Teledermatology Patient Satisfaction in the Pacific Northwest

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.

Patient perception and satisfaction with a smartphone-based teledermatology service initiated during the COVID-19 pandemic at a tertiary care hospital in North India

BACKGROUND

Telemedicine is being increasingly used to provide healthcare to patients, particularly during the COVID-19 pandemic.

AIMS

The study aimed to study patient perception and satisfaction with a smartphone-based hybrid teledermatology service initiated during the COVID-19 pandemic.

METHODS

This was a cross-sectional telephonic survey including patients ≥18 years of age who had received a teledermatology consultation. After noting the demographic, clinical and teleconsultation details, patients were administered the Telemedicine Satisfaction Questionnaire and an additional 6-item questionnaire. Patients were also asked to give qualitative feedback and suggestions for improvement using a semi-structured interview guide.

RESULTS

We interviewed 201 subjects. The most common diagnoses were pemphigus (27, 13.4%), superficial fungal infections (24, 11.8%), psoriasis (22, 10.9%) and dermatitis (21, 10.4%). The overall mean Telemedicine Satisfaction Questionnaire score was 4.20± 0.71. One hundred seventy-one (85.1%) patients responded that they would use teledermatology services again, while 168 (83.6%) reported satisfaction with the quality of services. A majority of the patients were largely satisfied with the various components involved, though some concerns were raised about the care perceived as not at par with physical consultations, difficulty in procuring medicines, lack of confidence in photographic diagnoses and the lack of a personal touch. Patients with urticaria (P=0.020), those who were advised a change in treatment (P=0.029) and those with improvement in their skin disease (P=0.026) were more likely to be satisfied.

LIMITATIONS

Our study was conducted during the COVID-19 pandemic when patient acceptability was likely to be higher. Only follow-up patients were included in the study.

CONCLUSION

Patient satisfaction levels were generally high with teledermatology. Addressing lacunae that negatively impact patient perception and satisfaction will help in greater acceptance of teledermatology services.

The Utilization and Impact of Live Interactive and Store-and-Forward Teledermatology in a Veterans Affairs Medical Center During the COVID-19 Pandemic

Introduction: Teledermatology has emerged as a promising method of continuing dermatologic care during the coronavirus 2019 (COVID-19) pandemic, including in the Department of Veterans Affairs (VA). Analysis of the utilization and impact of teledermatology within the San Francisco Veterans Affairs Health Care System (SFVAHCS) may elucidate the ways that teledermatology programs can continue to be optimized. Methods: We conducted a retrospective analysis of live interactive encounters, Veterans Affairs Video Connect (VVC), store-and-forward telehealth (SFT), and face-to-face (FTF) consultations, performed within the SFVAHCS from March 2020 to December 2020. To assess utilization, we analyzed numbers of encounters throughout 2020. To assess impact, we analyzed primary diagnoses for each encounter and rates of recommendations for medications and lesion biopsies. Additionally, we assessed diagnostic accuracy associated with each teledermatology type by measuring concordance between teledermatologists' clinical diagnoses and histopathological diagnoses. Results: Two thousand two hundred fifty FTF, 347 VVC, and 470 SFT encounters were conducted from March to December 2020. More female patients utilized VVC, and patients who utilized VVC were younger than SFT and FTF users (p < 0.01). SFT was utilized more by patients from rural areas (p < 0.01). Diagnoses addressed were significantly different between VVC and SFT. A majority of VVC encounters involved referrals for inflammatory conditions; primary diagnoses associated with SFT consultations were most frequently neoplasms. Comparison of VVC and SFT outcomes showed that more VVC visits resulted in a medication recommendation, while more SFT consultations resulted in a biopsy recommendation. Conclusions: Teledermatology contributed to meeting patient needs throughout 2020 and created an impact on clinical management. Patient characteristics, diagnoses, and type of impact associated with encounters varied between SFT and VVC. This analysis provides insight into teledermatology utilization within the VA system and can contribute to efforts to improve the quality of teledermatology care for veterans.

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.

Comparison of Dermatologist Density Between Urban and Rural Counties in the United States

Importance

As the US population continues to increase and age, there is an unmet need for dermatologic care; therefore, it is important to identify and understand the characteristics and patterns of the dermatologist workforce.

Objective

To analyze the longitudinal dermatologist density and urban-rural disparities using a standardized classification scheme.

Design, Setting, and Participants

This study analyzed county-level data for 1995 to 2013 from the Area Health Resources File to evaluate the longitudinal trends and demographic and environmental factors associated with the geographic distribution of dermatologists.

Main Outcomes and Measures

Active US dermatologist and physician density.

Results

In this study of nationwide data on dermatologists, dermatologist density increased by 21% from 3.02 per 100 000 people to 3.65 per 100 000 people from 1995 to 2013; the gap between the density of dermatologists in urban and other areas increased from 2.63 to 3.06 in nonmetropolitan areas and from 3.41 to 4.03 in rural areas. The ratio of dermatologists older than 55 years to younger than 55 years increased 75% in nonmetropolitan and rural areas (from 0.32 to 0.56) and 170% in metropolitan areas (from 0.34 to 0.93). Dermatologists tended to be located in well-resourced, urban communities.

Conclusions and Relevance

Our findings suggest that substantial disparities in the geographic distribution of dermatologists exist and have been increasing with time. Correcting the workforce disparity is important for patient care.

Impact of standardized templates and skin cancer learning modules for teledermatology consultations

BACKGROUND

Little research has been done in teledermatology to examine the effects of standardized templates and subject-specific learning modules.

METHODS

We performed a prospective study examining the effects of standardized templates and standardized cutaneous oncology learning modules on teledermatology referrals at Mayo Clinic. This data was then compared to previous teledermatology referrals before standardized templates were adopted.

RESULTS

A total of 42 teledermatology consultations were performed during the 4-month study period. The use of standardized templates resulted in an absolute reduction in face-to-face referrals. Teledermatology consultation increased the absolute diagnostic and management concordance by 26.2% (P = 0.02) and 33.3% (P < 0.01), respectively, and decreased the absolute diagnostic and management discordance by 19.1% (P = 0.03) and 31.0% (P < 0.01), respectively. The largest knowledge gaps were identified in cutaneous oncology. Educational intervention improved theoretical referral rates and confidence in diagnosis and management overall.

CONCLUSION

The implementation of standardized intake templates reduces the rate of face-to-face referrals. Teledermatology improves primary care-based dermatological care and reduces theoretical referral rates.

Impact of Telemedicine in Pediatric Postoperative Care

Background: A shortage of pediatricians and long wait times in the hospitals render more efficient follow-up visits increasingly important. Virtual visits between physician and patient offer a solution to this problem. Increased awareness, improved technology, and efficient scheduling methods will contribute to the quality and adoption of telemedicine programs. Introduction: The aim of this study was to analyze the impact of pediatric telemedicine on wait times and visit durations, as compared with in-person visits. A secondary goal was to assess the efficiency of different scheduling methods for virtual visits. Materials and Methods: The study included >800 postoperative virtual visits from urology, cardiovascular surgery, and ophthalmology, comprising data on wait times, visit duration, and postvisit satisfaction collected through SBR Health and Redcap. In-person visit data were collected on 14 patients in urology, and satisfaction scores were obtained through Press Ganey for urology and ophthalmology. Results: Patients reported very high satisfaction with virtual visits and benefitted from reduced wait times, while receiving care of comparable duration and quality. Longer blocks of time scheduled exclusively for virtual visits correlated with shorter wait times. Discussion: Supplementing health care with telemedicine is a viable way to provide patient-centered care. Implemented effectively, a telemedicine program can contribute greatly to the value a hospital provides to its patients. Conclusions: Virtual visits provide an efficient way to conduct postoperative visits, reducing wait times and increasing physician efficiency while retaining high satisfaction and quality of care.

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.

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.

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.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

What are the cost savings associated with providing access to specialist care through the Champlain BASE eConsult service? A costing evaluation

OBJECTIVE

This study estimates the costs and potential savings associated with all eConsult cases completed between 1 April 2014 and 31 March 2015.

DESIGN

Costing evaluation from the societal perspective estimating the costs and potential savings associated with all eConsults completed during the study period.

SETTING

Champlain health region in Eastern Ontario, Canada.

POPULATION

Primary care providers and specialists registered to use the eConsult service.

MAIN OUTCOME MEASURES

Costs included (1) delivery costs; (2) specialist remuneration; (3) costs associated with traditional (face-to-face) referrals initiated as a result of eConsult. Potential savings included (1) costs of traditional referrals avoided; (2) indirect patient savings through avoided travel and lost wages/productivity. Net potential societal cost savings were estimated by subtracting total costs from total potential savings.

RESULTS

A total of 3487 eConsults were completed during the study period. In 40% of eConsults, a face-to-face specialist visit was originally contemplated but avoided as result of eConsult. In 3% of eConsults, a face-to-face specialist visit was not originally contemplated but was prompted as a result of the eConsult. From the societal perspective, total costs were estimated at $207 787 and total potential savings were $246 516. eConsult led to a net societal saving of $38 729 or $11 per eConsult.

CONCLUSIONS

Our findings demonstrate potential cost savings from the societal perspective, as patients avoided the travel costs and lost wages/productivity associated with face-to-face specialist visits. Greater savings are expected once we account for other costs such as avoided tests and visits and potential improved health outcomes associated with shorter wait times. Our findings are valuable for healthcare delivery decision-makers as they seek solutions to improve care in a patient-centred and efficient manner.

Electronic consultation systems: worldwide prevalence and their impact on patient care-a systematic review

BACKGROUND

Many health organizations are exploring the potential of electronic consultation (eConsult) services to address excessive wait times for specialist care.

OBJECTIVE

To understand the effectiveness, population impact and costs associated with implementation of eConsult services.

METHODS

We conducted a systematic review using a narrative synthesis approach. We searched Medline and Embase from inception to August 2014 (English/French). Included studies focused on communication between primary care providers and specialist physicians through an asynchronous, directed communication over a secure electronic medium. We assessed study quality with a modified version of the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies. We synthesized the results using the Triple Aim framework.

RESULTS

A total of 36 studies were included. Most were set in the USA and focused on single-specialty services (most commonly dermatology). Population health outcomes included patient populations, adoption/utilization and provider attitudes. Providers cited timely advice from specialists, good medical care, confirmation of diagnoses and educational benefits. No clinical outcomes were reported. Patient experience of care was generally positive, with quick specialist response times (4.6 hours to 3.9 days), avoided referrals (12-84%) and satisfaction ranging from 78% to 93%. System costs were reported in only seven studies using different outcome measures and settings, limiting comparability.

CONCLUSION

Though eConsult systems are highly acceptable for patients and providers and deliver improved access to specialist advice, gaps remain regarding eConsult's impact on population health and system costs. To achieve optimized health system performance, eConsult services must include specialty services as determined by community needs and further explore cost-effectiveness.

The Empirical Foundations of Teledermatology: A Review of the Research Evidence

INTRODUCTION

This article presents the scientific evidence for the merit of telemedicine interventions in the diagnosis and management of skin disorders (teledermatology) in the published literature. The impetus for this work derives from the high prevalence of skin disorders, the high cost, the limited availability of dermatologists in certain areas, and the promise of teledermatology to address unmet needs in this area.

MATERIALS AND METHODS

The findings are based on a targeted review of scientific studies published from January 2005 through April 2015. The initial search yielded some 5,020 articles in Google Scholar and 428 in PubMed. A review of the abstracts yielded 71 publications that met the inclusion criteria for this analysis. Evidence is organized according to the following: feasibility and acceptance; intermediate outcomes (use of service, compliance, and diagnostic and treatment concordance and accuracy); outcomes (health improvement and problem resolution); and cost savings. A special section is devoted to studies conducted at the Veterans Health Administration.

RESULTS

Definitions of teledermatology varied across a wide spectrum of skin disorders, technologies, diagnostic tools, provider types, settings, and patient populations. Outcome measures included diagnostic concordance, treatment plans, and health.

CONCLUSIONS

Despite these complexities, sufficient evidence was observed consistently supporting the effectiveness of teledermatology in improving accessibility to specialty care, diagnostic and treatment concordance, and skin care provided by primary care physicians, while also reducing cost. One study reported suboptimal clinical results from teledermatology for patients with pigmented skin lesions. On the other hand, confocal microscopy and advanced dermoscopy improved diagnostic accuracy, especially when rendered by experienced teledermatologists.

Teledermatology

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

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

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

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

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

Teleneurology: successful delivery of chronic neurologic care to 354 patients living remotely in a rural state

BACKGROUND

Delivery of specialty healthcare to rural citizens in the United States remains largely unmet. The Veterans Health Administration is in a unique position to deliver specialty care to rural Veterans because it is mandated to deliver medical care to all eligible Veterans regardless of residence. To accomplish this, the VHA developed large national telehealth networks that provided over 1 million episodes of care in 2012. We investigated whether clinical video telehealth technologies can provide quality efficient neurologic follow-up care to Veterans living in the rural southwest United States.

PATIENTS AND METHODS

Veterans with chronic neurologic conditions living remotely in New Mexico, southern Colorado, eastern Arizona, and western Texas were offered follow-up teleneurology care at 11 rural community-based outpatient clinics following initial evaluation at the Albuquerque, NM, neurology outpatient clinic.

RESULTS

Over a 2-year period, 87% of 354 consecutive patients returned a performance improvement satisfaction questionnaire. Ninety percent of the patients were fully satisfied with their visit, and 92% felt teleneurology saved them time and money. We calculated an average time savings of 5 h and 325 miles driven, plus at least $48,000 total cost savings. Ninety-five percent reported they wanted to continue their neurologic care by teleneurology.

CONCLUSIONS

Our study confirms earlier pilot studies of successful follow-up care through telemedicine. Our patients were highly satisfied with the convenience and quality of their teleneurology visit, and the neurology providers were convinced that neurologic care to both teleneurology and clinic follow-up patients was equivalent. Teleneurology to rural Veterans can provide quality neurologic care and overwhelming patient satisfaction and save considerable time and money.