Reliability and accuracy of dermatologists' clinic-based and digital image consultations

From diagnosis to intervention: a review of telemedicine's role in skin cancer care

Skin cancer treatment is a core aspect of dermatology that relies on accurate diagnosis and timely interventions. Teledermatology has emerged as a valuable asset across various stages of skin cancer care including triage, diagnosis, management, and surgical consultation. With the integration of traditional dermoscopy and store-and-forward technology, teledermatology facilitates the swift sharing of high-resolution images of suspicious skin lesions with consulting dermatologists all-over. Both live video conference and store-and-forward formats have played a pivotal role in bridging the care access gap between geographically isolated patients and dermatology providers. Notably, teledermatology demonstrates diagnostic accuracy rates that are often comparable to those achieved through traditional face-to-face consultations, underscoring its robust clinical utility. Technological advancements like artificial intelligence and reflectance confocal microscopy continue to enhance image quality and hold potential for increasing the diagnostic accuracy of virtual dermatologic care. While teledermatology serves as a valuable clinical tool for all patient populations including pediatric patients, it is not intended to fully replace in-person procedures like Mohs surgery and other necessary interventions. Nevertheless, its role in facilitating the evaluation of skin malignancies is gaining recognition within the dermatologic community and fostering high approval rates from patients due to its practicality and ability to provide timely access to specialized care.

Evaluation of Synchronous and Asynchronous Telemedical Applications in Primary Care in Rural Regions of Northern Germany-Results and Lessons Learned from a Pilot Study

(1) Background: Telemedical applications (TAs) that are centered around General practitioners' (GP) practices could be beneficial for patients in rural areas in order to better their access to care. This could become more and more relevant as specialists favor practicing in more urban regions, leaving GPs as the first medical contact of patients in rural areas. (2) Methods: Three TAs, one synchronous, one asynchronous and one used in delegation were implemented and evaluated in ten GP practices and two specialists' practices in rural areas of northern Germany. (3) Results: Overall satisfaction with the TAs was generally high. GPs as well as specialists were especially satisfied with asynchronous TAs. A number of valuable "Lesson learned" were obtained and can be used as recommendations for further studies, e.g., taking time to identify market-ready technologies prior to implementation, developing dedicated trainings for users, and preparation of a technical support plan. Overall, the benefits of the TAs were rated high for the patients by the medical professionals. (4) Conclusion: Especially asynchronous TAs that are based on existing technology can be successfully implemented into a developing digital health care system such as the one in Germany. The impact on treatment of those TAs needs to be further investigated.

Concordance and Accuracy of Teledermatology Using Mobile Phones in the Outpatient Clinic of Jose R Reyes Memorial Medical Center: Cross-sectional Study

BACKGROUND

Dermatologists rely on visual findings; thus, teledermatology is uniquely compatible to providing dermatologic care. The use of mobile phones in a store-and-forward approach, where gathered data are sent to a distant health provider for later review, may be a potential bridge in seeking dermatologic care.

OBJECTIVE

This study aimed to determine the agreement between face-to-face consultations and teledermatologic consultations through the store-and-forward approach using mobile phones and its accuracy compared to a histopathologic diagnosis.

METHODS

The study design was a cross-sectional study of participants consecutively recruited from dermatology patients who presented with skin or mucosal complaint and without prior dermatologist consultation. Photographs were taken using a standard smartphone (iPhone 6s Plus), and a 4-mm skin punch biopsy was taken on each patient-the gold standard to which the study result was compared to. The photographs were sent to 3 consultant dermatologists using a store-and-forward approach, for independent diagnosis and treatment plan.

RESULTS

A total of 60 patients were included, with a median age of 41 years. There was moderate-to-almost perfect agreement in terms of final diagnosis between the face-to-face dermatologic diagnosis and teledermatologic diagnoses. The third teledermatologist had the highest agreement with the clinical dermatologist in terms of final diagnosis (κ=0.84; P<.001). Among the 3 dermatologists, there was moderate-to-almost perfect agreement as well. Agreement between pairs of teledermatologists ranged from 0.45 to 0.84. The 3 teledermatologists had moderate-to-substantial agreement with the biopsy results, with the third teledermatologist having the highest accuracy (κ=0.77; P<.001). Overall, there was a moderate agreement in the diagnosis of patients across raters.

CONCLUSIONS

Teledermatology is a viable alternative to face-to-face consultations. Our results show moderate-to-substantial agreement in diagnoses from a face-to-face consultation and store-and-forward teledermatology.

Teledermatologie: Fluch oder Segen?

Teledermatologische Dienste haben sich insbesondere während der COVID-19-Pandemie als Alternative zu „Echt“visiten verbreitet. Der Mangel an Dermatologen und die Möglichkeit einer präzisen Diagnose auch bei unterversorgten Regionen macht diese Alternative für alle Beteiligten besonders attraktiv. Trotzdem ist der Bedarf an Schulungen des Personals und der Anwender hoch. Ebenfalls können Implementierungs-, Instandhaltungs- und Wartungskosten der notwendigen Ausrüstung und die Heterogenität der unterschiedlichen Anbieter nachteilig für Patient und Arzt sein. In diesem Artikel werden wesentliche Vorteile und Nachteile der Teledermatologie zusammengefasst.

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.

Diagnostic Reliability of In-Person Versus Remote Dermatology: A Meta-Analysis

Background:Studies comparing teledermatology with in-person dermatologists report wide variations in diagnostic agreement. Teledermatology studies should have two independent in-person consultations establishing a baseline for comparing diagnoses made face-to-face and those made remotely.Objective:To perform a meta-analysis of comparison studies having two in-person dermatologists and at least one remote dermatologist examining the same patients to determine the overall preponderance of agreement.Method:Studies having two in-person diagnosticians were identified from previous teledermatology research reviews and independent searches of PubMed and other databases. Data from six studies identified were meta-analyzed.Results:Some studies showed high levels of diagnostic concordance, while others did not. Meta-analysis revealed that concordance rates reported in the teledermatology and clinical (in-person) consultations were significantly different (odds ratio = 0.55 [Mantel-Haenszel, fixed effect model, 95% confidence interval = 0.42-0.72], χ2 = 11.87, p < 0.05, I2 = 58%). Overall results showed that in-person primary diagnoses are significantly more concordant than remote. The results also suggest that diagnoses made in-person and teledermatology were marginally but significantly different than remote.Conclusion:Although the results of this study suggest teledermatology diagnoses are less reliable than those in-person, there are still valid reasons for using teledermatology to improve access, reduce costs, and triage patients to determine those warranting further in-person consultation and/or laboratory tests. More caution should be exercised in teledermatology when diagnoses involve risky skin conditions. There is evidence that this happens in practice.

Use of teledermatology by dermatology hospitalists is effective in the diagnosis and management of inpatient disease

Background

Patient outcomes are improved when dermatologists provide inpatient consults. Inpatient access to dermatologists is limited, illustrating an opportunity to utilize teledermatology. Little is known about the ability of dermatologists to accurately diagnose and manage inpatients using teledermatology, particularly utilizing non-dermatologist generated clinical data.

Methods

This prospective study assessed the ability of teledermatology to diagnose and manage 41 dermatology consults from a large urban tertiary care center utilizing internal medicine referral documentation and photos. Twenty-seven dermatology hospitalists were surveyed. Interrater agreement was assessed by the kappa statistic.

Results

There was substantial agreement between in-person and teledermatology assessment of the diagnosis with differential diagnosis (median kappa = 0.83), substantial agreement in laboratory work-up decisions (median kappa = 0.67), almost perfect agreement in imaging decisions (median kappa = 1.0), and moderate agreement in biopsy decisions (median kappa = 0.43). There was almost perfect agreement in treatment (median kappa = 1.0), but no agreement in follow-up planning (median kappa = 0.0). There was no association between raw photo quality and the primary plus differential diagnosis or primary diagnosis alone.

Limitations

Selection bias and single-center nature.

Conclusions

Teledermatology may be effective in the inpatient setting, with concordant diagnosis, evaluation, and management decisions.

[Teleconsultation for vascular- and diabetes-associated chronic wounds : A systematic review of health-related and economic implications]

BACKGROUND

In addition to lowering the quality of life of those affected, long periods of treatment and high recurrence rates of chronic wounds cause major economic costs for health care systems. Furthermore, inadequate health care and undersupply of care can be observed in Germany. Thus, new forms of care such as teleconsultation are being discussed increasingly. Recent changes in the remuneration system and macerations in the ban of remote treatment support those trends.

METHODS

A systematic review was conducted in July 2018 using PubMed and CENTRAL databases for randomized controlled trials between 2008 and 2018. Only randomized clinical trials in which patients with chronic wound who received treatment and follow-up by teleconsultation using information and communication technology to share data were included. In total, 6 international clinical trials were identified.

RESULTS

Regarding the current state of research, there is no definite evidence that teleconsultation can improve the care of chronic wound patients. Most likely, wound healing time was positively influenced. No correlation was found between mortality and hospitalizations when teleconsultation was used.

CONCLUSION

On the basis of the included studies, the evidence for the care of chronic wounds by teleconsultation is unclear. Further research is needed to examine the health-related and economic benefits of teleconsultation to support integration into health care systems.

A 14-year review of a UK teledermatology service: experience of over 40 000 teleconsultations

BACKGROUND

There is a paucity of published evidence of established teledermatology (TD) services in the UK. An in-house TD service using store-and-forward technology was set up at a large regional dermatology department in 2004.

AIM

To review the TD service at our centre, including teleconsultation numbers, coding of diagnoses and patient outcomes.

METHODS

Retrospective data were retrieved using the electronic patient database, from 31 July 2004 to 31 July 2018. More detailed information on patient outcomes was obtained from patient notes and histology records. A paper questionnaire was distributed to 100 patients to obtain patient feedback.

RESULTS

In total, 40 201 teleconsultations were made over 14 years, and 64% of cases were coded (n = 25 555), of which 77% were lesions. The most common coded lesions were benign naevus (25%), seborrhoeic keratosis (22%) and basal cell carcinoma (19%). Of the total number of cases, 50% were discharged to their general practitioner with advice, 34% were booked for surgery and 16% were booked for a face-to-face appointment. In the survey, 82% of patients surveyed felt that the service was 'good' or 'very good'. A detailed study between 1 January 2015 and 1 January 2016 showed that there were 383 patients (10%) with no diagnosis made following teleconsultation, suggesting diagnostic uncertainty. Reasons for this included lack of diagnostic features, possibility of malignancy and service factors. Within this cohort, there was 68% diagnostic concordance.

CONCLUSIONS

We have set up a successful TD service at a UK centre, which has prevented 16 282 face-to-face appointments over 14 years. Patient feedback has been very good. Review of cases with diagnostic uncertainty provides important information for service improvement and has not previously been documented.

Teledermatology for diagnosing skin cancer in adults

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Improving cooperation between general practitioners and dermatologists via telemedicine: study protocol of the cluster-randomized controlled TeleDerm study

BACKGROUND

Internationally, teledermatology has proven to be a viable alternative to conventional physical referrals. Travel cost and referral times are reduced while patient safety is preserved. Especially patients from rural areas benefit from this healthcare innovation. Despite these established facts and positive experiences from EU neighboring countries like the Netherlands or the United Kingdom, Germany has not yet implemented store-and-forward teledermatology in routine care.

METHODS

The TeleDerm study will implement and evaluate store-and-forward teledermatology in 50 general practitioner (GP) practices as an alternative to conventional referrals. TeleDerm aims to confirm that the possibility of store-and-forward teledermatology in GP practices is going to lead to a 15% (n = 260) reduction in referrals in the intervention arm. The study uses a cluster-randomized controlled trial design. Randomization is planned for the cluster "county". The main observational unit is the GP practice. Poisson distribution of referrals is assumed. The evaluation of secondary outcomes like acceptance, enablers and barriers uses a mixed-methods design with questionnaires and interviews.

DISCUSSION

Due to the heterogeneity of GP practice organization, patient management software, information technology service providers, GP personal technical affinity and training, we expect several challenges in implementing teledermatology in German GP routine care. Therefore, we plan to recruit 30% more GPs than required by the power calculation. The implementation design and accompanying evaluation is expected to deliver vital insights into the specifics of implementing telemedicine in German routine care.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00012944 . Registered prospectively on 31 August 2017.

Teledermatology: A Review and Update

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

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

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

Comparing High Definition Live Interactive and Store-and-Forward Consultations to In-Person Examinations

BACKGROUND

There is little teledermatology research directly comparing remote methods, even less research with two in-person dermatologist agreement providing a baseline for comparing remote methods, and no research using high definition video as a live interactive method.

OBJECTIVE

To compare in-person consultations with store-and-forward and live interactive methods, the latter having two levels of image quality.

METHODS

A controlled study was conducted where patients were examined in-person, by high definition video, and by store-and-forward methods. The order patients experienced methods and residents assigned methods rotated, although an attending always saw patients in-person. The type of high definition video employed, lower resolution compressed or higher resolution uncompressed, was alternated between clinics. Primary and differential diagnoses, biopsy recommendations, and diagnostic and biopsy confidence ratings were recorded.

RESULTS

Concordance and confidence were significantly better for in-person versus remote methods and biopsy recommendations were lower. Store-and-forward and higher resolution uncompressed video results were similar and better than those for lower resolution compressed video.

LIMITATIONS

Dermatology residents took store-and-forward photos and their quality was likely superior to those normally taken in practice. There were variations in expertise between the attending and second and third year residents.

CONCLUSION

The superiority of in-person consultations suggests the tendencies to order more biopsies or still see patients in-person are often justified in teledermatology and that high resolution uncompressed video can close the resolution gap between store-and-forward and live interactive methods.

Potential effect of patient-assisted teledermatology on outpatient referral rates

We carried out a pilot study on the feasibility and accuracy of store-and-forward teledermatology based on patient-provided images and history as a triage tool for outpatient consultation. Patients referred by their general practitioner provided a history and images via the Internet. The information was reviewed by one of 12 teledermatologists and the patient then visited a different dermatologist in person within two days. Three independent dermatologists compared the remote and in-person diagnoses in random order to determine diagnostic agreement. Broader agreement was also measured, by comparing the main disease groups into which the two diagnoses fell. The teledermatologists indicated whether an in-person consultation or further investigations were necessary. There were 105 eligible patients, aged four months to 72 years, who were willing to participate. For the 96 cases included in the analysis, complete diagnostic agreement was found in 41% ( n= 39), partial diagnostic agreement in 10% ( n= 10) and no agreement in 49% ( n= 47). There was disease group agreement in 66% of cases ( n= 63). Nearly a quarter (23%) of participating patients could have safely been managed without an in-person visit to a dermatologist.

Practice Guidelines for Teledermatology

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

The Utility of Digital Clinical Photographs in Dermatopathology

Background and Objective:

Technological improvements have helped digital cameras become widely available and inexpensive. Dermatopathologic diagnosis is often aided by clinical information. The purpose of this study was to determine whether submitting a digital image along with a skin biopsy provides additional helpful information to the dermatopathologist.

Methods:

Digital pictures were taken of the lesion being biopsied and were submitted along with routine paper work to the dermatopathologists. The dermatopathologists interpreted the skin biopsy as usual without viewing the digital image, and then later viewed the submitted picture. The dermatopathologists evaluated the help provided by the image.

Results:

A clinical digital image was helpful in confirming the initial diagnosis and narrowing down the differential diagnosis ( p < 0.001). Including pictures did not change the diagnosis, result in an increase in the differential diagnosis, or result in fewer or additional step sections being performed. Digital imaging of inflammatory disorders was felt to be good help in 43 % of the biopsies and narrowed down the differential diagnosis in 31%.

Conclusion:

In certain cases the inclusion of a digital image may help a dermatopathologist. Digital imaging was found to be most helpful in evaluation of inflammatory disorders.

Teledermatology in New Zealand

Background:

Teledermatology is the delivery of specialist dermatological services at a distance. It has become possible because of technological advances in digital imaging and telecommunications. Consultations may be “interactive” using video-conferencing equipment or “store-and-forward” using prerecorded text and images. The best method to deliver teledermatology services is unknown.

Objective:

Studies were designed to determine (a) if it was possible to diagnose and manage skin diseases using video-conferencing equipment, (b) if teledermatology was acceptable to patients and medical practitioners, and (c) whether it offered any economic advantages. We have also compared interactive and store-and-forward techniques.

Method:

The trials were conducted in collaboration with the Institute of Telemedicine & Telecare, Queen's University, Belfast, as part of the UK Teledermatology Trials.

Remits:

The trials have involved more than 300 teledermatology consultations. Having established that a diagnosis can be made in more than two-thirds of the cases, the majority of video consultations have resulted in satisfactory management, with only small numbers of patients requiring face-to-face review. Teledermatology is generally popular with patients and can save them considerable time and money. Routine clinics continue in three centers. We have found that effective store-and-forward teledermatology requires very good images and comprehensive historical referral data.

Stakeholders’ experience of teledermatology in a nurse-led community clinic: a case study

Dermatology is regarded as especially suitable for the application of telemedicine because it relies to a large extent on visual information for diagnosis and holds promise as an alternative means of delivering healthcare. Interest in teledermatology has come at a time when there is an increased demand for dermatological services and has been advocated as a mode of delivery that may diminish inequalities in the provision of an overstretched service and improve access to dermatological care. A qualitative case study based on interviews and observations was undertaken to explore the perceptions of stakeholders (nurses, patients, GPs, consultants) when interacting with a nurse-led teledermatology service in primary care. The study found that the delineation of roles and changing professional boundaries were important issues for stakeholders. It has provided further evidence that teledermatology is more than images and diagnostics.

Interobserver reliability of teledermatology across all Fitzpatrick skin types

Introduction Demand for dermatologic services in safety net hospitals, which disproportionately serve patients with darker coloured skin, is growing. Teledermatology has the potential to increase access and improve outcomes, but studies have yet to demonstrate the reliability of teledermatology for all Fitzpatrick skin types. Methods We assessed the reliability of teledermatologists' diagnoses and management recommendations for store-and-forward teledermatology in patients with lightly pigmented (Fitzpatrick skin types I-III) versus darkly pigmented (Fitzpatrick skin types IV-VI) skin, when compared to in-person diagnosis and management decisions. This prospective study enrolled 232 adult patients, presenting with new, visible skin complaints in a Los Angeles county dermatology clinic. Forty-seven percent of patients were Fitzpatrick skin types I-III, and 53% were Fitzpatrick skin types IV-VI. Results Percent concordance for the identical primary diagnosis was 53.2% in lighter (Fitzpatrick I-III) skin types and 56.0% in darker (Fitzpatrick IV-VI) skin types. There was no statistically significant difference in concordance rates between lighter and darker skin types for primary diagnosis. Concordance rates for diagnostic testing, clinic-based therapy, and treatments were similar in both groups of Fitzpatrick skin types. Discussion These results suggest that teledermatology is reliable for the diagnosis and management of patients with all Fitzpatrick skin types.

Teledermatology

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

Teledermatology consultation using a smartphone multimedia messaging service for common skin diseases in the Korean army: a clinical evaluation of its diagnostic accuracy

Summary

We evaluated the diagnostic accuracy of teleconsultations for skin diseases common in the army using a smartphone multimedia messaging service (MMS). Images of skin lesions were obtained from 100 army patients using digital cameras built into smartphones. Three remotely located dermatologists received the dermatology images and associated clinical information via the MMS. The teledermatologists’ diagnoses were compared with those obtained from face-to-face examinations. The three most common diagnoses made at the dermatology clinics were eczema, viral warts and fungal infections. The mean diagnostic agreement between face-to-face and teledermatology consultations was 71% (SD 2). The mean kappa coefficient was 0.73 (SD 0.06) for the three most common diagnostic categories. The mean values for sensitivity were 78% (SD 0), 88% (SD 21) and 61% (SD 11) for eczema, viral warts and fungal infections, respectively, and the specificity values were above 90% for these skin diseases. Teledermatology consultation using smartphones is simple. Although diagnoses using telemedicine do not perfectly match diagnoses from face-to-face consultations the diagnostic accuracy using smartphones is superior to that of clinicians who are not specialized in dermatology.

Clinical Course Outcomes for Store and Forward Teledermatology Versus Conventional Consultation: A Randomized Trial

We assessed the clinical course of patients after store and forward teledermatology in comparison with conventional consultations. Patients being referred from primary care to dermatology clinics were randomly assigned to teledermatology or a conventional consultation. A total of 392 patients were randomized; 261 patients completed the study and were included in the analysis. Their clinical course was rated on a five-point scale by a panel of three dermatologists, blinded to study assignment, who reviewed serial digital image sets. The clinical course was assessed by comparing images sets between baseline and first clinic visit (if one occurred) and between baseline and nine months. There was no evidence to suggest a difference between the two groups in either clinical course between baseline and nine months post-referral ( P = 0.88) or between baseline and the first dermatology clinic visit ( P = 0.65). Among teledermatology referrals, subsequent presentation for an in-person dermatology clinic visit was significantly correlated with clinical course ( P = 0.023). Store and forward teledermatology did not result in a significant difference in clinical course at either of two post-referral time periods.

Reliability of a telemedicine system designed for rural Kenya

OBJECTIVE

Access to health care in rural areas of developing nations is hindered by both the lack of physicians and the preference of many physicians to practice in urban settings. As a result, rural patients often choose not to sacrifice wages or time to visit distant health care providers. A telemedicine system, Mashavu: Networked Health Solutions, designed to increase access to preprimary health care in rural areas, was field-tested in rural Kenya. This study aims to examine the reliability of the system compared to the traditional face-to-face method of health care delivery.

METHOD

Reliability of the telemedicine system was tested using a modified intraobserver concordance study. Community health workers operated the system in various remote locations. Patient health information including chief complaint, medical history, and vital statistics were sent via Internet to a consulting nurse. After patients completed the telemedicine consultation, they also met in-person with the same nurse. Subsequently, the nurse's advice during the in-person session was compared with his feedback provided through the telemedicine consultation.

RESULTS

When comparing the nurse's advice given through the telemedicine system with the advice given through more traditional face-to-face, in-person consultation, the nurse provided consistent medical feedback in 78.4% of the cases (n = 102). The nurse's advice regarding patient action (eg, clinical referrals or no further care necessary) was the same in 89.2% of the cases (n = 91).

CONCLUSION

The study found that this telemedicine system was able to provide patients with approximately the same quality of care and advice as if the patient had physically travelled to a clinic to see a nurse. In rural areas of developing nations where there are high logistical and economical barriers to accessing health care, this telemedicine system successfully increased the ease and lowered the cost of connecting rural patients with nurses to provide preprimary care.

Teledermatology in Air Force: Our Experience

BACKGROUND

Teledermatology is the science of telemedicine applied to the field of dermatology, with an aim to avoid travelling to nearest specialist facility.

METHODS

Patients from Air Force Stations Jaisalmer, Naliya, 5 Air Force Hospital, Jorhat and 9 Air Force Hospital, Halwara were consulted by the dermatologist at Command Hospital (Air Force) Bangalore through the telemedicine network provided by ISRO, Bangalore from March 06 to May 08.

RESULT

115 patients underwent teledermatology consultation using virtual teleconference (VTC) and this was compared with Store and Forward (S and F) consultation at all four stations as well as Face to Face (FTF) consultation at 5 Air Force Hospital Jorhat. Diagnosis concordance was 52.5% and 53% for Jorhat and Halwara for VTC vs S and F, while it was 75% and 25% for Jaisalmer and Naliya. For VTC vs FTF, the concordance improved to 60.66% and for S and F vs FTF it improved to 91.8%. Concordance was better for localized lesions than for generalized lesions especially of the papulosquamous group of disorders. Another reason for the discordance with VTC was poor resolution of cameras at the peripheral units.

CONCLUSION

Teledermatology is useful for patient care in the absence of local specialist cover and the patients have to travel long distances resulting in loss of manhours. However, better camera resolution at peripheral centres will result in greater concordance.

Teledermatology: its role in dermatosurgery

Dermatologic surgery and aesthetic dermatology are rapidly emerging and expanding specialties in India. However, dermatologists practicing surgeries and aesthetics in India represent a highly selected group and are mostly confined to metros. Dermatologists in the peripheral and remote regions need to reach these specialists for the benefit of their patients and teledermatology is an invaluable tool for this purpose. Video-conference, store and forward, Satellite communication, Hybrid teledermatology, mobile teledermatology, Integration model, nurse-led teledermatology, teledermatology focusing difficult-to-manage cases, screening and triage services are the various teledermatology services developed to suit the needs of dermatology care from a distance. Types of teledermatology service, pattern of net work connectivity and purpose of dermatology service are the three cardinal parameters for management of the dermatoses from a distance. This article reviews the literature, and analyzes the possible options available for a teledermatosurgery practice.

Dermatological diagnostic acumen improves with use of a simple telemedicine system for underserved areas of South Africa

OBJECTIVE

Telemedicine holds promise as a tool for improving the delivery of specialty care, especially in underserved regions, including those in South Africa. However, data that demonstrate the extent of its sustainable benefits to referring providers are currently insufficient. This study investigates whether utilization of a teledermatology network enhances the diagnostic acumen of primary care providers (PCPs) in underserved areas of South Africa.

MATERIALS AND METHODS

A longitudinal descriptive pilot study was conducted after establishing a telemedicine network linking University of Cape Town dermatology consultants to six providers from five underserved primary care sites using store-and-forward technology between October 2004 and January 2007. Of 120 total referrals, trend analysis was performed using 72 sets of patient histories, digital images, and corresponding consultant responses to evaluate the diagnostic concordance between six PCPs and teleconsultants over 12 consecutive referrals.

RESULTS

Strong positive Spearman rank-order correlations were observed between the number of referrals sent per PCP and proportion of primary diagnostic agreement with teledermatologists, rs=0.86 (p <0.001). The mean primary diagnostic concordance trend that started at 13% for the first four referrals increased nearly fourfold after referring as few as nine patients to the network.

CONCLUSIONS

If a simple and inexpensive teledermatology solution is carefully implemented in a resource-limited setting, an improvement of PCP diagnostic acumen can be achieved with a relatively small number of referrals. This educational benefit to referring PCPs could be sustainable and would ultimately enhance the quality of dermatological care in these underserved regions.

Agreement between dermatological diagnoses made by live examination compared to analysis of digital images

BACKGROUND

Teledermatology is seldom used in Brazil, although some incipient initiatives have been implemented in the state of Amazonas. Further studies are still required to confirm the feasibility and efficacy of this diagnostic tool.

OBJECTIVES

To evaluate the efficacy of an asynchronous method of teledermatology using simple, inexpensive technological resources.

METHODS

One hundred and seventy-four patients were examined by four dermatologists, two clinic-based dermatologists, who diagnosed the patients following live examination (A1 and A2), and two consultant specialists in image dermatology, who reached diagnoses by examining images of the lesions and the patients' clinical histories (B1 and B2). The agreement between live examination and examination of images was evaluated.

RESULTS

Agreement between the two live examiners (A1 and A2) with respect to the principal diagnosis was 83.3% compared to 81.0% between the physicians who diagnosed by examining images (B1 and B2). Agreement between the principal diagnosis established by live examination and that obtained from examining images ranged from 78.2% to 83.9%,

CONCLUSION

Agreement between diagnoses of dermatological diseases reached following examination of digital images and those reached following live examination of the patient was excellent.

Selecting the right digital camera for telemedicine-choice for 2009

Digital cameras are fundamental tools for store-and-forward telemedicine (electronic consultation). The choice of a camera may significantly impact this consultative process based on the quality of the images, the ability of users to leverage the cameras' features, and other facets of the camera design. The goal of this research was to provide a substantive framework and clearly defined process for reviewing digital cameras and to demonstrate the results obtained when employing this process to review point-and-shoot digital cameras introduced in 2009. The process included a market review, in-house evaluation of features, image reviews, functional testing, and feature prioritization. Seventy-two cameras were identified new on the market in 2009, and 10 were chosen for in-house evaluation. Four cameras scored very high for mechanical functionality and ease-of-use. The final analysis revealed three cameras that had excellent scores for both color accuracy and photographic detail and these represent excellent options for telemedicine: Canon Powershot SD970 IS, Fujifilm FinePix F200EXR, and Panasonic Lumix DMC-ZS3. Additional features of the Canon Powershot SD970 IS make it the camera of choice for our Alaska program.

Virtual Grand Rounds in Dermatology: an 8-year experience in web-based teledermatology

BACKGROUND

Teledermatology utilizes telecommunication technologies for the exchange of dermatologic information across distances. In 2000, we developed the Virtual Grand Rounds in Dermatology (VGRD) as a free, user-friendly platform for dermatologists to present complex dermatologic cases to the international community for clinical feedback, consultation, and continuing education.

METHODS

VGRD was designed using simple graphics to facilitate access in remote and developing geographic regions. Members present their case according to a recommended template and are encouraged to provide clinical and histopathologic photographs. Viewers' comments are posted on the site within 24-48 h following receipt.

RESULTS

VGRD's low-cost store-and-forward system allows easy accessibility to expertise for colleagues around the world. VGRD currently comprises a community of 344 clinicians across all dermatologic subspecialties, and links users to cases as well as a recent interactive addition for more urgent feedback: VGRD Blog. The Maine Virtual Skin Clinic is another sister site developed as an educational tool for physicians and residents in primary care. VGRD can be found at http://www.vgrd.org.

CONCLUSIONS

With its easy-to-use platform for teleconsultation services, VGRD has the potential to enhance clinical outcomes and education. In the next few years, we hope to continue to expand VGRD, including launching a comprehensive search engine in VGRD to provide users with a "one-stop resource." With the growth of teledermatology, we will combine web consultations with web-based education into a single resource for dermatologists interested in new possibilities in clinical practice, patient care, and continuing education.

Telemedicine through the use of digital cell phone technology in pediatric neurosurgery: a case series

BACKGROUND

Advances in medicine have largely followed advances in technology. Medical strides have been made when physicians and researchers have adapted growing science to target specific problems. A new medical field, telemedicine, has emerged that links physicians with colleagues and patients. Cell phone technology is affordable for almost everyone, and basic models include digital photography.

OBJECTIVE

We present a case series exhibiting the utility of digital pictures taken with patients' cell phones.

CLINICAL PRESENTATION

Our patients had wound infections requiring daily intravenous antibiotics and dressing changes. In years past, these patients would have required prolonged hospitalizations. In the era of managed care, patients with these infections are discharged from the hospital, but close outpatient observation is required to monitor the wound. Our patients lived up to 8 hours away from the hospital. Daily appointments for wound checks in the clinic were not practical. Wounds were thus monitored via cell phone images without the inconvenience of travel and the expense of staying in a local hotel, along with leaving appointments in the clinic available for others with new neurosurgical issues.

INTERVENTION

Wound evaluations were conducted with the cameras on patients' cell phones. These images were transmitted to the surgeon via text messaging and emails.

CONCLUSION

This application of cell phone technology has been documented previously in the literature of other specialties and could attain greater stature as a legitimate method for close outpatient observation by neurosurgeons if medicolegal issues are addressed.

Evaluation of a Telehealth Clinic as a Means to Facilitate Dermatologic Consultation: Pilot Project to Assess the Efficiency and Experience of Teledermatology Used in a Primary Care Network

Background:

Primary care offices spend considerable time coordinating the specialist referral process. Patients experience long wait times for consultation and intervention.

Objective:

To determine if telehealth combined with interdisciplinary team–based care can reduce wait times for dermatologic consultation while making the consultation process easier for physicians.

Methods:

Retrospective chart reviews as well as patient, referring physician, nonreferring physician, clinic physician, nurse, and teledermatologist interviews were used to evaluate the clinic. A comparative immersion approach generated themes from field notes. Wait times, appointment times, and encounter durations were measured.

Results:

Twenty-eight patients were seen (23 had previous specialist referral experience) within 1 week of referral compared to a wait period of 104 days for conventional referral. Patients requiring intervention were treated within 1 week of their initial appointment. Referring practitioners were concerned that they would lose control of patients' care. An easier referral process and faster intakes met physician expectations.

Conclusions:

Teledermatology improves the timeliness of appointments. Patients forgo face-to-face appointments if alternatives are available sooner. Physicians are concerned about their own liability if dermatologists do not assess the patient in person but will refer through teledermatology when patients are seen faster and they remain in control of the care process.