An assessment of the cost-effectiveness, safety of referral and patient satisfaction of a general practice teledermatology service

Insights, Advantages, and Barriers of Teledermatology vs. Face-to-Face Dermatology for the Diagnosis and Follow-Up of Non-Melanoma Skin Cancer: A Systematic Review

BACKGROUND

Teledermatology is employed in the diagnosis and follow-up of skin cancer and its use was intensified during and after the COVID-19 pandemic. At the same time, demographic changes result in an overall increase in non-melanoma skin cancer and skin precancerous lesions. The aim of this study was to elucidate the role of teledermatology in comparison to conventional face-to-face dermatology for such lesions and determine the advantages and limitations of this workflow for patients and physicians.

METHODS

Research was performed using relevant keywords in MEDLINE and CENTRAL. Relevant articles were chosen following a predetermined standardized extraction form.

RESULTS

Diagnostic accuracy and interrater/intrarater agreement can be considered comparable-although lower-than in-person consultation. Improvement of particular features such as image quality, medical history availability, and teledermoscopy can further increase accuracy. Further aspects of limitations and advantages (mean time-to-assessment, time-to-treatment, cost-effectiveness) are discussed.

CONCLUSIONS

Teledermatology has comparable diagnostic accuracy with face-to-face dermatology and can be utilized both for the effective triage of non-melanocytic epithelial tumors and precancerous lesions, as well as the follow-up. Easy access to dermatologic consultation with shorter mean times to diagnostic biopsy and/or treatment coupled with cost-effectiveness could compensate for the lower sensitivity of teledermatology and offer easier access to medical care to the affected populations.

Implementation evaluation of a teledermatology virtual clinic at an academic medical center

BACKGROUND

Teledermatology (TD) is an evidence-based practice that may increase access to dermatologic care. We sought to use the Exploration, Preparation, Implementation, and Sustainment (EPIS) and the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) frameworks to evaluate implementation of TD at Duke.

METHODS

The EPIS and RE-AIM frameworks were deployed to design and implement a TD program that leveraged the strengths of the Duke University Health System and addressed previously reported barriers to implementation of store-and-forward and synchronous TD models. In the resultant hybrid TD model, trained primary care providers (PCPs) sent e-comm referrals with clinical and dermatoscopic images to dermatology. These e-consults were reviewed asynchronously and patients were scheduled for a synchronous video visit with dermatology within days. Dermatologists managed the patient plan. This hybrid TD model was piloted at four primary care clinics. Pertinent outcomes from a TD-adapted RE-AIM framework were tracked using electronic health record data. Patient satisfaction was assessed using a post-video visit survey (n = 18). Implementation barriers and facilitators were also collected through provider surveys (n = 24 PCPs, n = 10 dermatologists, n = 10 dermatology residents).

RESULTS

At four PCP clinics throughout 9/1/2021-4/30/2022, there were 218 TD referrals. Video visits occurred on average 7.5 ± 0.5 days after referral and 18/18 patients completing the post-visit survey were satisfied. Adoption varied between clinics, with one placing 22% of all dermatology referrals as TD and another placing 2%. The primary PCP barriers to TD were time burdens, lack of fit in clinic flow, and discomfort with image taking. Top-endorsed potential facilitating interventions included allowing for rash referrals without dermoscopy and assurance for clinical evaluation within 3 days.

CONCLUSIONS

The use of implementation science frameworks allowed for identification of system and contextual strengths which informed the hybrid TD pilot. Barriers and facilitating interventions will provide guidance for expansion and ongoing maintenance of TD.

Acceptance of Telemedicine Compared to In-Person Consultation From the Providers' and Users' Perspectives: Multicenter, Cross-Sectional Study in Dermatology

BACKGROUND

Teledermatology is currently finding its place in modern health care worldwide as a rapidly evolving field.

OBJECTIVE

The aim of this study was to investigate the acceptance of teledermatology compared to in-person consultation from the perspective of patients and professionals.

METHODS

This multicenter, cross-sectional pilot study was performed at secondary and tertiary referral centers of dermatology in Switzerland from August 2019 to January 2020. A customized questionnaire addressing demographics and educational data, experience with telemedicine, and presumed willingness to replace in-patient consultations with teledermatology was completed by dermatological patients, dermatologists, and health care workers in dermatology.

RESULTS

Among a total of 664 participants, the ones with previous telemedicine experience (171/664, 25.8%) indicated a high level of overall experience with it (patients: 73/106, 68.9%, dermatologists: 6/8, 75.0%, and health care workers: 27/34, 79.4%). Patients, dermatologists, and health care workers were most likely willing to replace in-person consultations with teledermatology for minor health issues (353/512, 68.9%; 37/45, 82.2%; and 89/107, 83.2%, respectively). We observed a higher preference for telemedicine among individuals who have already used telemedicine (patients: P<.001, dermatologists: P=.03, and health care workers, P=.005), as well as among patients with higher educational levels (P=.003).

CONCLUSIONS

This study indicates that the preference for teledermatology has a high potential to increase over time since previous experience with telemedicine and a higher level of education were associated with a higher willingness to replace in-patient consultations with telemedicine. We assume that minor skin problems are the most promising issue in teledermatology. Our findings emphasize the need for dermatologists to be actively involved in the transition to teledermatology.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04495036; https://classic.clinicaltrials.gov/ct2/show/NCT04495036.

Implementation Evaluation of a Teledermatology Virtual Clinic at an Academic Medical Center

Background

Teledermatology (TD) is an evidence-based practice that may increase access to dermatologic care. We sought to evaluate implementation of TD at four Duke primary care practices.

Methods

We implemented a hybrid TD program where trained primary care providers (PCPs) sent referrals with clinical and dermatoscopic images to dermatology. Patients were seen by dermatologists over video visit within days, and dermatologists managed the patient plan. We evaluated implementation using the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework using electronic health record data. Implementation barriers and facilitators were collected through surveys (n = 24 PCPs, n = 10 dermatologists, n = 10 dermatology residents).

Results

At four PCP clinics throughout 9/1/2021-4/30/2022 there were 218 TD referrals. Video visits occurred on average 7.5 days after referral and 18/18 patients completing the post-visit survey were satisfied. Adoption varied between clinics, with one placing 22% of all dermatology referrals as TD and another placing 2%. The primary PCP barriers to TD were time burdens, lack of fit in clinic flow, and discomfort with image taking. Top-endorsed potential facilitating interventions included allowing for rash referrals without dermoscopy and assurance for clinical evaluation within 3 days.

Conclusions

Addressing TD process fit into PCP clinic flow and reducing time burdens may increase PCP uptake of TD.

Telehealth Strategies to Support Referral Management to Secondary Care in Brazil: A Cost-Effectiveness Analysis

OBJECTIVES

This study aimed to assess the cost-effectiveness of a remotely operated referral management system (RORMS) compared with a conventional referral management system (CRMS) in Brazil.

METHODS

This is a model-based cost-effectiveness analysis under the perspective of the Unified Healthcare System (Sistema Único de Saúde [SUS]) in Brazil. A Markov microsimulation model was developed to compare costs and referral outcomes of the RORMS and the CRMS. Model consisted of 4 states representative of sequential stepwise assessments of referral suitability, 3 states representative of referral outcomes, and 1 exit model state. Target population represented cases being referred from primary healthcare units to specialized care in SUS. Model inputs related to costs and effectiveness in the RORMS arm were obtained from the data set of a RORMS between July and December 2019. Model inputs for the CRMS model arm were obtained from administrative data sets of 2 Brazilian localities for the year 2019. Relative effect size of RORMS in comparison with CRMS in SUS was obtained from published studies. Effectiveness outcome was unnecessary referrals averted. The incremental cost-effectiveness ratio was calculated for the base case. Probabilistic sensitivity analysis was conducted.

RESULTS

In the base-case analyses, RORMS dominated CRMS, with expected cost-savings from $50.42 to $80.62 per unnecessary referral averted. RORMS was the dominant strategy in 83.7% of 100 000 simulations in the probabilistic sensitivity analysis. In 16.2% of simulations, incremental cost-effectiveness ratio was between $0 and $222 per unnecessary referral averted.

CONCLUSIONS

Model-based simulations indicate that the RORMS is likely to be cost saving in comparison with the CRMS.

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

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

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

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

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Intervention

Implementation of the TD triage system in January 2015.

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Needs, barriers and facilitators of older adults towards eHealth in general practice: a qualitative study

Background:

The strain on health care services is increasing due to an ageing population and the increasing prevalence of chronic health conditions. eHealth could contribute to optimise effective and efficient care to older adults with one or more chronic health conditions in the general practice.

Aim:

The aim of this study was to identify the needs, barriers and facilitators amongst community-dwelling older adults (60+) suffering from one or more chronic health conditions, in using online eHealth applications to support general practice services.

Methods:

A qualitative study, using semi-structured followed by think-aloud interviews, was conducted in the Netherlands. The semi-structured interviews, supported by an interview guide were conducted and analysed thematically. The think-aloud method was used to collect data about the cognitive process while the participant was completing a task within online eHealth applications. Verbal analysis according to the Chi approach was conducted to analyse the think-aloud interviews.

Findings:

A total of n = 19 older adults with a mean age of 73 years participated. The ability to have immediate contact with the GP on important health issues was identified as an important need. Identified barriers were non-familiarity with the online eHealth applications and a mismatch of user health needs. The low computer experience resulted in non-familiarity with the online eHealth applications. Faltering applications resulted in participants refusing to participate in the use of online eHealth applications. Convenience, efficiency and the instant availability of eHealth via applications were identified as important facilitators.

Conclusion:

To improve the use and acceptability of eHealth applications amongst older adults in the general practice, the applications should be tailored to meet individual needs. More attention should be given to improving the user-friendliness of these applications and to the promotion of the benefits such as facilitating older adults independent living for longer.

Definitions, survey methods, and findings of patient satisfaction studies in teledermatology: a systematic review

Remote consultations likely will grow in importance if the COVID-19 pandemic continues. This review analyzes which methods of teledermatology patients prefer by categorizing how recent studies have defined satisfaction, conducted surveys and concluded patients respond to the different modalities of teledermatology. Using PubMed and Cochrane databases, we reviewed studies from April 5th, 2010 to April 5th, 2020 that included the search terms patient satisfaction and teledermatology. All studies that included patient satisfaction as an outcome were included, but studies not published in English were excluded. We examined domains of satisfaction, survey method, study characteristics (including patient population, country, age, study design and evidence score), findings and statistical comparisons. We thoroughly reviewed 23 studies. Definitions of satisfaction varied, but all concluded patients were satisfied with the live-interactive and store-and-forward modalities. The studies reveal that store-and-forward is appropriate for clinicians with established patients who require regular follow-up. Verified areas of care include treatment of chronic conditions, topical skin cancer therapy, wound monitoring, and post-procedural follow-up. Only four studies conducted statistical analyses. One of those studies compared patient preference for each modality of teledermatology with face-to-face dermatology. While this study reported high satisfaction with each mode of teledermatology, patients still preferred face-to-face. Favorable responses to remote diagnostic capabilities suggest that these offerings improve preference for teledermatology. With only one study evaluating preference between each modality and face-to-face dermatology, more studies should address the discrepancy. Surveys that cover all domains of satisfaction may improve assessments and identify where gaps in preference exist.

Primary Care Professionals' Acceptance of Medical Record-Based, Store and Forward Provider-to-Provider Telemedicine in Catalonia: Results of a Web-Based Survey

While telemedicine services enjoy a high acceptance among the public, evidence regarding clinician’s acceptance, a key factor for sustainable telemedicine services, is mixed. However, telemedicine is generally better accepted by both patients and professionals who live in rural areas, as it can save them significant time. The objective of this study is to assess the acceptance of medical record-based, store and forward provider-to-provider telemedicine among primary care professionals and to describe the factors which may determine their future use. This is an observational cross-sectional study using the Catalan version of the Health Optimum questionnaire; a technology acceptance model-based validated survey comprised of eight short questions. The online, voluntary response poll was sent to all 661 primary care professionals in 17 primary care teams that had potentially used the telemedicine services of the main primary care provider in Catalonia, in the Central Catalan Region. The majority of respondents rated the quality of telemedicine consultations as “Excellent” or “Good” (83%). However, nearly 60% stated that they sometimes had technical, organizational or other difficulties, which might affect the quality of care delivered. These negatively predicted their declared future use (p = 0.001). The quality of telemedicine services is perceived as good overall for all the parameters studied, especially among nurses. It is important that policymakers examine and provide solutions for the technical and organizational difficulties detected (e.g., by providing training), in order to ensure the use of these services in the future.

Patient Satisfaction and Expectations Regarding Mobile Teledermoscopy in General Practice for Diagnosis of Non-melanoma Skin Cancer and Malignant Melanoma

The incidence of non-melanoma skin cancer and malignant melanoma is increasing. Diagnosing these skin lesions is primarily done visually, making it suitable to use new technology, such as teledermoscopy. Before the implementation of teledermoscopy, patient satisfaction, clinician satisfaction and diagnostic accuracy, need to be evaluated. A cross-sectional quantitative survey was conducted to evaluate patient satisfaction and expectations regarding a mobile teledermoscopy service, and to identify factors influencing patient satisfaction and choice of diagnostic method. A total of 287 out of 476 participants responded to the questionnaire. Almost 90% of respondents were satisfied with, or neutral towards, teledermoscopy. No associations between patient satisfaction and age, smartphone/tablet usage, travel time, prior history of non-melanoma skin cancer and malignant melanoma, or worries about malignancy, were found. There was equal distribution between patients who preferred teledermoscopy and those who preferred face-to-face consultation. Respondents with a high level of smartphone usage significantly preferred teledermoscopy.

Clinical effectiveness and cost-effectiveness of teledermatology: Where are we now, and what are the barriers to adoption?

There has been rapid growth in teledermatology over the past decade, and teledermatology services are increasingly being used to support patient care across a variety of care settings. Teledermatology has the potential to increase access to high-quality dermatologic care while maintaining clinical efficacy and cost-effectiveness. Recent expansions in telemedicine reimbursement from the Centers for Medicare & Medicaid Services (CMS) ensure that teledermatology will play an increasingly prominent role in patient care. Therefore, it is important that dermatologists be well informed of both the promises of teledermatology and the potential practice challenges a continuously evolving mode of care delivery brings. In this article, we will review the evidence on the clinical and cost-effectiveness of teledermatology and we will discuss system-level and practice-level barriers to successful teledermatology implementation as well as potential implications for dermatologists.

Dermoscopy for melanoma detection and triage in primary care: a systematic review

OBJECTIVE

Most skin lesions first present in primary care, where distinguishing rare melanomas from benign lesions can be challenging. Dermoscopy improves diagnostic accuracy among specialists and is promoted for use by primary care physicians (PCPs). However, when used by untrained clinicians, accuracy may be no better than visual inspection. This study aimed to undertake a systematic review of literature reporting use of dermoscopy to triage suspicious skin lesions in primary care settings, and challenges for implementation.

DESIGN

A systematic literature review and narrative synthesis.

DATA SOURCES

We searched MEDLINE, Cochrane Central, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and SCOPUS bibliographic databases from 1 January 1990 to 31 December 2017, without language restrictions.

INCLUSION CRITERIA

Studies including assessment of dermoscopy accuracy, acceptability to patients and PCPs, training requirements, and cost-effectiveness of dermoscopy modes in primary care, including trials, diagnostic accuracy and acceptability studies.

RESULTS

23 studies met the review criteria, representing 49 769 lesions and 3708 PCPs, all from high-income countries. There was a paucity of studies set truly in primary care and the outcomes measured were diverse. The heterogeneity therefore made meta-analysis unfeasible; the data were synthesised through narrative review. Dermoscopy, with appropriate training, was associated with improved diagnostic accuracy for melanoma and benign lesions, and reduced unnecessary excisions and referrals. Teledermoscopy-based referral systems improved triage accuracy. Only three studies examined cost-effectiveness; hence, there was insufficient evidence to draw conclusions. Costs, training and time requirements were considered important implementation barriers. Patient satisfaction was seldom assessed. Computer-aided dermoscopy and other technological advances have not yet been tested in primary care.

CONCLUSIONS

Dermoscopy could help PCPs triage suspicious lesions for biopsy, urgent referral or reassurance. However, it will be important to establish further evidence on minimum training requirements to reach competence, as well as the cost-effectiveness and patient acceptability of implementing dermoscopy in primary care.

TRIAL REGISTRATION NUMBER

CRD42018091395.

Disconnected: a survey of users and nonusers of telehealth and their use of primary care

OBJECTIVE

The study sought to assess awareness, perceptions, and value of telehealth in primary care from the perspective of patients.

MATERIALS AND METHODS

We conducted a cross-sectional, Web-based survey of adults with access to telehealth services who visited healthcare providers for any of the 20 most-commonly seen diagnoses during telehealth visits. Three groups were studied: registered users (RUs) of telehealth had completed a LiveHealth Online (a health plan telehealth service provider) visit, registered nonusers (RNUs) registered for LiveHealth Online but had not conducted a visit, and nonregistered nonusers (NRNUs) completed neither step.

RESULTS

Of 32 831 patients invited, 3219 (9.8%) responded and 766 met eligibility criteria and completed surveys: 390 (51%) RUs, 117 (15%) RNUs, and 259 (34%) NRNUs. RUs were least likely to have a primary care usual source of care (65.6% vs 78.6% for RNUs vs 80.0% for NRNUs; P < .001). Nearly half (46.8%) of RUs were unable to get an appointment with their doctor, and 34.8% indicated that their doctor's office was closed. Among the 3 groups, RUs were most likely to be employed (89.5% vs 88.9% vs 82.2%; P = .007), have post-high school education (94.4% vs 93.2% vs 86.5%; P = .003), and live in urban areas (81.0% vs 69.2% vs 76.0%; P = .021).

CONCLUSIONS

Telehealth users reported that they relied on live video for enhanced access and were less connected to primary care than nonusers were. Telehealth may expand service access but risks further fragmentation of care and undermining of the primary care function absent better coordination and information sharing with usual sources of patients' care.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparative effectiveness study of face-to-face and teledermatology workflows for diagnosing skin cancer

BACKGROUND

The effectiveness and value of teledermatology and face-to-face workflows for diagnosing lesions are not adequately understood.

OBJECTIVE

We compared the risks of biopsy and cancer diagnosis among 2 face-to-face workflows (direct referral and roving dermatologist) and 4 teledermatology workflows.

METHODS

Retrospective study of 59,279 primary care patients presenting with a lesion from January through June 2017.

RESULTS

One teledermatology workflow achieved high-resolution images with use of a dermatoscope-fitted digital camera, a picture archiving and communication system, and image retrieval to a large computer monitor (in contrast to a smartphone screen). Compared with direct referral, this workflow was associated with a 9% greater probability of cancer detection (95% confidence interval [CI], 2%-16%), a 4% lower probability of biopsy (relative risk, 0.96; 95% CI, 0.93-0.99), and 39% fewer face-to-face visits (relative risk, 0.61; 95% CI, 0.57-0.65). Other workflows were less effective.

LIMITATIONS

Differing proficiencies across teledermatology workflows and selection of patients for direct referral could have caused bias.

CONCLUSION

Implementation is critical to the effectiveness of teledermatology.

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

Objective

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

Methods

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

Results

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

Conclusion

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

A cost savings analysis of asynchronous teledermatology compared to face-to-face dermatology in Catalonia

BACKGROUND

A teledermatology pilot scheme was first conducted in the town of Manresa (Barcelona) in the summer of 2010. The clinical success of the scheme prompted its expansion to the whole county of Bages in 2011 and to the adjacent county of Berguedà in 2012. In the teledermatology service, primary care physicians take a photograph of the lesion and attach it to the electronic medical records of the patient together with a brief clinical account. In the referral hospital, the consultant dermatologists access the electronic medical records, review the images and suggest a treatment or action plan. Next, the primary care physicians review these recommendations and call the patient to report the results. This whole process is usually completed in less than 5 working days.

METHODS

A cost saving analysis comparing teledermatology with dermatology face-to-face visits was performed in the county of Bages measuring the cost difference attributable to visits saved.

RESULTS

The estimated added costs of the teledermatology service during 2016 amounted to 61,870 €. For the same period, the estimated costs of traditional outpatient dermatology services were of 113,034 €. This represents savings of 51,164 € per year. After subtraction of societal costs, the savings equal 10,350 € per year.

CONCLUSIONS

Using a teledermatology service instead of face-to-face dermatology consultations could save 51,164 € per year (11.4 € per patient visited) in the county of Bages. Societal savings are the most significant.

Recent trends in teledermatology and teledermoscopy

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

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

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

Patient and Provider Satisfaction with Teledermatology

BACKGROUND

There is little research comparing dermatologist and patient satisfaction with in-person, store-and-forward, and live interactive examinations.

OBJECTIVE

To compare satisfaction with in-person examinations to store-and-forward and live interactive consultations having two types of video.

METHODS

A controlled study was conducted where patients referred for dermatology consultations were examined in-person, by video, and by store-and-forward methods. Video changed between compressed and uncompressed on alternate clinics. Patients and dermatologists rated encounters after each examination. Dermatologists doing store-and-forward evaluations rated the quality of information provided. After experiencing all methods patients ranked their preferences. Dermatologists ranked their preferences at the end of the study.

RESULTS

In-person examinations were preferred by both patients and dermatologists. Overall, satisfaction with teledermatology was still high. Patients were evenly divided in preferring store-and-forward workups or live interactive video. Dermatologists were also divided on store-and-forward and uncompressed video, but tended toward the latter. Compressed video was the least preferred method among dermatologists.

LIMITATIONS

Dermatology residents took store-and-forward photos and their quality was likely superior to those normally taken in practice.

CONCLUSIONS

Patients and dermatologists prefer in-person examinations and diverge on preferring store-and-forward and live interactive when video is not compressed. The amount of video compression that can be applied without noticeable image degradation is a question for future research.

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.

A systematic review of satisfaction with teledermatology

Background The two most commonly used modalities of teledermatology (TD) are store-and-forward (SF) and live-interactive (LI) TD. Existing studies have not compared these tools with respect to patient and provider satisfaction. Objective To systematically review all published studies of patient and provider satisfaction with SF and LI TD. Methods PubMed, EMBASE, and Cochrane databases were systematically searched for studies on provider or patient satisfaction with SF or LI TD between January 2000 and June 2016. Results Forty eligible studies were identified: 32 with SF TD, 10 with LI TD, and 2 evaluating both. With SF TD, 96% of studies assessing patient satisfaction and 82% of studies assessing provider satisfaction demonstrated satisfaction ( n = 24 and 17, respectively). With LI TD, 89% of studies assessing patient satisfaction and all studies assessing provider satisfaction revealed satisfaction (n = 9 and 6, respectively). Conclusion Patients and providers are satisfied with both SF and LI TD. Studies assessing satisfaction with LI have not been conducted in recent years, and have only been conducted in limited geographic patient populations. Further research assessing satisfaction with TD will help address any dissatisfaction with its uses and allow for increased support and funding of future programmes.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

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.

Patient and practitioner satisfaction with tele-dermatology including Australia's indigenous population: A systematic review of the literature

Background

Australia’s health disparity, combined with evolving technologies, has evoked increasing interest and funding in health services that could address inequities. One such emerging service is tele-medicine.

Objective

The purpose of this report is to discuss and evaluate the current literature regarding patient and practitioner satisfaction with tele-medicine, and more specifically tele-dermatology.

Methods

We searched for literature relevant to tele-dermatology use among Australia’s indigenous population. We synthesized the literature in our report and identified elements of tele-dermatology not yet researched.

Results

Most significantly, all available research is currently based on descriptive studies and there is no validated tool to assess the efficacy of tele-dermatology.

Limitations

No published research currently exists on the use of tele-dermatology among Australia’s indigenous population.

Conclusion

A review of the literature shows that tele-dermatology is considered a valuable service, particularly to patients living in rural areas who might not otherwise have access to specialist care.