Assessment of the accuracy of low-cost store-and-forward teledermatology consultation

Developing and evaluating a mobile-based teledermatology system for skin lesion diagnosis in Iran

Asynchronous teledermatology (TD) has shown promise in improving access to dermatological care, yet studies reveal varied methodologies and results. This study aimed to design a mobile app using the store-and-forward model, marking a pioneering effort in Iran to facilitate written documentation of patient history and skin lesion imagery for accurate diagnosis. Conducted from July 2022 to July 2023, this study involved the development and implementation of a smartphone app to collect clinical data and photographs from 89 patients at a dermatology clinic. Diagnoses made at the clinic served as the gold standard. Three dermatologists independently reviewed the app-recorded data, providing diagnoses that were compared to in-person assessments using the Kappa coefficient and agreement percentage. Lesions were predominantly located on the whole body (47%), with psoriasis (19.1%), acne vulgaris (11.2%), and eczema (10%) being the most common. The overall inter-observer Kappa value demonstrated excellent agreement at 0.856. The study's findings endorse the use of a mobile app for TD as an effective adjunct in regions with scarce dermatological services, such as Iran. To promote the broader application of TD, ongoing research is essential to further establish its reliability and practicality.

Digital otoscopy in remote consultations

Introduction

Otoscopes and otomicroscopes are the most commonly used instruments for visualizing the ear. Digital otoscopy (DO) could be used to improve diagnostics in primary health care by utilizing image enlargement. The aim of the study was to explore the possibilities of DO in remote consultations.

Materials and Methods

Based on real-life referrals, 45 otologic outpatients were recruited. DO was performed followed by an attending otologist's appointment, serving as the gold standard. Twenty-four patient cases were analyzed on a digital platform as remote consultation cases containing the given referral information supplemented with DO videos (DOVs). A total of 71 evaluations were performed by five otologists. The quality of the DOVs, their suitability for remote consultations, the accuracy of diagnoses and the usefulness of remote consultations were determined.

Results

The average DOV quality was judged to be 7.4 ± 0.3 (mean ± standard error of the mean; scale of 1-10). The diagnosis was correct in 79% of the cases. In 59% of the patients, the otologists considered that remote consultation could have replaced an in-person visit.

Conclusions

In our simulated remote consultation setup, DOV quality was sufficient for diagnostic purposes, DO improved diagnostics and treatment planning in most cases and could be used to reduce the need for in-person visits. DO-aided remote consultation may improve diagnostics and access to care.Level of evidence: 3.

Digital vs. physical ear-nose-and-throat specialist assessment screening for complicated hearing loss and serious ear disorders in hearing-impaired adults prior to hearing aid treatment: a randomized controlled trial

Introduction

This study introduces a digital assessment tool for asynchronous and remote ear-nose-and-throat (ENT) specialist assessment screening for complicated hearing loss and serious ear disorders in hearing-impaired adults prior to hearing aid (HA) treatment. The +60 population will nearly double from 12% to 22% between 2015 and 2050 increasing the incidence of age-induced hearing impairment and the need for hearing rehabilitation. If un-diagnosed, age-related hearing loss negatively affects quality of life by accelerating social distancing and early retirement as well as increasing risk of anxiety, depression, and dementia. Therefore, innovative measures are essential to provide timely diagnostics and treatment.

Methods

A total of 751 hearing-impaired adults without previous HA usage or experience were randomly assigned to digital or physical ENT specialist assessment screening prior to HA treatment initiation in 20 public and private hearing rehabilitation and ENT specialist clinics in the North Denmark Region. A total of 501 test group participants were assigned to digital assessment screening and 250 control group participants to physical assessment screening prior to HA treatment.

Results

In all, 658 (88%) participants completed the trial and were eligible for analysis. Digital screening sensitivity (0.85, 95% confidence interval (CI) 0.71-0.94) was significantly higher than physical screening sensitivity (0.2, 95% CI: 0.03-0.56). Screening specificity was high for both assessment methods.

Discussion

In a setting where hearing-impaired adults were assessed for HA treatment, digital ENT specialist assessment screening did not compromise patient safety or increase the risk of misdiagnosis in patients with complicated hearing loss and/or serious ear disorders when compared to physical ENT specialist assessment screening.

Clinical Trial registration

https://clinicaltrials.gov/ct2/show/NCT05154539, identifier: NCT05154539.

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.

The policy dimensions, regulatory landscape, and market characteristics of teledermatology in the United States

The COVID-19 pandemic has spurred healthcare systems across the world to rapidly redesign their models of care delivery. As such, this pandemic has accelerated the adoption of teledermatology in the United States. However, it remains unknown whether this momentum will be maintained after the pandemic. The future of teledermatology in the United States will be significantly influenced by a complex set of policy, legal, and regulatory frameworks. An understanding of these frameworks will help dermatologists more effectively adopt and implement teledermatology platforms. In this article, we review the current state of teledermatology in the United States, including policy dimensions, the regulatory landscape, market characteristics, and future directions.

Clinical Outcomes of Asynchronous Versus Synchronous Telepsychiatry in Primary Care: Randomized Controlled Trial

BACKGROUND

Asynchronous telepsychiatry (ATP; delayed-time) consultations are a novel form of psychiatric consultation in primary care settings. Longitudinal studies comparing clinical outcomes for ATP with synchronous telepsychiatry (STP) are lacking.

OBJECTIVE

This study aims to determine the effectiveness of ATP in improving clinical outcomes in English- and Spanish-speaking primary care patients compared with STP, the telepsychiatry usual care method.

METHODS

Overall, 36 primary care physicians from 3 primary care clinics referred a heterogeneous sample of 401 treatment-seeking adult patients with nonurgent psychiatric disorders. A total of 184 (94 ATP and 90 STP) English- and Spanish-speaking participants (36/184, 19.6% Hispanic) were enrolled and randomized, and 160 (80 ATP and 80 STP) of them completed baseline evaluations. Patients were treated by their primary care physicians using a collaborative care model in consultation with the University of California Davis Health telepsychiatrists, who consulted with patients every 6 months for up to 2 years using ATP or STP. Primary outcomes (the clinician-rated Clinical Global Impressions [CGI] scale and the Global Assessment of Functioning [GAF]) and secondary outcomes (patients' self-reported physical and mental health and depression) outcomes were assessed every 6 months.

RESULTS

For clinician-rated primary outcomes, ATP did not promote greater improvement than STP at 6-month follow-up (ATP vs STP, adjusted difference in follow-up at 6 months vs baseline differences for CGI: 0.2, 95% CI -0.2 to 0.6; P=.28; and GAF: -0.6, 95% CI -3.1 to 1.9; P=.66) or 12-month follow-up (ATP vs STP, adjusted difference in follow-up at 12 months vs baseline differences for CGI: 0.4, 95% CI -0.04 to 0.8; P=.07; and GAF: -0.5, 95% CI -3.3 to 2.2; P=.70), but patients in both arms had statistically and clinically significant improvements in both outcomes. There were no significant differences in improvement from baseline between ATP and STP on any patient self-reported ratings at any follow-up (all P values were between .17 and .96). Dropout rates were higher than predicted but similar between the 2 arms. Of those with baseline visits, 46.8% (75/160) did not have a follow-up at 1 year, and 72.7% (107/147) did not have a follow-up at 2 years. No serious adverse events were associated with the intervention.

CONCLUSIONS

This is the first longitudinal study to demonstrate that ATP can improve clinical outcomes in English- and Spanish-speaking primary care patients. Although we did not find evidence that ATP is superior to STP in improving clinical outcomes, it is potentially a key part of stepped mental health interventions available in primary care. ATP presents a possible solution to the workforce shortage of psychiatrists and a strategy for improving existing systems of care.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02084979; https://clinicaltrials.gov/ct2/show/NCT02084979.

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.

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.

Potential solutions for pediatric weight loss programs in the treatment of obesity in rural communities

Pediatric obesity remains disproportionately more prevalent in rural communities; however, multidisciplinary, pediatric weight loss programs, which are often located in tertiary-care centers, may not be accessible to rural families. Limited models to specifically address pediatric obesity in rural communities exist. Therefore, innovative solutions are required for expanded treatment of pediatric obesity in rural communities. This article discusses potential solutions for multidisciplinary, tertiary-care pediatric weight loss programs to improve access and treatment of pediatric obesity in rural communities. A selected review of the literature suggests that strategies to overcome barriers to treatment in rural communities include telephone calls and telemedicine conferencing by obesity specialists from academic centers (obesity medicine specialists, endocrinologists, dietitians, and psychotherapists) as well as training local primary care providers in rural communities to screen, diagnose, and treat patients with obesity. Multidisciplinary, tertiary-care pediatric weight loss programs have a profound opportunity to impact the treatment of pediatric obesity in rural communities by training practicing rural primary care providers as well as strengthening their commitment to educate future generations of clinicians on the treatment of pediatric obesity through medical training including physician assistant, nurse practitioner, and pediatric and family medicine resident education and skill building. This article identifies potential mechanisms for expansive treatment of pediatric obesity in rural communities by multidisciplinary, tertiary-care weight loss programs and highlights areas of specific focus needed for future investigation.

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.

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.

Trial of low-cost teledermatology in primary care

We examined the feasibility of a low-cost, store-and-forward teledermatology service for general practitioners (GPs) in regional Queensland. Digital pictures and a brief case history were transmitted by email. A service coordinator carried out quality control checks and then forwarded these email messages to a consultant dermatologist. On receiving a clinical response from the dermatologist, the service coordinator returned the message to the referring GP. The aim was to provide advice to rural GPs within one working day. Over six months, 63 referrals were processed by the teledermatology service, covering a wide range of dermatological conditions. In the majority of cases the referring doctors were able to treat the condition after receipt of email advice from the dermatologist; however, in 10 cases (16%) additional images or biopsy results were requested because image quality was inadequate. The average time between a referral being received and clinical advice being provided to the referring GPs was 46 hours. The number of referrals in the present study, 1.05 per month per site, was similar to that reported in other primary care studies. While the use of low-cost digital cameras and public email is feasible, there may be other issues, for example remuneration, which will militate against the widespread introduction of primary care teledermatology in Australia.

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.

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.

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 protocol for screening of skin cancer

BACKGROUND

Telemedicine refers to the use of technology as improvement of healthcare delivery to places where distance becomes an obstacle. Its use represents a great potential for dermatology, a specialty whose visual analysis phase is essential in diagnosis.

OBJECTIVES

To analyze the compatibility index of skin cancer diagnoses between primary care and teledermatology, and to validate a protocol for standardization of digital imaging to obtain the reports in teledermatology.

METHODS

An observational cross-sectional study developed through the census of 333 examination requests, received between January/2012 and July/2012, in the Center for Telemedicine and Telehealth of SES-SC. We used a protocol for photographic lesion standardization, consisting of three steps (panoramic photo, close-up with ruler and dermoscopy). After collection, the data were sent to a virtual site on the Internet, and recorded with the use of an electronic health record containing the images, the skin phototype and demographic characteristics.

RESULTS

The level of compatibility between the diagnosis of skin cancer in Santa Catarina's primary care and the diagnosis proposed by teledermatology was 19.02%. Proportionally, it was 21.21% for BCC, 44.44% for SCC and 6.98% for MM. The protocol was statistically significant (p <0.05), with an OR of 38.77.

CONCLUSION

The rate of diagnostic compatibility of skin cancer was low and the use of the protocol optimized the chance of validating requests for examination.

Pediatric teledermatology: a survey of usage, perspectives, and practice

Pediatric dermatology is one of the smallest subspecialties, and expanding the availability of care is of great interest. Teledermatology has been proposed as a way to expand access and improve care delivery, but no current assessment of pediatric teledermatology exists. The objective of the current study was to assess usage and perspectives on pediatric teledermatology. Surveys were distributed electronically to all 226 board-certified U.S. pediatric dermatologists; 44% (100/226) responded. Nearly all respondents (89%) have experience with teledermatology. Formal teledermatology reimbursement success rates have increased to 35%. Respondents were positive about teledermatology's present and future prospects, and 41% want to use teledermatology more often, although they viewed teledermatology as somewhat inferior to in-person care regarding accuracy of diagnosis and appropriation of management plans. Significant differences were found between formal teledermatology users and nonusers in salary structure, practice environment, sex, and region. Substantial increases in pediatric teledermatology have occurred in the last 5 to 10 years, and there remains cause for optimism for teledermatology's future. Concerns about diagnostic confidence and care quality indicate that teledermatology may be best for care of patients with characteristic clinical presentations or management of patients with established diagnoses.

A mobile app for securely capturing and transferring clinical images to the electronic health record: description and preliminary usability study

Background

Photographs are important tools to record, track, and communicate clinical findings. Mobile devices with high-resolution cameras are now ubiquitous, giving clinicians the opportunity to capture and share images from the bedside. However, secure and efficient ways to manage and share digital images are lacking.

Objective

The aim of this study is to describe the implementation of a secure application for capturing and storing clinical images in the electronic health record (EHR), and to describe initial user experiences.

Methods

We developed CliniCam, a secure Apple iOS (iPhone, iPad) application that allows for user authentication, patient selection, image capture, image annotation, and storage of images as a Portable Document Format (PDF) file in the EHR. We leveraged our organization’s enterprise service-oriented architecture to transmit the image file from CliniCam to our enterprise clinical data repository. There is no permanent storage of protected health information on the mobile device. CliniCam also required connection to our organization’s secure WiFi network. Resident physicians from emergency medicine, internal medicine, and dermatology used CliniCam in clinical practice for one month. They were then asked to complete a survey on their experience. We analyzed the survey results using descriptive statistics.

Results

Twenty-eight physicians participated and 19/28 (68%) completed the survey. Of the respondents who used CliniCam, 89% found it useful or very useful for clinical practice and easy to use, and wanted to continue using the app. Respondents provided constructive feedback on location of the photos in the EHR, preferring to have photos embedded in (or linked to) clinical notes instead of storing them as separate PDFs within the EHR. Some users experienced difficulty with WiFi connectivity which was addressed by enhancing CliniCam to check for connectivity on launch.

Conclusions

CliniCam was implemented successfully and found to be easy to use and useful for clinical practice. CliniCam is now available to all clinical users in our hospital, providing a secure and efficient way to capture clinical images and to insert them into the EHR. Future clinical image apps should more closely link clinical images and clinical documentation and consider enabling secure transmission over public WiFi or cellular networks.

Design of a randomized, non-inferiority trial to evaluate the reliability of videoconferencing for remote consultation of diabetes

Background

An estimated 366 million people are living with diabetes worldwide and it is predicted that its prevalence will increase to 552 million by 2030. Management of this disease and its complications is a challenge for many countries. Optimal glycaemic control is necessary to minimize complications, but less than 70% of diabetic patients achieve target levels of blood glucose, partly due to poor access to qualified health care providers. Telemedicine has the potential to improve access to health care, especially for rural and remote residents. Video teleconsultation, a real-time (or synchronous) mode of telemedicine, is gaining more popularity around the world through recent improvements in digital telecommunications. If video consultation is to be offered as an alternative to face-to-face consultation in diabetes assessment and management, then it is important to demonstrate that this can be achieved without loss of clinical fidelity. This paper describes the protocol of a randomised controlled trail for assessing the reliability of remote video consultation for people with diabetes.

Methods/Design

A total of 160 people with diabetes will be randomised into either a Telemedicine or a Reference group. Participants in the Reference group will receive two sequential face-to-face consultations whereas in the Telemedicine group one consultation will be conducted face-to-face and the other via videoconference. The primary outcome measure will be a change in the patient’s medication. Secondary outcome measures will be findings in physical examination, detecting complications, and patient satisfaction. A difference of less than 20% in the aggregated level of agreement between the two study groups will be used to identify if videoconference is non-inferior to traditional mode of clinical care (face-to-face).

Discussion

Despite rapid growth in application of telemedicine in a variety of medical specialities, little is known about the reliability of videoconferencing for remote consultation of people with diabetes. Results of this proposed study will provide evidence of the reliability of specialist consultation offered by videoconference for people with diabetes.

Trial registration number

Australian New Zealand Clinical Trials Registry ACTRN12612000315819.

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.

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.

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.

Geriatric teledermatology: store-and-forward vs. face-to-face examination

BACKGROUND

Telemedicine could be useful in countries like Italy to meet the needs of elderly patients and in particular in those in precarious general conditions, for whom travelling even short distances can pose considerable practical and economical difficulties.

OBJECTIVE

The aim of this study was to determine the efficacy of store-and-forward teledermatology vs face-to-face consultations in elderly patients.

METHODS

A total of 130 geriatric patients with skin diseases requiring dermatological examination were enrolled. The patients examined, consisting of 60 men (46.15%) and 70 women (53.85%), were aged between 66 and 97 years (mean age 80.58 years). Three dermatologists of the department, with equal experience took turns in face-to-face examination and teledermatology (store-and-forward). To compare face-to-face dermatological examinations with the asynchronous store-and-forward approach of teledermatology, we considered diagnostic agreement (ICD-9 code), therapeutic agreement and concordance of diagnostic confidence.

RESULTS

One hundred and fourteen of 130 patients were diagnosed with the same ICD-9 code, making a total observed agreement of 87.7% with a Cohen's κ estimated of 0.863. Agreement between therapies was 69.6% (Cohen's κ = 0.640). As it concerns diagnostic confidence, dermatologists appeared generally slightly less certain of their diagnosis by telemedicine.

CONCLUSIONS

Store-and-forward teledermatology can improve diagnostic and therapeutic care for skin disease in elderly who lack easy and/or direct access to dermatologists.

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.

Pediatric obesity management in rural clinics in California and the role of telehealth in distance education

OBJECTIVE

To determine health care provider needs related to pediatric obesity management in rural California and to explore strategies to improve care through telehealth.

METHODS

Cross-sectional survey of health care providers who treated children and adolescents at 41 rural clinics with existing telehealth connectivity.

RESULTS

Most of the 135 respondents were family physicians at designated rural health clinics serving low-income families. Respondents had practiced in rural areas for an average of 10 years. Most providers rated their self-efficacy in managing pediatric obesity as 2 or 3 on a 5-point scale. The barriers most frequently reported by health care providers were lack of local weight management programs, lack of patient motivation, and lack of family involvement in treatment. Providers reported that the resources they would find most helpful were readily accessible patient education materials, strategies to link patients with community treatment programs and training in brief, focused counseling skills. Three-quarters of providers already used telehealth for distance learning. Providers reported very high interest in participating in continuing education on pediatric obesity delivered by telehealth, specifically Internet communication with specialists, web-based education, and interactive video case-conferencing.

CONCLUSIONS

Rural health care providers face several barriers related to pediatric obesity management. Targeted interventions provided via telehealth to rural health care providers may enhance the care of obese children and adolescents. The results of this study provide directions and priorities for the design of appropriate interventions.

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.