Evaluation of an Internet-based teledermatology system

Implementation science in resource-poor countries and communities

Background

Implementation science in resource-poor countries and communities is arguably more important than implementation science in resource-rich settings, because resource poverty requires novel solutions to ensure that research results are translated into routine practice and benefit the largest possible number of people.

Methods

We reviewed the role of resources in the extant implementation science frameworks and literature. We analyzed opportunities for implementation science in resource-poor countries and communities, as well as threats to the realization of these opportunities.

Results

Many of the frameworks that provide theoretical guidance for implementation science view resources as contextual factors that are important to (i) predict the feasibility of implementation of research results in routine practice, (ii) explain implementation success and failure, (iii) adapt novel evidence-based practices to local constraints, and (iv) design the implementation process to account for local constraints. Implementation science for resource-poor settings shifts this view from “resources as context” to “resources as primary research object.” We find a growing body of implementation research aiming to discover and test novel approaches to generate resources for the delivery of evidence-based practice in routine care, including approaches to create higher-skilled health workers—through tele-education and telemedicine, freeing up higher-skilled health workers—through task-shifting and new technologies and models of care, and increasing laboratory capacity through new technologies and the availability of medicines through supply chain innovations. In contrast, only few studies have investigated approaches to change the behavior and utilization of healthcare resources in resource-poor settings. We identify three specific opportunities for implementation science in resource-poor settings. First, intervention and methods innovations thrive under constraints. Second, reverse innovation transferring novel approaches from resource-poor to research-rich settings will gain in importance. Third, policy makers in resource-poor countries tend to be open for close collaboration with scientists in implementation research projects aimed at informing national and local policy.

Conclusions

Implementation science in resource-poor countries and communities offers important opportunities for future discoveries and reverse innovation. To harness this potential, funders need to strongly support research projects in resource-poor settings, as well as the training of the next generation of implementation scientists working on new ways to create healthcare resources where they lack most and to ensure that those resources are utilized to deliver care that is based on the latest research results.

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.

The efficacy of telemedicine for ophthalmology triage by a general practitioner

Although there are enough ophthalmologists for the Brazilian population, they are not evenly distributed throughout the country. Tele-ophthalmology may therefore be a useful tool. We have examined the feasibility of ophthalmology triage, performed by a general practitioner (GP) with remote support from an ophthalmologist. Forty patients with a variety of external and internal eye disorders were examined by the GP and also reassessed by an ophthalmologist, face to face, and then remotely by another ophthalmologist. There was agreement in 95% of the diagnoses between face-to-face and distant evaluation. The use of a digital camera and slit-lamp allowed greater accuracy of telediagnosis than the use of a digital camera alone. The GP would have referred 36 patients to an ophthalmologist, while both the local and the remote ophthalmologist saw the need for referral in 31 cases, i.e. assessment by tele-ophthalmology resulted in a 14% decrease in referrals. GP triage therefore appears to be feasible after appropriate training.

Medical regulation and health outcomes: the effect of the physician examination requirement

This article investigates the effect on health outcomes of the regulation prohibiting physicians from prescribing drugs without a prior physical examination. This requirement could improve health by reducing illegal access to prescription drugs. However, it reduces access to health care by making it more difficult for patients and physicians to use many forms of telemedicine. Thus, this regulation generates a trade-off between access and safety. Using matching techniques, we find that the physician examination requirement leads to an increase of 1% in mortality rates from disease, the equivalent of 8.5 more deaths per 100,000 people, and a decrease of 6.7% in injury mortality, the equivalent of 2.5 deaths per 100,000 people. The magnitude of these effects is larger in rural areas and in areas with low physician density and is accompanied by an 18% increase in the number of days lost each month to illness.

Using electronic referral with digital imaging between primary and secondary ophthalmic services: a long term prospective analysis of regional service redesign

PURPOSE

Demands on publicly funded ophthalmic services worldwide continue to increase with new treatments, waiting time targets, working time limits, and restricted budgets. These highlight the necessity to develop innovative ways of utilising existing capacity more effectively.

METHOD

A new regional, fully electronic ophthalmic-referral service with digital imaging was trialled using existing information-technology (IT) infrastructure. Following successful pilot study, the service was rolled out regionally. Service delivery data was prospectively collated for all the attendances in the year prior to (2006) and the year following (2008) introduction.

RESULTS

Comparing 2006 against 2008, median waiting times reduced (14 vs 4 weeks), and fewer new patients were observed (8714 vs 7462 P<0.0001), with 1359 referrals receiving electronic diagnosis (e-diagnosis). New patient did not arrive (635 vs 503 P<0.0001) and emergencies also reduced (2671 v 1984 P<0.0001).

DISCUSSION

Novel use of existing IT infrastructure improves communication between primary and secondary care. This promotes more effective use of limited outpatient capacity by retaining patients with non-progressive, asymptomatic pathology in the community, whilst fast-tracking patients with sight-threatening disease. Resultant significant, sustained improvements in regional service delivery point to a simple model that could easily be adopted by other providers of universal healthcare globally.

Evaluation of a tele-education programme in Brazil

We evaluated a tele-education programme for primary care staff in Pernambuco State, Brazil. During 2008 and 2009, tele-education sessions occurred four times each week for one hour per day. The topics included public health, child and adolescent health, mental health and nursing. After each session, participants completed an evaluation questionnaire. A total of 73 municipalities and 141 health centres participated in the programme. There were 254 tele-education sessions scheduled during the 20-month study period; of these, 224 sessions were successfully performed and 30 were cancelled. We collected 3504 responses from the satisfaction survey. There was high acceptance of the programme: 97% rated it as excellent or good.

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.

Virtual Grand Rounds in Dermatology: an 8-year experience in web-based teledermatology

BACKGROUND

Teledermatology utilizes telecommunication technologies for the exchange of dermatologic information across distances. In 2000, we developed the Virtual Grand Rounds in Dermatology (VGRD) as a free, user-friendly platform for dermatologists to present complex dermatologic cases to the international community for clinical feedback, consultation, and continuing education.

METHODS

VGRD was designed using simple graphics to facilitate access in remote and developing geographic regions. Members present their case according to a recommended template and are encouraged to provide clinical and histopathologic photographs. Viewers' comments are posted on the site within 24-48 h following receipt.

RESULTS

VGRD's low-cost store-and-forward system allows easy accessibility to expertise for colleagues around the world. VGRD currently comprises a community of 344 clinicians across all dermatologic subspecialties, and links users to cases as well as a recent interactive addition for more urgent feedback: VGRD Blog. The Maine Virtual Skin Clinic is another sister site developed as an educational tool for physicians and residents in primary care. VGRD can be found at http://www.vgrd.org.

CONCLUSIONS

With its easy-to-use platform for teleconsultation services, VGRD has the potential to enhance clinical outcomes and education. In the next few years, we hope to continue to expand VGRD, including launching a comprehensive search engine in VGRD to provide users with a "one-stop resource." With the growth of teledermatology, we will combine web consultations with web-based education into a single resource for dermatologists interested in new possibilities in clinical practice, patient care, and continuing education.

[Teledermatology: diagnostic correlation in a primary care service]

BACKGROUND

Telemedicine can be defined as the use of telecommunication technologies for the transmission of health data. It has been described in different medical specialties, especially those in which interpretation of images represents a fundamental key in formulating diagnosis.

OBJECTIVE

To evaluate the role of teledermatology in primary care system.

METHODS

A prospective analysis included 60 patients seen in a primary care unit. All patients were seen by a dermatologist as regular outpatient dermatology consultation. A medical student obtained digital images and a brief clinical history of all patients. Using a Telemedicine system these data were reviewed by two dermatologists for distance diagnosis. Agreement between the diagnoses was assessed.

RESULTS

Good agreement, ranging from 86.6% to 91.6%, was achieved between direct observation and teleconsultation. Good agreement was also achieved between two telemedicine diagnosis (Kappa = 0.62).

CONCLUSION

Teledermatology is a form of care with great potential for use in dermatology, and could represent a useful tool in cases of low complexity from primary health units.

Accuracy of store-and-forward diagnosis in leprosy

Telemedicine might increase the speed of diagnosis for leprosy and reduce the development of disabilities. We compared the accuracy of diagnosis made by telemedicine with that made by in-person examination. The cases were patients with suspected leprosy at eight public health clinics in outlying areas of the city of São Paulo. The case history and clinical examination data, and at least two clinical images for each patient, were stored in a web-based system developed for teledermatology. After the examination in the public clinic, patients then attended a teaching hospital for an in-person examination. The benchmark was the clinical examination of two dermatologists at the university hospital. From August 2005 to April 2006, 142 suspected cases of leprosy were forwarded to the website by the doctors at the clinics. Of these, 36 cases were excluded. There was overall agreement in the diagnosis of leprosy in 74% of the 106 remaining cases. The sensitivity was 78% and the specificity was 31%. Although the specificity was low, the study suggests that telemedicine may be a useful low-cost method for obtaining second opinions in programmes to control leprosy.

Teledermatology: how to start a new teaching and diagnostic era in medicine

"Telemedicine" is defined as the use of telecommunication technologies for the exchange of medical information across distances. Applications include patient management as well as research and education. Teledermatology is a steadily growing category of telemedicine. This article presents general aspects of telemedicine, such as modes of data transmission, and practical applications with a special emphasis on their significance for teledermatology.

Maturity of teledermatology evaluation research: a systematic literature review

BACKGROUND

There is a growing interest in teledermatology in today's clinical practice, but the maturity of the evaluation research of this technology is still unclear.

OBJECTIVES

This systematic review describes the maturity of teledermatology evaluation research over time and explores what kind of teledermatology outcome measures have been evaluated.

METHODS

Systematic review of literature found in Medline database (1966 up to April 2006). A telemedicine evaluation strategy consisting of four consecutive research phases (parallel to drug and diagnostics evaluation research) extended with a fifth postimplementation phase was used to classify all included studies by two independent reviewers. In addition, main characteristics (store-and-forward or real-time, study design, outcome measures) were registered.

RESULTS

Three hundred and forty-five papers were systematically selected from Medline, and 244 papers were excluded. For two randomized controlled trials (RCTs), multiple papers in phase III were found. After correcting for this, 99 studies remained included (11 phase I, 72 phase II, two phase III, six phase IV, eight postimplementation phase). The number of phase II studies is the largest and still growing, while other phases are much less represented. Diagnostic accuracy was the most often used outcome measure and was found in phase I, II and IV. Store-and-forward teledermatology has been evaluated more since 2001, but most phase IV studies (RCTs, including cost aspects) are on real-time teledermatology.

CONCLUSIONS

Most teledermatology evaluation studies are classified as feasibility studies (phase II). The number of phase III and IV studies remains low through the years. Compared with other specialties in telemedicine (i.e. telesurgery, telepaediatrics), teledermatology seems to be a mature application. However, more evaluation studies with a focus on clinical outcomes such as preventable referrals or time to recovery are needed to prove that teledermatology indeed is a promising and cost-saving technology.

Attitudes of Iranian patients with skin problems towards using the Internet as a medical resource

BACKGROUND

Internet use has grown rapidly in Iran, but there is no information about how Iranian Internet users gather medical information through this medium.

OBJECTIVE

To study the use of the Internet as a medical resource by Iranian patients with chronic dermatologic problems.

METHODS

We carried out a structured interview of all patients 20-40 years of age attending a private dermatology clinic between July and September 2003 for chronic skin disease.

RESULTS

Of the 205 patients enrolled in the study, 104 (50.8%) had computer access and 74 (36.1% of the total) had Internet access. Nine patients (4.4%) had performed a search on the Internet for their skin condition, but only one had used an academic website.

CONCLUSION

Despite the significant growth in Internet use in Iran, it appears that the Internet is not a significant medical resource for patients in Iran.

Teledermatologia: passado, presente e futuro

Teledermatologia é a área da telemedicina que estuda a aplicação das tecnologias de telecomunicação e informática para a prática dermatológica sem necessidade da presença física do especialista, com potencial de levar planejamento de saúde, pesquisa, educação, discussão clínica, segunda opinião e assistência dermatológica às populações com dificuldades de deslocamento para ações presenciais. A evolução, redução de custos e a difusão das tecnologias de telecomunicação e informática têm viabilizado a implantação de sistemas de teledermatologia de larga abrangência e baixo custo para apoio à prática clínica em todo o mundo.