Diagnostic accuracy and image quality using a digital camera for teledermatology

Impact of dermoscopy-aided pediatric teledermatology program on the accessibility and efficiency of dermatology care at community health centers

BACKGROUND

There are few studies focusing on pediatric teledermatology, and the impact of a large-scale pediatric teledermatology program on the accessibility and efficiency of dermatology care remains unclear. This study evaluated the impact of a state-wide implementation of a store-and-forward teledermatology program augmented by the incorporation of dermoscopy in pediatric patients visiting community health centers.

METHODS

It was a descriptive, retrospective cohort study of 876 pediatric dermatology referrals.

RESULTS

In the traditional referral system, only 60 patients (17.6%) were seen by dermatologists with average waiting times of 75 days due to limited access. In comparison, with an implementation of dermoscopy-aided teledermatology, all 536 teledermatology referrals received dermatological care within 24 h, of which only 64 (12%) patients requires face-to-face (F2F) consultation. Patients referred for F2F consultation via eConsults had a much lower no-show rate as compared to the traditional referral system (39% vs. 71%). Side by side comparison between general population and pediatric population has demonstrated shared features in efficiency and access improvement but revealed specific characteristics of pediatric teledermatology in terms of diagnosis and treatment.

CONCLUSION

Coordinated store-and-forward teledermatology platform with incorporation of dermoscopy between large community care network and dermatology provider can greatly improve access to pediatric dermatology care especially in underserved population. The efficiency of teledermatology in access improvement for pediatric population is comparable with adult population in eConsults. There are also unique features and challenges in pediatric teledermatology that require further research.

Minimum resolution requirements of digital pathology images for accurate classification

Digitization of pathology has been proposed as an essential mitigation strategy for the severe staffing crisis facing most pathology departments. Despite its benefits, several barriers have prevented widespread adoption of digital workflows, including cost and pathologist reluctance due to subjective image quality concerns. In this work, we quantitatively determine the minimum image quality requirements for binary classification of histopathology images of breast tissue in terms of spatial and sampling resolution. We train an ensemble of deep learning classifier models on publicly available datasets to obtain a baseline accuracy and computationally degrade these images according to our derived theoretical model to identify the minimum resolution necessary for acceptable diagnostic accuracy. Our results show that images can be degraded significantly below the resolution of most commercial whole-slide imaging systems while maintaining reasonable accuracy, demonstrating that macroscopic features are sufficient for binary classification of stained breast tissue. A rapid low-cost imaging system capable of identifying healthy tissue not requiring human assessment could serve as a triage system for reducing caseloads and alleviating the significant strain on the current workforce.

Inter-rater variability in patch test readings and final interpretation using store-forward teledermatology

BACKGROUND

Data regarding teledermatology for patch testing are limited.

OBJECTIVES

Compare patch test readings and final interpretation by two in-person dermatologists (IPDs) with eight teledermatologists (TDs).

METHODS

Patch tested patients had photographs taken of 70 screening series of allergens at 48 hours and second readings. Eight TDs reviewed photos and graded reactions (negative, irritant, doubtful, +, ++, +++) at 48 hours and second readings; in addition, they coded a final interpretation (allergic, indeterminant, irritant, negative) for each reaction. TDs rated overall image quality and confidence level for each patient and patch test reaction, respectively. Percentage of TD-IPD agreement based on clinical significance (success, indeterminate, and failure) was calculated. Primary outcome was agreement at the second reading.

RESULTS

Data were available for 99, 101, and 66 participants at 48 hours, second reading, and final interpretation, respectively. Pooled failure (+/++/+++ vs negative) at second reading was 13.6% (range 7.9%-20.4%). Pooled failure at 48 hours and final interpretation was 5.4% (range 2.9%-6.8%) and 24.6% (range 10.2%-36.8%), respectively. Confidence in readings was statistically correlated with quality of images and disagreement.

CONCLUSION

For patch testing, teledermatology has significant limitations including clinically significant pooled failure percentages of 13.6% for second readings and 24.6% for final interpretation.

Teledermatology Addressing Disparities in Health Care Access: a Review

Purpose of Review

Dermatologists have been at the forefront of researching telemedicine to expand access to care. The current COVID-19 pandemic has prompted even greater expansion and implementation of teledermatology. This review discusses the research examining the potential impact of teledermatology addressing disparities in care.

Recent Findings

Teledermatology appears to increase access to dermatology given expanded means to deliver care. Specifically, recent studies have found increased access among Medicaid-insured, resource-poor urban and rural, and elderly populations. Teledermatology implementation also facilitates education among providers at different levels of training. Still, as some patients have inconsistent access to the required technology, increased reliance on telemedicine may also potentially increase disparities for some populations.

Summary

Teledermatology may serve to reduce disparities in health care access in many underserved and marginalized communities. Future research should continue to study implementation, especially given the expansion during the COVID-19 pandemic. Ultimately, teledermatology may play an important role in ensuring equitable care access for all.

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

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

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.

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.

Patient satisfaction with dermatology teleconsultation by using MedX

BACKGROUND

The development of telecommunication has strongly affected comprehensive scientific disciplines, including medical sciences.

OBJECTIVE

This study aims to assess the patient satisfaction of the teleconsultation system used for the consultation of dermatological follow-up care.

METHODS

The study was performed cross sectional patient satisfaction survey method conducted between February and April 2017 to determine patient satisfaction using MedX teleconsultation system. The patient sample of the current study was recruited from cosmetic laser clinic, Wanfang and Taipei Medical University hospital. The study was performed on 32 patient (n = 32) participants. All of them were at least university graduate. Consultants and patients were handled using the Android-based MedX mobile application, which is available through an application for Google Android cellular telephones. Its application consists of a demographic information, structured step-by-step questionnaire, essential medical information about each patient, and digital images of skin lesions.

RESULTS

28 patients completed the questionnaire. The mean ± SD age of the patients was 27.25 ± 4.039 years; 78.6% were women. The study shows that respondents have reported a high level (85.8%) of mean overall satisfaction for the teleconsultation service. The usability of the system has highest satisfaction rate of 90.5% among the other subscales especially in terms of data transfer and data displayed. Responses of the patient satisfaction questionnaire were analyzed by age and gender, no statistically significant difference between the variables was found.

CONCLUSION

Patients have shown high satisfaction with teleconsultation service and it is well accepted in the management of cosmetic dermatology service. In the future, MedX application can be integrated into other instant messaging applications such as Line, thus allowing doctors and patients to easily communicate with each other.

Teledermatology: A Review and Update

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

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

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.

Automatic colour correction of digital skin images in teledermatology

We have developed an algorithm for automatic colour correction of skin images obtained in imperfect conditions. The algorithm has been incorporated into a computer program, TransImage. In a set of 31 digital skin images (including cases of dermatitis, eczema, mycotic lesions and skin cancer), 19 images underwent colour correction with the computer program, while 12 remained uncorrected. The images were presented to three experienced dermatologists who reviewed them without knowing if they had been corrected or not. The mean colour accuracy score (on a scale from 1 = very poor to 5 = excellent) for the corrected skin images was 4.1, while the mean score for uncorrected images was 3.7; the difference was significant (P<0.05). Using the 19 corrected images, the dermatologists made 11 inaccurate diagnoses out of 57 (a mean diagnostic accuracy of 81 %). Using the 12 uncorrected images, three dermatologists made 16 inaccurate diagnoses out of 36 (i.e. a mean diagnostic accuracy of 56%); the difference was significant (P<0.05). Colour correction increased the diagnostic accuracy of teledermatology.

Potential effect of patient-assisted teledermatology on outpatient referral rates

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

Practice Guidelines for Teledermatology

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

The Utility of Digital Clinical Photographs in Dermatopathology

Background and Objective:

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

Methods:

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

Results:

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

Conclusion:

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

"Evaluation of a very low-cost and simple teleradiology technique"

This paper describes and analyzes a proposed solution of fundamental limitative factor of teleradiology to overcome the teleradiology usages problems in underdeveloped and developing countries. The goal is to achieve a very simple and cost-efficient way to take advantage of teleradiology in anywhere even in remote and rural areas. To meet the goal of this study, the following methodology which is consists of two main procedures was done: (1) Using a digital camera in order to provide a digital image from radiographs. (2) Using an image compression tool in order to compress digital images. The results showed that there is no significant difference between digital images (non-compress and compress images) and radiographic films. Also, there was a logic relationship between the diagnostic quality and diagnostic accuracy. Since the maximum percent of diagnostic accuracy can be seen among "Good" quality images and the minimum to was related "Poor". The results of our study indicate that a digital camera could be utilized to capture digital images from radiographic films of chest x-ray. To reduce the size of digital images, a lossy compression technique could be applied at compression percent of 50 or less without any significant differences. The compressed images can be sent easily by email to other places for consultation and also they can be stored with a smaller size.

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.

A Browser-Server-Based Tele-audiology System That Supports Multiple Hearing Test Modalities

INTRODUCTION

Millions of global citizens suffering from hearing disorders have limited or no access to much needed hearing healthcare. Although tele-audiology presents a solution to alleviate this problem, existing remote hearing diagnosis systems support only pure-tone tests, leaving speech and other test procedures unsolved, due to the lack of software and hardware to enable communication required between audiologists and their remote patients. This article presents a comprehensive remote hearing test system that integrates the two most needed hearing test procedures: a pure-tone audiogram and a speech test.

MATERIALS AND METHODS

This enhanced system is composed of a Web application server, an embedded smart Internet-Bluetooth(®) (Bluetooth SIG, Kirkland, WA) gateway (or console device), and a Bluetooth-enabled audiometer. Several graphical user interfaces and a relational database are hosted on the application server. The console device has been designed to support the tests and auxiliary communication between the local site and the remote site.

RESULTS

The study was conducted at an audiology laboratory. Pure-tone audiogram and speech test results from volunteers tested with this tele-audiology system are comparable with results from the traditional face-to-face approach.

CONCLUSIONS

This browser-server-based comprehensive tele-audiology offers a flexible platform to expand hearing services to traditionally underserved groups.

Digital photography in skin cancer screening by mobile units in remote areas of Brazil

BACKGROUND

Non-melanoma skin cancer (NMSC) is one of the most common neoplasms in the world. Despite the low mortality rates, NMSC can still cause severe sequelae when diagnosed at advanced stages. Malignant melanoma, the third most common type of skin cancer, has more aggressive behavior and a worse prognosis. Teledermatology provides a new tool for monitoring skin cancer, especially in countries with a large area and unequal population distribution. This study sought to evaluate the performance of digital photography in skin cancer diagnosis in remote areas of Brazil.

METHODS

A physician in a Mobile Prevention Unit (MPU) took four hundred sixteen digital images of suspicious lesions between April 2010 and July 2011. All of the photographs were electronically sent to two oncologists at Barretos Cancer Hospital who blindly evaluated the images and provided a diagnosis (benign or malignant). The absolute agreement rates between the diagnoses made by direct visual inspection (by the MPU physician) and through the use of digital imaging (by the two oncologists) were calculated. The oncologists' accuracy in predicting skin cancer using digital imaging was assessed by means of overall accuracy (correct classification rate), sensitivity, specificity and predictive value (positive and negative). A skin biopsy was considered the gold standard.

RESULTS

Oncologist #1 classified 59 lesions as benign with the digital images, while oncologist #2 classified 27 lesions as benign using the same images. The absolute agreement rates with direct visual inspection were 85.8% for oncologist #1 (95% CI: 77.1-95.2) and 93.5% for oncologist #2 (95% CI: 84.5-100.0). The overall accuracy of the two oncologists did not differ significantly.

CONCLUSIONS

Given the high sensitivity and PPV, Teledermatology seems to be a suitable tool for skin cancer screening by MPU in remote areas of Brazil.

Understanding visual search patterns of dermatologists assessing pigmented skin lesions before and after online training

The goal of this investigation was to explore the feasibility of characterizing the visual search characteristics of dermatologists evaluating images corresponding to single pigmented skin lesions (PSLs) (close-ups and dermoscopy) as a venue to improve training programs for dermoscopy. Two Board-certified dermatologists and two dermatology residents participated in a phased study. In phase I, they viewed a series of 20 PSL cases ranging from benign nevi to melanoma. The close-up and dermoscopy images of the PSL were evaluated sequentially and rated individually as benign or malignant, while eye position was recorded. Subsequently, the participating subjects completed an online dermoscopy training module that included a pre- and post-test assessing their dermoscopy skills (phase 2). Three months later, the subjects repeated their assessment on the 20 PSLs presented during phase I of the study. Significant differences in viewing time and eye-position parameters were observed as a function of level of expertise. Dermatologists overall have more efficient search than residents generating fewer fixations with shorter dwells. Fixations and dwells associated with decisions changing from benign to malignant or vice versa from photo to dermatoscopic viewing were longer than any other decision, indicating increased visual processing for those decisions. These differences in visual search may have implications for developing tools to teach dermatologists and residents about how to better utilize dermoscopy in clinical practice.

Remote measurements of heart and respiration rates for telemedicine

Non-contact and low-cost measurements of heart and respiration rates are highly desirable for telemedicine. Here, we describe a novel technique to extract blood volume pulse and respiratory wave from a single channel images captured by a video camera for both day and night conditions. The principle of our technique is to uncover the temporal dynamics of heart beat and breathing rate through delay-coordinate transformation and independent component analysis-based deconstruction of the single channel images. Our method further achieves robust elimination of false positives via applying ratio-variation probability distributions filtering approaches. Moreover, it enables a much needed low-cost means for preventing sudden infant death syndrome in new born infants and detecting stroke and heart attack in elderly population in home environments. This noncontact-based method can also be applied to a variety of animal model organisms for biomedical research.

Pediatric teledermatology consultations: relationship between provided data and diagnosis

There is a shortage of pediatric dermatologists. Teledermatology has emerged as a tool to facilitate access to dermatologists. Many questions remain regarding how to optimize consultations in order to provide the best diagnosis and management recommendations. The aim of this retrospective cohort study was to categorize the historical data and judge the adequacy of photographs sent by referring providers to our academic pediatric teledermatology practice at the University of California, San Francisco, and to evaluate the relationship of these data to our ability to render a diagnosis. A diagnosis was rendered in 75% of cases. The only historical data associated with receiving a diagnosis was prior treatment (OR 2.01, CI 1.01, 4, p < 0.05). Appropriate image distance from the target was associated with receiving a diagnosis for rashes (OR 2.69, CI 1.07, 6.8, p = 0.04) and growths (OR 4.16, CI 1.04, 16.6, p = 0.04). A lack of diagnosis was significantly associated with a recommendation for referral for biopsy (OR 0.03, CI 0.01, 0.10, p < 0.0001) or for in-person consultation (OR 0.19, CI 0.05, 0.66, p < 0.001). In conclusion, pediatric teledermatologists are able to make a diagnosis most of the time, regardless of historical information provided or image quality. The rate of diagnosis may be improved with the use of standardized templates for historical information. Similarly, photography training could minimize the need for in-person consultation. Specific information regarding prior treatments could also help in providing useful management recommendations.

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.

The effect of image quality on the assessment of child abuse photographs

OBJECTIVES

Although child abuse pediatricians are frequently asked to evaluate risk of abuse based on photographs, the effect of photographic quality on this process is presently unknown. Photographs of abused children are often taken by professionals without photographic training, and quality varies widely. This article reports the first study of the effect of image quality on clinical assessment from photographs.

METHODS

A total of 120 images depicting 60 cutaneous lesions were selected for the study. Paired images of single lesions varied in quality of focus, exposure, or framing. Seventy medical and nursing professionals were recruited from the Internet listservs focusing on child abuse. Subjects evaluated the images for quality (1-9 scale), opined if the image was "inadequate for interpretation," and answered a clinical question about the type of lesion displayed. Accuracy was defined as concordance between the subject and the live examiner's written documentation. Adequacy was defined as the proportion of subjects that did not indicate that the photograph was inadequate for interpretation.

RESULTS

Mean accuracy among subjects was 64% and ranged from 35% to 84%. Accuracy was not predicted by subject profession, experience, or self-rated computer skill. Image quality and adequacy were independently associated with increased accuracy.

CONCLUSIONS

Higher-quality images improved accuracy. An examiner's impression that an image is adequate did not guarantee an accurate interpretation. Reliance on photographs alone is not sufficiently accurate in the assessment of cutaneous trauma.

Application of mobile teledermatology for skin cancer screening

BACKGROUND

With advancements in mobile technology, cellular phone-based store-and-forward teledermatology may be applied to skin cancer screening.

OBJECTIVE

We sought to determine diagnostic and management concordance between in-person and teledermatology evaluations for patients at skin cancer screening whose clinical images and history were transmitted through mobile phones.

METHODS

A total of 86 patients with 137 skin lesions presented to a skin cancer screening event in California. These patients' clinical history and skin images were captured by a software-enabled mobile phone. Patients were assessed separately by an in-person dermatologist and a teledermatologist, who evaluated the mobile phone-transmitted history and images. Diagnostic and management concordance was determined between the in-person and teledermatology evaluations.

RESULTS

The primary categorical diagnostic concordance was 82% between the in-person dermatologist and the teledermatologist (95% confidence interval 0.73-0.89), with a Kappa coefficient of 0.62 indicating good agreement. The aggregated diagnostic concordance between the in-person dermatologist and the teledermatologist was 62% (95% confidence interval 0.51-0.71), with Kappa coefficient of 0.60 indicating good agreement. Management concordance between the in-person dermatologist and the teledermatologist was 81% (95% confidence interval 0.72-0.88), with a Kappa coefficient of 0.57, which indicates moderate agreement between the dermatologists. Multivariate analysis showed that older age and presentation of atypical nevus were significantly associated with disagreement in diagnosis between the teledermatologist and in-person dermatologist, after adjusting for other factors.

LIMITATIONS

Dermatoscopic images were not captured via mobile phones, which might improve diagnostic accuracy.

CONCLUSION

Mobile teledermatology using cellular phones is an innovative and convenient modality of providing dermatologic consultations for skin cancer screening.

Institutionalizing telemedicine applications: the challenge of legitimizing decision-making

During the last decades a variety of telemedicine applications have been trialed worldwide. However, telemedicine is still an example of major potential benefits that have not been fully attained. Health care regulators are still debating why institutionalizing telemedicine applications on a large scale has been so difficult and why health care professionals are often averse or indifferent to telemedicine applications, thus preventing them from becoming part of everyday clinical routines. We believe that the lack of consolidated procedures for supporting decision making by health care regulators is a major weakness. We aim to further the current debate on how to legitimize decision making about the institutionalization of telemedicine applications on a large scale. We discuss (1) three main requirements--rationality, fairness, and efficiency--that should underpin decision making so that the relevant stakeholders perceive them as being legitimate, and (2) the domains and criteria for comparing and assessing telemedicine applications--benefits and sustainability. According to these requirements and criteria, we illustrate a possible reference process for legitimate decision making about which telemedicine applications to implement on a large scale. This process adopts the health care regulators' perspective and is made up of 2 subsequent stages, in which a preliminary proposal and then a full proposal are reviewed.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Selecting the right digital camera for telemedicine-choice for 2009

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

The validity and reliability of diagnosing foot ulcers and pre-ulcerative lesions in diabetes using advanced digital photography

BACKGROUND

The goal of this study was to determine the validity and reliability of assessing the presence of plantar foot ulceration and pre-ulcerative lesions in diabetes patients from digital photographs that were produced using a new photographic foot imaging device.

METHODS

In 32 diabetes patients who had a foot ulcer or were at high risk of ulceration (a total of 60 feet), high-quality photographic images of the plantar foot surface were collected. Each foot was assessed live, from photographs 2 weeks later, and again 4 weeks later for the presence of an ulcer, abundant callus, or the absence of signs. Each foot was assessed by four independently operating foot care specialists. Agreement scores were calculated using κ values (range, 0-1). Sensitivity and specificity scores were also calculated.

RESULTS

Foot ulceration was cumulatively scored 59 times, callus 78 times, and absence of signs 149 times during live assessment. Agreement with photographic assessment was very good for ulcer (κ = 0.87) and absence of signs (κ = 0.83) and good for callus (κ = 0.61). Sensitivity and specificity were high for ulcer (88% and 98%, respectively), callus (69% and 89%, respectively), and absence of signs (both 90%). Intra-observer agreement between repeated photographic assessments was good to excellent for all outcomes and observers (κ between 0.70 and 1.00). Inter-observer agreement for photographic assessments was good for ulcer (κ = 0.72-0.88) and absence of signs (κ = 0.59-0.75) and moderate to good for callus (κ = 0.48-0.73). For live assessment, inter-observer agreement scores were only slightly higher.

CONCLUSIONS

The data illustrate that diabetic foot ulcers and pre-ulcerative lesions can be diagnosed in a valid and reliable manner by trained professionals from digital photographs produced with the foot imaging device. This supports the intended use of the device as a telemedical monitoring tool in the home environment for early detection of diabetic foot disease and prevention of severe complications in high-risk diabetes patients.

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.

Current perspectives in medical image perception

Medical images constitute a core portion of the information a physician utilizes to render diagnostic and treatment decisions. At a fundamental level, this diagnostic process involves two basic processes: visually inspecting the image (visual perception) and rendering an interpretation (cognition). The likelihood of error in the interpretation of medical images is, unfortunately, not negligible. Errors do occur, and patients' lives are impacted, underscoring our need to understand how physicians interact with the information in an image during the interpretation process. With improved understanding, we can develop ways to further improve decision making and, thus, to improve patient care. The science of medical image perception is dedicated to understanding and improving the clinical interpretation process.

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

BACKGROUND

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

OBJECTIVE

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

CLINICAL PRESENTATION

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

INTERVENTION

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

CONCLUSION

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

The workload of web-based consultations with atopic eczema patients at home

BACKGROUND

Atopic eczema is a chronic inflammatory non-contagious skin disease characterised by intensive itch and inflamed skin. Due to its chronic and relapsing course atopic eczema imposes a great burden on affected families. Review articles about home care telemedicine have indicated advantageous effects of home telehealth. However, few studies have investigated how home care telemedicine applications affect the workload of the clinician.

METHODS

The use of a web-based counselling system was recorded through computerised logging. The doctor who answered the requests sent via the Internet recorded the amount of time needed for reading and answering 93 consecutive requests.

RESULTS

The time needed by the physician to read and answer a request was less than 5 minutes in 60% of the cases. The doctor spent significantly more time to answer requests that had photographs attached compared to requests without photographs (P = 0.005). The time needed to answer requests received during the winter season (October-March) was significantly longer than the rest of the year (P = 0.023). There was no correlation between the answering time and the age of the patient.

CONCLUSIONS

Individual web-based follow-up of atopic eczema patients at home is feasible. The amount of time needed for the doctor to respond to a request from the patient appears to be small. The answering time seems to depend on whether photographs are supplied and also on seasonal variations of disease activity. Since the management of atopic eczema is complex involving many different types of treatments and educational aspects, we expect this type of communication to be useful also to other chronic disease patients requiring close follow-up.

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.

Validity of pressure ulcer diagnosis using digital photography

The purpose of this study was to evaluate the validity of digital photographs for the assessment of the presence of pressure ulcers stage 2 or higher. Participants were 48 patients (28 white and 20 black) with pressure ulcers identified in the course of a wound specialist's routine clinical practice at the University of Maryland Medical Center. One pressure ulcer and one unaffected skin area were photographed on each participating patient. The gold standard diagnosis (stage 2 pressure ulcer vs. stage 1 or no pressure ulcer) was recorded by the wound specialist based on bedside examination. The photographs were reviewed blindly by another wound expert. The sensitivity of the blinded assessment was 97% (95% confidence interval [CI] 91-100%). The specificity was 97% (95% CI 92-100%). The sensitivity and specificity were both 100% in the white patients. In black patients, the sensitivity and specificity were 92% (95% CI 75-100%) and 93% (95% CI 82-100%), respectively. These results suggest that the use of photographic images to assess the presence or absence of a pressure ulcer stage 2 or higher has a high degree of validity. Since blinded outcome assessment is one of the cornerstones of good clinical trial design, photography offers the potential to strengthen future studies.

The prevalence of melasma and its association with quality of life in adult male Latino migrant workers

BACKGROUND

Melasma is a common condition of Latino women that detracts from their quality of life (QOL). The prevalence and impact of melasma in Latino men is not well characterized.

AIM

To assess the prevalence of melasma and its association with QOL in Latino men from Mexico and Central America working in the USA.

METHODS

The prevalence of melasma was assessed in three studies of Latino men: by direct examination in a study of 25 Latino poultry workers; by direct examination in a study of 54 Latino farm workers; and by examination of store-and-forward teledermatology images in a study of 300 Latino farm workers. QOL was assessed with a Spanish version of the Dermatology Life Quality Index (DLQI).

RESULTS

The prevalence of melasma was 36.0%, 7.4%, and 14.0% in the three studies. The prevalence of melasma was greatest amongst those aged 31 years and older, who were from Guatemala, and who spoke an indigenous language. The presence of melasma was associated with higher DLQI scores, indicating a poorer QOL, in the poultry worker population.

CONCLUSIONS

Melasma is a common condition in Latino men and is associated with a poor QOL in some affected individuals. Clinicians should be aware that melasma may be a concern for their male Latino patients. Research on the association of skin conditions with QOL amongst minority men is needed.