTD) by primary care nurse practitioners (NPs) working in Arizona.

DATA SOURCES

Sixty-two participants recruited from NP and academic listservs in Arizona completed an online survey prefaced by a MTD definition, device photographs, and a practice case, followed by 33 items measuring Teledermatology Technology Acceptance Model (TeleTAM) constructs.

CONCLUSIONS

Participants were highly interested in using MTD to assess skin lesions. They perceived MTD utility to greatly improve diagnosis and positively impact their practice. Most participants had never used MTD, but had high mean scores for MTD attitude and moderate scores for MTD perceived ease of use, perceived use, and facilitators of MTD. They had moderate scores for intention to use MTD. The construct facilitators (organizational infrastructure) were most strongly associated with intention to use MTD. Cronbach alphas were 0.70 or higher for all subscales except compatibility and habit.

IMPLICATIONS FOR PRACTICE

Moderate acceptance of MTD may reflect NPs' knowledge of the technology, self-confidence for using it, or MTD financial constraints. Future research will address these factors to foster use of MTD by NPs, thereby improving patients' access to early skin lesion assessment and diagnosis.