Pediatric dermatology eConsults: Reduced wait times and dermatology office visits

Revolutionizing teledermatology: Exploring the integration of artificial intelligence, including Generative Pre-trained Transformer chatbots for artificial intelligence-driven anamnesis, diagnosis, and treatment plans

The integration of teledermatology and artificial intelligence (AI) marks a significant advancement in dermatologic care. This study examines the synergistic interplay between these two domains, highlighting their collective impact on enhancing the accuracy, accessibility, and efficiency of teledermatologic services. Teledermatology expands dermatologic care to remote and underserved areas, and AI technologies show considerable potential in analyzing dermatologic images and performing various tasks involved in teledermatology consultations. Such integration facilitates rapid, precise diagnoses, personalized treatment plans, and data-driven insights. Our explorative study involved designing a GPT-based chatbot named "Dr. DermBot" and exploring its performance in a teledermatologic consultation process. The design phase focused on the chatbot's ability to conduct consultations autonomously. The subsequent testing phase assessed its performance against the backdrop of current teledermatologic practices, exploring the potential of AI and chatbots to simulate and potentially enhance teledermatologic health care. Our study demonstrates the promising future of combining teledermatology with AI. It also brings to light ethical and legal concerns, including the protection of patient data privacy and adherence to regulatory standards. The union of teledermatology and AI not only aims to enhance the precision of teledermatologic diagnoses but also broadens the accessibility of dermatologic services to previously underserved populations, benefiting patients, health care providers, and the overall health care system.

Successful Electronic Consultation Service Initiative in Quebec, Canada With Primary Care Physicians' and Specialists' Experiences on Acceptance and Use of Technological Innovation: Cross-Sectional Exploratory Study

BACKGROUND

Electronic consultation (eConsult) is an eHealth service that allows primary care providers (PCPs) to electronically consult specialists regarding their patients' medical issues. Many studies have demonstrated that eConsult services improve timely access to specialist care; prevent unnecessary referrals; improve PCPs', specialists', and patients' satisfaction; and therefore have a large impact on costs. However, no studies have evaluated PCPs' and specialists' acceptance of eConsult services in Quebec, Canada, and worldwide.

OBJECTIVE

This exploratory study aims to identify factors affecting eConsult service acceptance by PCPs and specialists in urban and rural primary care clinics across 3 regions in the province of Quebec, Canada, by integrating the Unified Theory of Acceptance and Use of Technology and Task-Technology Fit (TTF) models and user satisfaction. This research was designed to broaden and assist in scaling up this effective eHealth service innovation across the province.

METHODS

A cross-sectional web-based survey was sent to all PCPs (n=263) and specialists (n=62) who used the eConsult Quebec Service between July 2017 and May 2021. We proposed a unified model integrating the Unified Theory of Acceptance and Use of Technology model and TTF model and user satisfaction by endorsing 11 hypotheses. The partial least squares was used to investigate factors influencing the acceptance of the eConsult Quebec Service.

RESULTS

Of the 325 end users, 136 (41.8%) users responded (PCPs: 101/263, 38.4%; specialists: 35/62, 57%). The results of the analysis with partial least squares method indicate that 9 of our 11 hypotheses are supported. The direct relationships uniting the various constructs of the model highlighted the importance of several key constructs and predominant correlations. The results suggest that satisfaction is the key driver behind the use of the eConsult Quebec Service. Performance expectancy (P<.001) and effort expectancy (P=.03) can have a positive impact on behavioral intention (BI), and BI (P<.001) can impact adoption. TTF has an influence on performance expectancy (P<.001), adoption (P=.02), and satisfaction (P<.001). However, the results show that there is no direct effect between social influence (P=.38) and BI or between facilitating conditions (P=.17) and adoption.

CONCLUSIONS

This study provides a better understanding of the factors influencing PCPs' and specialists' intention to adopt the eConsult Quebec Service. Furthermore, this study tests a research model and a technology that have never been explored in Quebec until now. On the basis of the results, the service is a good fit to meet the users' need to improve access to specialized medical advice. Therefore, the results of our study have made a valuable contribution to the implementation of the service by policy makers in order to maximize acceptance, use, adoption, and success across the province of Quebec. Moreover, after 4 successful years, the eConsult Quebec pilot project is now the Conseil Numérique digital consultation service.

Does the Diagnostic Accuracy and Rates of Face-to-Face Visits Occurring Shortly after an Asynchronized Teledermatology Consultation Justify Its Implementation? An 18-Month Cohort Study

INTRODUCTION

In 2019, Maccabi Health Services (MHS) rolled out the store-and-forward "Dermadetect" teledermatology consultation (TC) application. Study goal was to analyze MHS records of TCs (August 2019-February 2021) for the rate and reasons for face-to-face consultations (FTFC) occurring shortly after a TC with emphasis on FTFCs resulting in a different diagnosis for the same indication.

METHODS

The records of FTFCs held up shortly after TCs were reviewed and classified into cases marked as unsuited for teledermatology, cases in which the indication differed, and cases with the same indication, which were analyzed for concordance of diagnoses.

RESULTS

Dermadetect was used by 12,815 MHS beneficiaries. In 30% of cases, following FTFC occurred within the subsequent 5 months, and 901 of them occurred in the subsequent 2 weeks and were analyzed. Thirty percent were not suited for teledermatology, 15% were held for a different indication, and 55% occurred for the same indication. The diagnosis concordance between the TC and recurrent FTFC for the same indication was 97.4%, with full concordance at 68.1% and partial concordance at 29.3%. Overall, 13 patients (1.4%) of the 901 patients using the application only once had a subsequent FTFC within 2 weeks and received a different diagnosis than the one given in the TC.

CONCLUSIONS

When considering the implementation of store-and-forward TC's, a 30% rate of following FTFC's during the next 5 months should be considered when planning the reimbursement model. Diagnosis discordance may be disregarded due to its low rates.

Impact of coordination mechanisms based on information and communication technologies on cross-level clinical coordination: A scoping review

Background

Coordination mechanisms based on information and communication technologies (ICTs) are gaining attention, especially since the pandemic, due to their potential to improve communication between health professionals. However, their impact on cross-level clinical coordination remains unclear. The aim is to synthesize the evidence on the impact of ICT-based coordination mechanisms on clinical coordination between primary care and secondary care (SC) doctors and to identify knowledge gaps.

Methods

A scoping review was conducted by searching for original articles in six electronic databases and a manual search, with no restrictions regarding time, area, or methodology. Titles and abstracts were screened. Full texts of the selected articles were reviewed and analysed to assess the impact of each mechanism, according to the cross-level clinical coordination conceptual framework.

Results

Of the 6555 articles identified, 30 met the inclusion criteria. All had been conducted in high-income countries, most (n = 26) evaluated the impact of a single mechanism - asynchronous electronic consultations via electronic health records (EHR) - and were limited in terms of design and types and dimensions of cross-level clinical coordination analysed. The evaluation of electronic consultations showed positive impacts on the appropriateness of referrals and accessibility to SC, yet the qualitative studies also highlighted potential risks. Studies on other mechanisms were scarce (shared EHR, email consultations) or non-existent (videoconferencing, mobile applications).

Conclusions

Evidence of the impact of ICT-based mechanisms on clinical coordination between levels is limited. Rigorous evaluations are needed to inform policies and strategies for improving coordination between healthcare levels, thus contributing to high-quality, efficient healthcare.

The Role of Dermoscopy in Provider-to-Provider Store-and-Forward Dermatology eConsults: A Scoping Review of the Recent Literature

Purpose of Review

This scoping review maps recent literature on dermatology provider-to-provider asynchronous store-and-forward (SAF) electronic consult (eConsult) platforms with dermoscopy. It offers a descriptive overview, highlighting benefits and challenges.

Recent Findings

Incorporating dermoscopy into SAF eConsults improves diagnostic accuracy for benign and malignant skin neoplasms. Diagnostic and treatment concordance with traditional face-to-face (FTF) visits is high. SAF eConsults with dermoscopy enhance access to dermatological care by improving triage and reducing wait times for FTF visits. Pediatric patients benefit with improved evaluation of melanocytic and vascular growths. eConsult platforms with dermoscopy serve as a telementoring opportunity for clinicians interested in improving their dermoscopy skills.

Summary

Adding dermoscopy to SAF eConsults is valuable and results in improved diagnostic accuracy and reduced need for FTF visits. Implementation barriers can be overcome through collaboration between primary care and dermatology. Dermoscopy in SAF eConsults has significant potential for managing skin conditions and reducing the burden caused by unnecessary FTF visit and biopsies.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Investigation of the effectiveness of teledermatology in the diagnosis of skin lesions in pediatric patients

OBJECTIVE

Teledermatology is the use of communications technology to enable the remote evaluation of skin lesions. Dermatological complaints are common among pediatric patients and should be handled differently than adults. The aim of this study is to group the dermatological lesions of pediatric patients who visited a dermatology outpatient clinic and to investigate in which groups the teledermatology method is more effective.

METHODS

This is a prospective observational study. Images of skin lesions, which were examined face-to-face in a dermatology outpatient clinic, were transmitted to another dermatologist via telecommunication. The diagnoses by the physician who examined patients face-to-face were compared with the diagnoses by the teledermatologist. Informed consent was obtained from the parents or legal representatives of all patients participating in this study.

RESULTS

A total of 93 pediatric patients were evaluated. In our study, the diagnoses by a dermatologist who evaluated patients face-to-face and the diagnoses by a teledermatologist were in agreement with 74.2% of the time. There was 100% agreement between both dermatologists for the diagnosis of acne and scabies. The diagnosis for verruca was consistent with 91.7% of the time, and for atopic dermatitis, it was 72.7%. There was a 25% consistency between both dermatologists on the diagnosis of contact dermatitis. The diagnostic consistency between both physicians was 53% in the erythematous disease group, 89% in the papulopustular group, and 70% in the pigmented group.

CONCLUSION

Teledermatology is a reliable diagnostic method that shortens the waiting time of patients and provides a quick consultation with a dermatologist. When using the teledermatology method, it is important to know which skin lesions or disease groups are more accurately diagnosed.

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

Background

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

Methods

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

Results

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

Conclusions

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

The potential of telemedicine for dermatological care of pediatric patients in Germany

BACKGROUND AND OBJECTIVES

Skin diseases are a common reason for consultations in pediatric practice. The present study aims to characterize the dermatological requests of resident pediatric specialists using teledermatology in Germany.

PATIENTS AND METHODS

This analysis of consultation requests, submitted by pediatricians to a designated pediatric dermatologist via a telemedical consultation system (PädExpert) using the store-and-forward technology, was performed between February 2021 and December 2021.

RESULTS

The study analysis included 504 telemedical consultation requests. The mean age of the patients was 6.5 ± 5.0 years with 45.5% of the patients being female. Telemedicine was useful in providing a definite diagnosis in 88.3%. The diagnoses were most frequently assigned to the group of infectious skin diseases (28.8%). Referral to a dermatologist was recommended in 11.5%. The requests were answered on the same day in 63.8% of the cases.

CONCLUSIONS

The study data shows the great potential of teledermatology to improve access for children with skin diseases to specialized dermatological care. Another advantage is its function as a triage instrument. Since most cases could be managed by teledermatology only, it is possible to reduce the need for an in-person visit to the dermatologist, thus saving resources.

Access to pediatric dermatology

PURPOSE OF REVIEW

To identify factors that impact accessibility to pediatric dermatology and review healthcare delivery models that improve access and address these barriers.

RECENT FINDINGS

Up to one-third of pediatric primary care visits include a skin-related problem, yet pediatric dermatology subspecialist services are highly inaccessible. Workforce shortages and geographic, sociocultural, and economic barriers perpetuate inaccessibility. Teledermatology expands care, particularly to underserved or geographically remote communities, and reduces healthcare-related costs. Federal legislation to support telehealth services with adequate reimbursement for providers with parity between live, video, and phone visits will dictate the continued feasibility of virtual visits. Innovative care delivery models, such as language-based clinics, multidisciplinary teleconferencing, or embedded dermatology services within primary care are other promising alternatives.

SUMMARY

Despite efforts to expand access, dermatology still ranks among the most underserved pediatric subspecialties. Improving access requires a multipronged approach. Efforts to expand exposure and mentorship within pediatric dermatology, diversify the workforce and clinical curriculum, recruit and retain clinicians in geographically underserved areas, and collaborate with policymakers to ensure adequate reimbursement for teledermatology services are necessary.

Synchronous and asynchronous teledermatology: A narrative review of strengths and limitations

The policy changes prompted by the COVID-19 pandemic caused synchronous models (primarily video visits) to supplant asynchronous models (store-and-forward or shared digital photographs) as the default and predominant modality of teledermatology care. Here, we call attention to the unique strengths and limitations of these models in terms of clinical utility, accessibility, and cost-effectiveness. Strengths of synchronous visits include direct physician-patient interaction and current reimbursement parity; limitations include variable video image quality, technological difficulties, and accessibility barriers. Strengths of asynchronous visits include greater convenience, especially for clinicians, and potential for image quality superior to video; limitations include less direct physician-patient communication, barriers to follow-up, and limited reimbursement. Both synchronous and asynchronous models have been shown to be cost-effective. Teledermatology is positioned to play a prominent role in patient care post-pandemic. Moving forward, dermatologists are challenged to optimize teledermatology use in order to improve outcomes, efficiency, and workflows to meet diverse patient needs. Future directions will depend on sustainable reimbursement of both teledermatology formats by government and private payers.

Evaluation of electronic consults for outpatient pediatric patients with dermatologic complaints

BACKGROUND

Although dermatologic complaints are frequently encountered by pediatricians, access to pediatric dermatologists remains limited. Teledermatology has been proposed to expand access to dermatologic care for children. We report our experience with a physician-to-physician store-and-forward teledermatology service (eConsults), focusing on patient and consult characteristics and their relationship with teledermatologist confidence and follow-up recommendations as well as clinical outcomes.

METHODS

We reviewed electronic health records of all pediatric patients referred through eConsults at the Massachusetts General Hospital from 1/13/2020 to 7/17/2020. We assessed pediatrician and parental receptiveness with a confidential survey.

RESULTS

A total of 302 referrals (median patient age 4.6 years (IQR 0.6-12); 54% female) and 310 cases were completed in 1.8 days on average (SD = 1.2). Teledermatologists rated their confidence as definite and moderate in 51.3% and 39.4% cases, respectively. Teledermatologists felt comfortable managing rashes remotely, but patients with alopecia, pigmented and vascular lesions, and warts frequently required formal dermatology evaluation. Among patients seen subsequently, full concordance was seen for 70.1% of diagnoses and 74.4% of management recommendations. All responding pediatricians were satisfied with the service, and 97.5% felt that the parents were receptive to it.

CONCLUSIONS

Our study supports the growing evidence that store-and-forward teledermatology can quickly and effectively provide the access to pediatric dermatologic care and is well received by pediatricians and parents. To maximize cost-effectiveness of store-and-forward teledermatology, dermatologists should work with referring providers to improve the quality of submitted photographs and patient history as well as advise in-person referrals for cases likely to require further follow-up.

Pediatric teledermatology: A review of the literature

Skin complaints are common among pediatric patients, yet as of 2020, fewer than 400 board-certified pediatric dermatologists currently practice in the United States. Pediatric teledermatology may address barriers to dermatologic care in children, assisting with distant geographic locations and long wait times. A review of the literature was conducted to synthesize important features of teledermatology for pediatric dermatologists. We summarize types of telemedicine platforms, common dermatologic conditions seen by pediatric teledermatologists, diagnostic accuracy and concordance, and guidelines from the American Academy of Dermatology and the American Telemedicine Association regarding teledermatology. This report highlights the utility of pediatric telemedicine in both the outpatient and inpatient dermatology setting to increase access to high-quality dermatologic care.