Teledermatology scale-up frameworks: a structured review and critique

Improving the prevention and diagnosis of melanoma on a national scale: A comparative study of performance in the United Kingdom and Australia

We undertook this study in light of an uncontrolled rise of melanoma incidence and mortality rates in the United Kingdom (UK). We aim to assess the effectiveness of prevention and early melanoma diagnosis in the UK's National Health Service (NHS) in comparison to the Australian system that has limited the melanoma rise. We compare the prevention campaigns against skin cancer and the stage at which melanoma is diagnosed. We analyse key drivers of early diagnosis. Overall, Australia has performed better than the UK and provides an example for the UK's NHS for better preventing melanoma and diagnosing it. Technologies under development, such as tele-dermatology and artificial intelligence applications, could aid in making melanoma early diagnosis easier, more cost-efficient, and lessen the burden on health systems. Diagnoses also provide the data to help public health officials target prevention programs.

"Even though I am alone, I feel that we are many" - An appreciative inquiry study of asynchronous, provider-to-provider teleconsultations in Turkana, Kenya

Non-physician clinicians (NPCs) in low and middle-income countries (LMICs) often have little physical proximity to the resources-equipment, supplies or skills-needed to deliver effective care, forcing them to refer patients to distant sites. Unlike equipment or supplies, which require dedicated supply chains, physician/specialist skills needed to support NPCs can be sourced and delivered through telecommunication technologies. In LMICs however, these skills are scarce and sparsely distributed, making it difficult to implement commonly used real-time (synchronous), hub-and-spoke telemedicine paradigms. An asynchronous teleconsultations service was implemented in Turkana County, Kenya, connecting NPCs with a volunteer network of remote physicians and specialists. In 2017-18, the service supported over 100 teleconsultations and referrals across 20 primary healthcare clinics and two hospitals. This qualitative study aimed to explore the impact of the telemedicine intervention on health system stakeholders, and perceived health-related benefits to patients. Data were collected using Appreciative Inquiry, a strengths-based, positive approach to assessing interventions and informing systems change. We highlight the impact of provider-to-provider asynchronous teleconsultations on multiple stakeholders and healthcare processes. Provider benefits include improved communication and team work, increased confidence and capacity to deliver services in remote sites, and professional satisfaction for both NPCs and remote physicians. Health system benefits include efficiency improvements through improved care coordination and avoiding unnecessary referrals, and increased equity and access to physician/specialist care by reducing geographical, financial and social barriers. Providers and health system managers recognised several non-health benefits to patients including increased trust and care seeking from NPCs, and social benefits of avoiding unnecessary referrals (reduced social disruption, displacement and costs). The findings reveal the wider impact that modern teleconsultation services enabled by mobile technologies and algorithms can have on LMIC communities and health systems. The study highlights the importance of viewing provider-to-provider teleconsultations as complex health service delivery interventions with multiple pathways and processes that can ultimately improve health outcomes.

Implementing Teledermatology for Rural Veterans: An Evaluation Using the RE-AIM Framework

Introduction: Few systematic evaluations of implementing teledermatology programs in large health care systems exist. We conducted a longitudinal evaluation of a U.S. Department of Veterans Affairs (VA) initiative to expand asynchronous consultative teledermatology services for rural veterans. Methods: The reach, effectiveness, adoption, implementation, and maintenance framework guided the evaluation, which included analysis of quantitative VA administrative data as well as an online survey completed by participating facilities. The first 2 years of the program were compared with the year before the start of funding. Results: Sixteen hub facilities expanded teledermatology's reach over the 2-year period, increasing the number of referral spoke sites, unique patients served, and teledermatology encounters. Effectiveness was reflected as teledermatology constituted an increasing fraction of dermatology activity and served more remotely located patients. Adoption through defined stages of implementation progressed as facilities engaged in a variety of strategies to enhance teledermatology implementation, and facilitators and barriers were identified. Program maintenance was assessed by Program Sustainability Index scores, which reflected the importance of executive support, and ongoing concerns about staffing and longitudinal funding. Discussion: Enabling hubs to create solutions that best fit their needs and culture likely increased reach and effectiveness. Important facilitators included organizational leadership and encouraging communication between stakeholders before and during the intervention. Conclusions: A systematic analysis of teledermatology implementation to serve rural sites in VA documented a high degree of implementation and sustainability as well as areas for improvement.

A Teledermatology Scale-Up Framework and Roadmap for Sustainable Scaling: Evidence-Based Development

Background

The objectives of South Africa’s electronic health (eHealth) strategy recognize the value proposition that telemedicine practices hold for rural and urban referrals, but a lack of accepted and formalized scale-up has impeded realization of benefits. While both synchronous and asynchronous teledermatology exist, these remain localized and not scaled-up. Skin pathology is often the first sign of an HIV/AIDS infection, which remains a major cause of morbidity and mortality in South Africa. It is essential to replace the current inefficient dermatology referral process with a swift, organized, and efficacious one.

Objective

The objective of this study is to present an evidenced-based teledermatology scale-up framework (TDSF) and implementation roadmap (TDSF-IR).

Methods

A qualitative method with a design science research process model was used which consisted of 5 phases: (1) Awareness, which confirmed the need for an evidence-based TDSF and supporting TDSF-IR; (2) Suggestion, where a proposal was delivered on how to develop a TDSF and TDSF-IR; (3) Development, where we identified recommended design requirements and used these to identify and critique existing teledermatology or related scale-up frameworks; (4) Evaluation and validation, where we assessed outputs of the development phase against the design requirements and validated by confirming the veracity of the TDSF and TDSF-IR (validation involved 4 key senior teledermatology stakeholders using a questionnaire with a 5-point Likert scale); and (5) Conclusion, where validation results were used to finalize and communicate the TDSF and TDSF-IR to users.

Results

The study identified 5 TDSF components: eHealth building blocks, eHealth strategic objectives and budget, scale-up continuum periods, scale-up drivers, and scale-up phases. In addition, 36 subcomponents were identified. Each was further characterized and described to enable design of the final evidence-based TDSF. An implementation roadmap (TDSF-IR) was also prepared as a guide for an implementer with step-by-step instructions for application of the TDSF. For the validation study of the TDSF and supporting TDSF-IR, 4 purposively selected key senior teledermatology management stakeholders were asked if they found it useful as a guide to assist the South African public health system with teledermatology scale-up. The mean (SD) of Likert-scale rating was 4.0 (0.53) where 4=Agree and 33 of 36 responses were either agree or strongly agree.

Conclusions

This study developed a TDSF and supporting roadmap (TDSF-IR) that are evidence-based. The proposed approach and described tools could be adapted to assist with ensuring scale-up and sustainability for other eHealth practices in other locations.