Accuracy and reliability of store-and-forward teledermatology: preliminary results from the St George Teledermatology Project

Descriptive and Concordance Data for Asynchronous Teledermatology Consultations for Dermatitis: A Retrospective Study

Background: Implementation of teledermatology for assessing dermatitis patients provides comparable diagnostic and management outcomes to in-person visits, but studies on consumer to physician asynchronous teledermatology (eDerm) consults submitted by patients in large dermatitis cohorts are limited. The objective of this study was to retrospectively assess associations of eDerm consults with diagnostic accuracy, management, and follow-up in a large cohort of dermatitis patients. Methods: One thousand forty-five eDerm encounters between April 1, 2020, and October 29, 2021, recorded in the University of Pittsburgh Medical Center Health System Epic electronic medical record were reviewed. Descriptive statistics and concordance were analyzed using chi-square. Results: Asynchronous teledermatology modified/changed treatment in 97.6% of cases and had the same diagnosis between teledermatology and in-person follow-up in 78.3% of cases. Patients following up in the time line requested were more likely to follow-up in person (61.2% vs. 43.8%) than those who did not. Patients with intertriginous dermatitis (p = 0.003), preexisting conditions (p = 0.002), who required follow-ups (<0.0001), and moderate-high severity scores of 4-7 (p = 0.019) were more likely to follow up in the time line requested. Limitations: Lack of similar in-person visit data did not allow us to compare descriptive and concordance data between eDerm and clinic visits. Conclusions: eDerm offers a quick accessible solution to provide comparable dermatologic care for patients with dermatitis.

Social Media and Dermatology During the COVID-19 Pandemic: Analyzing User-Submitted Posts Seeking Dermatologic Advice on Reddit

INTRODUCTION

Reddit, a popular social media website, has numerous forums where users may discuss healthcare-related topics and request diagnostic and treatment advice for dermatologic conditions. We sought to analyze and grade user-submitted requests for dermatologic advice and their top responses on Reddit.

METHODS

User-submitted posts requesting diagnostic advice and their respective responses on two popular Reddit forums, SkinCareAddiction (ScA) and DermatologyQuestions (DQ), were reviewed by three board-certified dermatologists using a grading rubric designed for this study.

RESULTS

300 posts and comments were reviewed. Diagnoses among all graders matched in 52.3% of posts with a mean grader confidence score of 4/5 (95% CI 3.89-4.11). 31% of responder's comments recommended a diagnosis not included by any reviewer. Mean scores for the top comment's accuracy, appropriateness, and potential to be misleading/dangerous were 3.28/5 (95% CI 3.12-3.45), 3.3/5 (95% CI 3.14-3.45), and 2.33/5 (95% CI 2.18-2.48), respectively.

CONCLUSION

Reddit may be informative to patients requesting dermatologic advice. However, responses should be taken with caution as the information provided may be inaccurate or insufficient for treatment recommendations. Dermatologists should be aware of these resources used by patients.

impact of the COVID-19 pandemic on the management of cutaneous malignancies in Australia

Introduction: The Australian healthcare system, including its management of cutaneous malignancies, has faced unprecedented challenges due to the COVID-19 pandemic. This study aimed to quantify the impact of the first wave of the pandemic on the diagnosis and management of cutaneous malignancies in Australia. Methods: Monthly service data was extracted from the Australian Medicare Benefits Schedule database for all cutaneous biopsies, non-melanotic skin cancer (NMSC) excisions and melanoma excisions performed between January 2017 and December 2019. Holt-Winters exponential smoothing forecasting models were developed for total biopsies, NMSC excisions and melanoma excisions. These models were used to predict monthly data between January 2020 and June 2020 with a 95 per cent confidence interval (p < 0.05). Absolute and percentage residual differences (RDs) between actual and predicted excisions for this time period were calculated. Results: There were statistically significant reductions in total NMSC excisions in March 2020 (RD: −6,943, −13.0%), April 2020 (RD: −8,954, −12.2%), May 2020 (RD: −17,667, −20.9%) and June 2020 (RD: −5,152, −6.9%). There were statistically significant reductions in melanoma excisions in April 2020 (RD: –695, –11.1%), May 2020 (RD: −1,982, –28.7%) and June 2020 (RD: –973, –16.0%). Conclusions: There was a significant reduction in skin cancer excisions in Australia during the COVID-19 pandemic. This observed reduction in skin cancer surgery has significant public health implications, highlighting the need for improved surveillance, diagnosis and treatment capacity of cutaneous malignancies during the recovery phase of the pandemic.

Evaluation of High-Efficiency Image Coding algorithm for dermatology images in teledermatology

BACKGROUND

Currently, teledermatology assumes a progressively greater role in the modern healthcare system, especially in consultation, diagnosis, or examining lesions and skin cancers. One of the major challenges facing teledermatology systems is determining the optimal image compression method to efficiently reduce the space needed for electronic storage and data transmission.

OBJECTIVE

To the objective and subjective assessment of HEIC compression method on dermatological color images and benchmarking the performance of High-Efficiency Image Coding (HEIC) with different algorithms to a feasibility study of the method for teledermatology.

METHODS

Twenty-five clinical and five skin histopathology images were taken in department of dermatology, Imam Reza Hospital, Mashhad, Iran. For each image, a set of 24 compressed images with different compression rates, which is composed of eight JPEG, eight JPEG2000, and eight HEIC images, has been prepared. Compressed and original images were shown simultaneously to three dermatologists and one dermatopathologist with different experiences. Each dermatologist scored quality and suitability of compressed images for diagnostic, as well as educational/scientific purposes. An objective evaluation was performed by calculating the mean "distance" of pixel colors and peak signal-to-noise ratio (PSNR).

RESULTS

All compression rates for HEIC were objectively better than JPEG and JPEG2000, particularly at PSNR. Moreover, mean "color distance" per pixel for compressed images using HEIC was lower than others. The subjective image quality assessment also confirms the results of objective evaluation. In both educational and clinical diagnostic applications, HEIC compressed images have the highest score.

CONCLUSION

In consideration of objective and subjective evaluation, the HEIC algorithm represents an optimal performance in dermatology images compression compared with JPEG and JPEG2000.

Teledermatology in times of COVID-19

Remote consultations are likely to grow in importance in the following years, especially if the coronavirus disease 2019 (COVID‐19) pandemic continues. Patients’ opinions on teledermatology have already been analyzed, but a current analysis during the COVID‐19 pandemic is lacking. The purpose of this survey was to investigate the satisfaction of patients who had received dermatological advice via telephone during the COVID‐19 pandemic and to analyze their general opinion about eHealth as well as possible limitations for a broad implementation. Ninety‐one patients managed in the dermatology department using telephone consultation during the COVID‐19 pandemic were interviewed. An anonymous questionnaire, including the established quality of life questionnaire (Dermatology Life Quality Index [DLQI]), was used. It was found that men were more satisfied with telephone consultations than women (p = 0.029), educational level and age did not correlate with satisfaction (p = 0.186 and 388, respectively), and the longer the waiting time for a telephone consultation, the lower the satisfaction (p = 0.001). Grouped analysis of all participants showed that the majority (54.0% n = 38/71) were “very happy” with the telephone consultation. Higher disease burden (DLQI) was associated with lower satisfaction (p = 0.042). The main stated reasons for using telemedicine were shorter waiting times (51.6% n = 47/91) and no travel requirement (57.1% n = 47/91). Almost one‐quarter (23.1% n = 21/89) of patients would use teledermatology in the future, 17.6% (n = 16/89) would not, and 57.1% (n = 51/89) would only use it in addition to a traditional consultation with personal contact. In conclusion, most patients in the study group still preferred traditional face‐to‐face medical consultations to telephone consultations, but also desired an add‐on telemedical tool. Dermatological care using more modern telemedicine technologies than telephone conferencing is needed to better address patients’ desires, especially in times of the COVID‐19 pandemic.

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.

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.

Part II: Accuracy of Teledermatology in Skin Neoplasms

Teledermatology has been proving to be of great help for delivering healthcare, especially now, during the SARS-CoV-2 pandemic. It is crucial to assess how accurate this method can be for evaluating different dermatoses. Such knowledge can contribute to the dermatologists' decision of whether to adhere to teledermatology or not. Our objective was to determine the accuracy of teledermatology in the 10 most frequent skin neoplasms in our population, comparing telediagnosis to histopathological report and in-person dermatologists' diagnosis. A retrospective cohort study was conducted in São Paulo, Brazil, where a store-and-forward teledermatology project was implemented under primary-care attention to triage surgical, more complex, or severe dermatoses. A total of 30,976 patients presenting 55,012 lesions took part in the project. Thirteen teledermatologists who participated in the project had three options to refer the patients: send them directly to biopsy, to the in-person dermatologist, or back to the general physician with the most probable diagnosis and management. In the groups referred to the in-person dermatologist and biopsy, we looked for the 10 most frequent International Statistical Classification of Diseases and Related Health Problems-10 (ICD-10) of skin neoplasms, which resulted in 289 histopathologic reports and 803 in-person dermatologists' diagnosis. We were able to compare the ICD-10 codes filled by teledermatologists, in-person dermatologists, and from histopathological reports. The proportion of complete, partial, and no agreement rates between the in-person dermatologist's, histopathologic report, and the teledermatologist's diagnosis was assessed. We also calculated Cohen's kappa, for complete and complete plus partial agreement. The mean complete agreement rate comparing telediagnosis to histopathological report was 54% (157/289; kappa = 0.087), being the highest for malign lesions; to in-person dermatologists was 61% (487/803; kappa = 0.213), highest for benign lesions. When accuracy of telediagnosis for either malign or benign lesions was evaluated, the agreement rate with histopathology was 70% (kappa = 0.529) and with in-person dermatologist, 81% (kappa = 0.582). This study supports that teledermatology for skin neoplasms has moderate accuracy. This result reassures that it can be a proper option for patient care, especially when the goal is to differentiate benign from malign lesions.

Part I: Accuracy of Teledermatology in Inflammatory Dermatoses

Teledermatology is assuming a progressively greater role as a healthcare delivery method, especially now, during this pandemic time. It is important to know how accurate this tool is for different skin diseases. Most of the studies have focused on skin neoplasms or general dermatology. Studies based on a large number of inflammatory dermatoses have not yet been performed. Such knowledge can help dermatologists to decide whether endorsing this method or not. Our objective was to determine the accuracy of teledermatology in inflammatory dermatoses in a robust number of cases. A retrospective cohort study was conducted in São Paulo, Brazil, from July 2017–18, where a store-and-forward Teledermatology project was implemented under primary-care attention to triage surgical, more complex, or severe dermatoses. A total of 30,976 patients presenting 55,012 lesions took part in the project. Thirteen participating teledermatologists had three options to refer the patients: directly to biopsy, to the in-person dermatologist or back to the general physician with most probable diagnosis and management. In the group referred to the in-person dermatologist, we looked for the 20 most frequent International Classification of Diseases and Related Health Problems- 10th revision (ICD-10) of inflammatory dermatoses, which resulted in 739 patients and 739 lesions. As patients had been triaged by teledermatology previously, we were able to compare ICD-10 codes filled both by teledermatogists and by in-person dermatologists. The proportion of complete, partial, and no agreement rates between the in-person dermatologist's and the teledermatologist's diagnoses was used for accuracy. We also calculated Cohen's kappa, a statistical measure of inter-rater agreement, for complete agreement. The mean complete agreement rate for all twenty dermatoses was 78% (31–100%) and kappa = 0.743; partial agreement 8%; and no agreement 14%, presenting variability according to the disease. Our study showed that teledermatology for inflammatory dermatoses has a high accuracy. This result reassures that it can be a proper option for patient care.

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.

The use of teledermoscopy in the accurate identification of cancerous skin lesions in the adult population: A systematic review

Background The use of teledermoscopy in the diagnostic management of pre-cancerous and cancerous skin lesions involves digital dermoscopic images transmitted over telecommunication networks via email or web applications. Teledermoscopy may improve the accuracy in clinical diagnoses of melanoma skin cancer if integrated into electronic medical records and made available to rural communities, potentially leading to decreased morbidity and mortality. Objective and method The purpose of this paper is to present a systematic review of evidence on the use of teledermoscopy to improve the accuracy of skin lesion identification in adult populations. The PRISMA method guided the development of this systematic review. A total of seven scholarly databases were searched for articles published between the years of 2000 and 2015. All studies were critically appraised using the Rosswurm and Larrabee critique worksheet, placed in a matrix for comparison evaluating internal and external validity and inspected for homogeneity of findings. Results Sixteen articles met inclusion criteria for this review. A majority of the studies were cross-sectional and non-experimental. Ten of the 16 focused on interobserver concordance and diagnostic agreement between teledermoscopy and another comparator. Instrumentation in conducting the studies showed inconsistency with reported results. Discussion Higher level evidence is needed to support clinical application of teledermoscopy for accuracy of diagnostic measurement in the treatment of pre-cancerous and cancerous skin lesions in adults. Future research is needed to develop a standardized, reliable and valid measurement tool for implementation in clinical practice.

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.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

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.

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: from historical perspective to emerging techniques of the modern era: part I: History, rationale, and current practice

Telemedicine is the use of telecommunications technology to support health care at a distance. Technological advances have progressively increased the ability of clinicians to care for diverse patient populations in need of skin expertise. Dermatology relies on visual cues that are easily captured by imaging technologies, making it ideally suited for this care model. Moreover, there is a shortage of medical dermatologists in the United States, where skin disorders account for 1 in 8 primary care visits and specialists tend to congregate in urban areas. Even in regions where dermatologic expertise is readily accessible, teledermatology may serve as an alternative that streamlines health care delivery by triaging chief complaints and reducing unnecessary in-person visits. In addition, many patients in the developing world have no access to dermatologic expertise, rendering it possible for teledermatologists to make a significant contribution to patient health outcomes. Teledermatology also affords educational benefits to primary care providers and dermatologists, and enables patients to play a more active role in the health care process by promoting direct communication with dermatologists.

Audit of a state-wide store and forward teledermatology service in Australia

In 2008, the Skin Emergency Telemedicine Service was established at the Princess Alexandra Hospital (PAH) in Brisbane. We conducted an audit by evaluating all email communication during 2012, and administering a clinician questionnaire. A total of 167 cases were discussed via 685 email communications (46 being in-house PAH referrals). The highest number of external referrals came from Mt Isa (27%), located 1200 km from the nearest dermatology clinic, with a further 25% sent from centres located 50-600 km from a clinic. The main referring condition was rash (65%), followed by skin lesions (13%). The most commonly provided telemedicine diagnoses were dermatitis/eczema (23%), infection (20%) and drug eruption (17%). Most external referrals received a reply within 3 hours of the enquiry. Junior doctors (2nd-4th postgraduate year) represented the majority of referring clinicians (62% of questionnaire respondents). There were 111 potential questionnaire recipients. Responses were received from 34 clinicians, a response rate of 31%. Overall 100% of respondents stated that the service was useful to them and 97% said they would use it again in the future with one respondent stating 'possibly'. It seems likely that teledermatology will serve an important role in the provision of healthcare to Queensland, and other remote Australian communities in the future.

Development of a teledermatopathology consultation system using virtual slides

Background

An online consultation system using virtual slides (whole slide images; WSI) has been developed for pathological diagnosis, and could help compensate for the shortage of pathologists, especially in the field of dermatopathology and in other fields dealing with difficult cases. This study focused on the performance and future potential of the system.

Method

In our system, histological specimens on slide glasses are digitalized by a virtual slide instrument, converted into web data, and up-loaded to an open server. Using our own purpose-built online system, we then input patient details such as age, gender, affected region, clinical data, past history and other related items. We next select up to ten consultants. Finally we send an e-mail to all consultants simultaneously through a single command. The consultant receives an e-mail containing an ID and password which is used to access the open server and inspect the images and other data associated with the case. The consultant makes a diagnosis, which is sent to us along with comments.

Because this was a pilot study, we also conducted several questionnaires with consultants concerning the quality of images, operability, usability, and other issues.

Results

We solicited consultations for 36 cases, including cases of tumor, and involving one to eight consultants in the field of dermatopathology. No problems were noted concerning the images or the functioning of the system on the sender or receiver sides. The quickest diagnosis was received only 18 minutes after sending our data. This is much faster than in conventional consultation using glass slides. There were no major problems relating to the diagnosis, although there were some minor differences of opinion between consultants. The results of questionnaires answered by many consultants confirmed the usability of this system for pathological consultation. (16 out of 23 consultants.)

Conclusion

We have developed a novel teledermatopathological consultation system using virtual slides, and investigated the usefulness of the system. The results demonstrate that our system can be a useful tool for international medical work, and we anticipate its wider application in the future.

Virtual slides

The virtual slides for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1902376044831574

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.

Disruptive innovation: the future of healthcare?

The traditional face-to-face doctor-patient relationship is the core of conventional medical practice. One key aspect of this changing relationship is the increasing dependency on asynchronous data collection in clinical consultations. Such electronic communications and data streams may be numeric, text-based, audio, digitized still pictures, video and radiologic, as well as emanating from multiple medical devices. While asynchronous medicine may be established in specialties like radiology and dermatology, there is little research regarding the use of asynchronous medicine in areas of medicine that traditionally rely on the physical doctor-patient interaction such as primary care, internal medicine, geriatrics, and psychiatry. The practice of psychiatry stands out as a discipline that is highly dependent on the quality of the physical meeting between the doctor and the patient, yet even in this specialty it is possible to utilize asynchronous medicine for some types of psychiatric consultations. Asynchronous medicine has the potential to be significantly disruptive to our current healthcare processes, as well as more clinically and economically efficient.

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

BACKGROUND

The expansion of store-and-forward teledermatology into underserved regions of the world has long been hampered by the requirement for computers with Internet connectivity. To our knowledge, this study is one of the first to demonstrate the feasibility of teledermatology using newer-generation mobile telephones with specialized software and wireless connectivity to overcome this requirement in a developing country.

OBJECTIVE

We sought to demonstrate that mobile telephones may be used on the African continent to submit both patient history and clinical photographs wirelessly to remote expert dermatologists, and to assess whether these data are diagnostically reliable.

METHODS

Thirty patients with common skin diseases in Cairo, Egypt, were given a diagnosis by face-to-face consultation. They were then given a diagnosis independently by local senior dermatologists using teleconsultation with a software-enabled mobile telephone containing a 5-megapixel camera. Diagnostic concordance rates between face-to-face and teleconsultation were tabulated.

RESULTS

Diagnostic agreement between face-to-face consultation and the two local senior dermatologists performing independent evaluation by teleconsultation was achieved in 23 of 30 (77%) and in 22 of 30 (73%) cases, respectively, with a global mean of 75%.

LIMITATIONS

Limited sample size and interobserver variability are limitations.

CONCLUSION

Mobile teledermatology is a technically feasible and diagnostically reliable method of amplifying access to dermatologic expertise in poorer regions of the globe where access to computers with Internet connectivity is unreliable or insufficient.

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.

Experience with the implementation of a web-based teledermatology system in a nursing home in Singapore

We introduced a web-based teledermatology system, the distributed personal health information management system (DPHIMS), into a nursing home in Singapore. The introduction was conducted in two phases. Five staff nurses in Phase 1 and nine nurse aides in Phase 2 performed the data entry and uploaded digital images of the resident's skin condition. By the end of Phase 2, there were 50 residents registered with DPHIMS. The average age of the participants was 82 years and 84% were women. There were 31 first-time referral requests registered in the system during Phase 2. The average time taken to complete a referral request was 86 minutes. The average time taken by the dermatologist to prepare and submit a diagnosis/treatment report was 11 minutes. An online survey form was given to the nurses and the dermatologists to gauge their level of satisfaction and their experience of using DPHIMS. All the nurses said they would readily recommend DPHIMS to other nurses. Overall, the dermatologists felt that DPHIMS was helpful in obtaining specialist care for the residents. However, some skin conditions required a face-to-face consultation. Thus a mixture of face-to-face consultations and consultations via teledermatology may be necessary to provide complete diagnosis and treatment to patients. Our experience suggests that understanding and addressing the organizational concerns is as important as solving the technical problems.

Teledermatology: how to start a new teaching and diagnostic era in medicine

"Telemedicine" is defined as the use of telecommunication technologies for the exchange of medical information across distances. Applications include patient management as well as research and education. Teledermatology is a steadily growing category of telemedicine. This article presents general aspects of telemedicine, such as modes of data transmission, and practical applications with a special emphasis on their significance for teledermatology.

Efficacy and feasibility of teledermatology for paediatric medical education

Summary

We evaluated a teledermatology consultation service in the education of medical trainees. The selection of cases for consultation was at the discretion of the trainees, who could contact the study team for advice about obtaining photographs and submitting the case to a web-based system. Asynchronous structured feedback was provided to trainees by an academic paediatric dermatology consultant using a web-based interface. Efficacy was evaluated by examining the trainees' self-reported competency in clinical dermatology skills before and after teleconsultation. A total of 44 trainees (31 residents and 13 medical students) completed 50 consultations. Trainees reported significant improvement (mean improvement 22%, P < 0.002) in competency in five of the six areas assessed. In addition, 88% of trainees were very satisfied with the teaching methodology (≥5 on a 7-point scale) and 86% were very likely to apply the information in their future practice (≥5 on a 7-point scale). We believe that teledermatology has great potential in the education of medical trainees.