Benefits of Teledermatology for Geriatric Patients: Population-Based Cross-Sectional Study

Teledermatology: an evidence map of systematic reviews

BACKGROUND

Although the number of teledermatology studies is increasing, not all variables have been researched in equal depth, so there remains a lack of robust evidence for some teledermatology initiatives. This review describes the landscape of teledermatology research and identifies knowledge gaps and research needs. This evidence map can be used to inform clinicians about the current knowledge about teledermatology and guide researchers for future studies.

METHODS

Our evidence map was conducted according to the Campbell Collaboration checklist for evidence and gap maps. Eight databases were searched (CINAHL, Embase, PubMed, Scopus, Web of Science, Cochrane Library, JBI Database of Systematic Reviews and Implementation Reports, and OpenGray), and only included systematic reviews of teledermatology involving humans published in English; while excluding non-systematic reviews (i.e., abstracts, conference proceedings, editorials, commentaries, or letters). From 909 records, 14 systematic reviews published between 2004 and 2022 were included. Our analysis focused on the systematic reviews' characteristics, dermatological conditions studied, rate of overlap and quality assessment of primary studies reviewed, and main findings reported.

RESULTS

Teledermatology was reportedly comparable with clinic dermatology and generally accepted by patients as a mode of care delivery for dermatological conditions. However, there are concerns about privacy, communication, completeness of information transmitted, familiarity with the technology, and technical problems. Healthcare professionals were generally satisfied with teledermatology but found telemedicine consultations longer than face-to-face consultations, and less confident in asynchronous teledermatology than conventional consultations. Teledermatology was reportedly more cost-effective than clinic dermatology; especially considering the distance traveled by patients, referral volume to teledermatology, and clinic dermatology costs. Although patients and providers are satisfied with teledermatology, face-to-face dermatology has higher diagnostic and management accuracy. Teledermatology was also used for training medical professionals. Regarding the validity and reliability of teledermatology outcome measures, no significant discussions were found.

CONCLUSIONS

COVID-19 spotlighted telemedicine in clinical care, and we must ensure telemedicine continually improves with robust research. Further research is necessary for establishing a standardized outcome set, enhancing accuracy, concordance, cost-effectiveness, and safety, comparing teledermatology with non-dermatologist care, examining its effectiveness in non-Western low and middle-income countries, and incorporating patient involvement for improved study design.

SYSTEMATIC REVIEW REGISTRATION

https://www.researchregistry.com/ (Unique Identifying Number: reviewregistry878).

Optimizing Dermatological Care Triage in a Safety-Net Hospital: Retrospective Analysis of Diagnoses and In-Person Referrals

OBJECTIVES

Teledermatology is a cost-effective and efficient approach to delivering care and is particularly beneficial for patients with limited access to specialized services. Considering the rapid expansion of telehealth, it is crucial to focus on optimization. The purpose of our study was to evaluate the triaging of dermatologic care in an electronic consultation (e-consultation) service in a safety-net hospital.

METHODS

This was a 2-year retrospective review of a dermatology asynchronous store-and-forward e-consultation service.

RESULTS

A total of 1425 patients completed 1502 e-consultation. Of these e-consultations, 46% of the patients had Medicaid and 44% were Black or African American. The top three diagnoses were dermatitis unspecified, neoplasm of uncertain behavior, and acne/rosacea. Most (68%) were managed via e-consultation and did not require an in-person appointment. Children and adolescents were more likely to require an in-person appointment (74%) compared with adults (30%, P < 0.0001). Patients with a chief complaint of hair loss or skin lesion were more likely to require in-person evaluation (58% and 41%, respectively) compared with rash (24%) and acne (18%) (P < 0.0001). There was no difference found in recommendations for in-person evaluation based on race, non-English-language preference, or insurance status.

CONCLUSIONS

E-consultation services seem well suited for certain concerns, and underserved populations can be evaluated by teledermatology.

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.

[How the individual characteristics and area of residence influence the request for virtual consultations?]

INTRODUCTION

The foundation of virtual consultation is to improve the cooperation and the coordination between Primary Care and other specialties. However, in its use inequities related to socioeconomic determinants have been described. The aim of this study was to identify individual and geographical factors affecting the likelihood of accessing this resource.

MATERIAL AND METHODS

Descriptive study of virtual and non-virtual consultations requested by Primary Care doctors from other specialists doctors in Aragon between 1 January 2020 and 31 December 2022. Characteristics of the interconsultations and variables specific to the patient treated were recorded and analyzed; and the request rate for virtual consultations by specialty and the standardized rates by age by Basic Health Zone and stratified by sex were calculated.

RESULTS

Progressive increase in the number of virtual consultations for the study period, being Traumatology, Neurology, Urology, General Surgery and Dermatology the specialties that received the most. The standardized rates by age and stratified by sex were higher in women and the Health Areas of Huesca, Calatayud and Alcañiz. The request was higher in 2022 and the specialized referral was the main type of response. Regarding variables of the patients treated, virtual consultations were requested more in urban and less dispersed areas, women, patients with lower adjusted morbidity and with free pharmacy, pensioners and active users with income less than €18,000/year.

CONCLUSIONS

Despite the rise of telemedicine and its potential advantages, it is necessary to adapt it to the needs of the local population, to mitigate inequalities in access, and to integrate it with face-to-face care.

Teledermatology Use in the Elderly: An Analysis of Teledermatology Utilization Patterns Across Age Groups

Introduction: Telehealth is an emerging tool used to improve access to care for patients. However, there is a lack of literature comparing the use of telehealth between patients of different age groups in dermatology. Our study aims to determine whether differences exist in teledermatology usage between elderly and younger dermatology patients. Methods: We conducted a cross-sectional study using the 2020-2021 Medical Expenditure Panel Survey. Our study population included a weighted total of 150,290,604 patients: Of these, 16.35% were young adults (18-44 years old), 26.32% were midlife adults (45-64 years old), and 57.33% were elderly (65+ years old). Results: Our results showed that elderly patients had significantly lower rates of teledermatology use than young adults (odds ratio [OR] = 0.184, (confidence interval [CI]: 0.081-0.421)), p < 0.000) and midlife adults (OR = 0.193, [CI: 0.091-0.406], p < 0.000). Midlife adults had similar rates of telehealth use when compared with young adults (OR = 1.044, [CI: 0.508-2.145], p = 0.907). Our results were adjusted for sex, race, ethnicity, insurance type, education level, income, travel time, and medical comorbidities. Discussion: We found that elderly patients seeking dermatology care are less likely to use telehealth than younger dermatology patients. Our results demonstrate that barriers to telehealth use for the elderly may be more prohibitive than expected. Understanding these differences in teledermatology use is essential for improving teledermatology delivery across all age groups.

Skin health of community-living older people: a scoping review

The population of older people is steadily increasing and the majority live at home. Although the home and community are the largest care settings worldwide, most of the evidence on dermatological care relates to secondary and tertiary care. The overall aims were to map the available evidence regarding the epidemiology and burden of the most frequent skin conditions and regarding effects of screening, risk assessment, diagnosis, prevention and treatment of the most frequent skin conditions in older people living in the community. A scoping review was conducted. MEDLINE, Embase and Epistemonikos were systematically searched for clinical practice guidelines, reviews and primary studies, as well as Grey Matters and EASY for grey literature published between January 2010 and March 2023. Records were screened and data of included studies extracted by two reviewers, independently. Results were summarised descriptively. In total, 97 publications were included. The vast majority described prevalence or incidence estimates. Ranges of age groups varied widely and unclear reporting was frequent. Sun-exposure and age-related skin conditions such as actinic keratoses, xerosis cutis, neoplasms and inflammatory diseases were the most frequent dermatoses identified, although melanoma and/or non-melanoma skin cancer were the skin conditions investigated most frequently. Evidence regarding the burden of skin conditions included self-reported skin symptoms and concerns, mortality, burden on the health system, and impact on quality of life. A minority of articles reported effects of screening, risk assessment, diagnosis, prevention and treatment, mainly regarding skin cancer. A high number of skin conditions and diseases affect older people living at home and in the community but evidence about the burden and effective prevention and treatment strategies is weak. Best practices of how to improve dermatological care in older people remain to be determined and there is a particular need for interventional studies to support and to improve skin health at home.

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.

Insights, Advantages, and Barriers of Teledermatology vs. Face-to-Face Dermatology for the Diagnosis and Follow-Up of Non-Melanoma Skin Cancer: A Systematic Review

BACKGROUND

Teledermatology is employed in the diagnosis and follow-up of skin cancer and its use was intensified during and after the COVID-19 pandemic. At the same time, demographic changes result in an overall increase in non-melanoma skin cancer and skin precancerous lesions. The aim of this study was to elucidate the role of teledermatology in comparison to conventional face-to-face dermatology for such lesions and determine the advantages and limitations of this workflow for patients and physicians.

METHODS

Research was performed using relevant keywords in MEDLINE and CENTRAL. Relevant articles were chosen following a predetermined standardized extraction form.

RESULTS

Diagnostic accuracy and interrater/intrarater agreement can be considered comparable-although lower-than in-person consultation. Improvement of particular features such as image quality, medical history availability, and teledermoscopy can further increase accuracy. Further aspects of limitations and advantages (mean time-to-assessment, time-to-treatment, cost-effectiveness) are discussed.

CONCLUSIONS

Teledermatology has comparable diagnostic accuracy with face-to-face dermatology and can be utilized both for the effective triage of non-melanocytic epithelial tumors and precancerous lesions, as well as the follow-up. Easy access to dermatologic consultation with shorter mean times to diagnostic biopsy and/or treatment coupled with cost-effectiveness could compensate for the lower sensitivity of teledermatology and offer easier access to medical care to the affected populations.

Teledermatology in Rural, Underserved, and Isolated Environments: A Review

Purpose of Review

Recent Findings

Summary

Partnering with a senior living community to optimise teledermatology via full body skin screening during the COVID-19 pandemic: A pilot programme

BACKGROUND

Elderly patients in senior communities faced high barriers to care during the COVID-19 pandemic, including increased vulnerability to COVID-19, long quarantines for clinic visits, and difficulties with telemedicine adoption.

OBJECTIVE

To pilot a new model of dermatologic care to overcome barriers for senior living communities during the COVID-19 pandemic and assess patient satisfaction.

METHODS

From 16 November 2020 to 9 July 2021, this quality improvement programme combined in-residence full body imaging with real-time outlier lesion identification and virtual teledermatology. Residents from the Sequoias Portola Valley Senior Living Retirement Community (Portola Valley, California) voluntarily enroled in the Stanford Skin Scan Programme. Non-physician clinical staff with a recent negative COVID-19 test travelled on-site to obtain in-residence full body photographs using a mobile app-based system on an iPad called SkinIO that leverages deep learning to analyse patient images and suggest suspicious, outlier lesions for dermoscopic photos. A single dermatologist reviewed photographs with the patient and provided recommendations via a video visit. Objective measures included follow-up course and number of skin cancers detected. Subjective findings were obtained through patient experience surveys.

RESULTS

Twenty-seven individuals participated, three skin cancers were identified, with 11 individuals scheduled for a follow up in-person visit and four individuals starting home treatment. Overall, 88% of patients were satisfied with the Skin Scan programme, with 77% likely to recommend the programme to others. 92% of patients agreed that the Skin Scan photographs were representative of their skin. In the context of the COVID-19 pandemic, 100% of patients felt the process was safer or comparable to an in-person visit. Despite overall appreciation for the programme, 31% of patients reported that they would prefer to see dermatologist in-person after the pandemic.

CONCLUSIONS

This programme offers a framework for how a hybrid skin scan programme may provide high utility for individuals with barriers to accessing in-person clinics.

Evaluation of WhatsApp as a Platform for Teledermatology in Botswana: Retrospective Review and Survey

BACKGROUND

In emerging market countries in sub-Saharan Africa, access to specialty services such as dermatology is limited. Teledermatology is an innovative solution to address this issue; however, many initiatives have been tried without sustained success. Recently, WhatsApp has been used as a store-and-forward telemedicine communication platform for consultation and education in Botswana.

OBJECTIVE

This study aims to describe the utilization of WhatsApp for teledermatology and the satisfaction levels of participating providers.

METHODS

A 2-part pilot study was conducted. First, a retrospective review was performed of WhatsApp communications received by participating dermatologists in Gaborone, Botswana, from January 2016 to December 2019. Sender information, patient demographics and history, response time, diagnoses made, and follow-up recommendations were collected. Second, a 12-question cross-sectional survey was distributed to health care providers who utilized WhatsApp for teledermatology during this period. Descriptive statistics were then performed.

RESULTS

There were 811 communication threads over the study period. The majority (503/811, 62%) of communications were consultations from providers inquiring about a specific patient, followed by multidisciplinary care coordination communications (90/811, 11%). Our in-depth analysis focused on the former. In 323 (64%) provider consultations, dermatologists responded within 1 hour. A diagnosis was made in 274 (55%) consultations. Dermatologists gave treatment recommendations remotely in 281 (56%) consultations and recommended an in-person dermatology visit in 163 (32%). Of the 150 health care providers surveyed, 23 (15%) responded. All respondents (100%) felt that there was a need for teledermatology and improved teledermatology education in Botswana. Moreover, 17 (74%) respondents strongly felt that the guidance received via WhatsApp was high quality, and 22 (96%) were satisfied with WhatsApp as a platform for teledermatology.

CONCLUSIONS

This retrospective review and survey demonstrated that WhatsApp is a quick, well-received, and sustainable method of communication between dermatologists and providers across Botswana. The app may offer a solution to the challenges providers face in accessing specialty referral systems, point-of-care education, and medical decision-making support for complex dermatologic cases in Botswana. The information gained from this pilot study can serve as the basis for future telemedicine studies to improve the implementation of teledermatology in Botswana and other resource-limited countries.

Egyptian dermatologists attitude toward telemedicine amidst the COVID19 pandemic: a cross-sectional study

BACKGROUND

Telemedicine involves distant exchange of medical information between health providers and patients via a telecommunication device with/without the aid of an audiovisual interactive assistance. The current COVID 19 pandemic impact on health services mandated an utmost readiness to implement telemedicine which in part is dependent on health care providers willingness to adopt such platforms.

AIM

The aim of this cross sectional study was to assess knowledge and attitude toward telemedicine Egyptian dermatologists amidst the COVID 19 pandemic.

PATIENTS AND METHODS

A cross sectional study was designed and data were collected using structured self-administered online questionnaires.

RESULTS

Dermatologists had a good knowledge about telemedicine (mean 4.17 ± 1.63; p < .05). Of those completing the questionnaire, 193 (68.9%) were familiar with the term 'telemedicine' and 164 (58.6%) were familiar with tools like teleconferencing. The majority of responding dermatologists 227 (81.1%) were confident that the COVID 19 pandemic is a good opportunity to start applying telemedicine protocols however the majority 234 (83.6%) preferred using it on trial basis at first before full implementation.

CONCLUSION

In conclusion an overall good attitude toward telemedicine was reported with a mean of 3.39 (p < .05). Further large scale studies are required to verify such findings.

Comanagement of Rashes by Primary Care Providers and Dermatologists: A Retrospective Study

BACKGROUND

There is a high demand for managing skin disease, and dermatologists are in short supply.

OBJECTIVES

To better understand how rashes and other specific skin conditions are co-managed by primary care providers (PCPs) and dermatologists, we estimated the frequency with which PCPs sought consultation with or referral to dermatology and the proportion of patients who had a follow-up dermatology office visit in the following 90 days.

DESIGN AND SETTING

The retrospective longitudinal study included 106,459 patients with a skin condition diagnosed by 3,830 PCPs, from January 2017 to March 2017.

METHODS

Comprehensive electronic medical record data with generalized linear mixed modeling accounted for patient factors including diagnosis and clustering by medical center and PCP.

RESULTS

PCPs escalated 9% of patients to dermatology through consultation or referral, while 5% required a follow-up dermatology office visit within 90 days. Patients with bullous, hair, or pigment conditions or psoriasis were most likely to be escalated. Clustering of escalation and follow-up visits was minimal in relation to medical center (intraclass correlation, 0.04 for both outcomes) or PCP (escalation, intraclass correlation, 0.16; follow-up visits, 0.09).

DISCUSSION

Improving primary care education in skin disease and, for certain skin conditions, standardizing approaches to workup, treatment, and escalation may further streamline care and reduce pressure on the dermatologist workforce.

CONCLUSION

PCPs managed 91% of rashes without consultation or referral to dermatology, and the frequency of patients scheduled for dermatology office visits after primary care was similar from one PCP to another.

Teledermatology Consults in a County Hospital Setting: Retrospective Analysis

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International Teledermatology Review

Purpose of Review

The use of teledermatology has been evolving slowly for the delivery of health care to remote and underserved populations. Improving technology and the recent COVID-19 pandemic have hastened its use internationally.

Recent Findings

Some barriers to the use of teledermatology have fallen considerably in the last year.

Summary

Teledermatology use has increased significantly in recent years in both government-sponsored and private health care systems and individual practices. There are no recognized international practice guidelines and variable use within countries. Many barriers remain to increasing the use of teledermatology.

Assessing Patient Satisfaction with Live-Interactive Teledermatology Visits During the COVID-19 Pandemic: A Survey Study

Background: Coronavirus disease 2019 (COVID-19) has brought teledermatology to the forefront. Understanding patients' experiences will clarify its benefits and limitations. Materials/Methods: Patients evaluated through live-interactive teledermatology at New York University Langone Health March-June 2020 were surveyed. Patient demographics, satisfaction with, and preferences between teledermatology and in-person visits across four domains (visit preparation, provider communication, physical examination, and treatment plan/follow-up) were collected. Results/Discussion: Of 602 respondents, >70% indicated at least equal satisfaction compared with in-person visits across all domains. More than a quarter of patients were dissatisfied with the virtual examination and more than half preferred in-person examinations. Male gender was associated with treatment plan/follow-up satisfaction (p = 0.03). Patients ≥66 years preferred in-person visit preparation, communication, and treatment plan/follow-up (all p < 0.01). New patients were less satisfied with teledermatology communication (p = 0.02) and treatment plan/follow-up (p < 0.01) but preferred teledermatology visit preparation (p = 0.01). Conclusions: Patients were satisfied with live-interactive teledermatology during the COVID-19 pandemic, although preferred in-person physical examinations. Satisfaction and preferences varied between patient populations.

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 in 2020: past, present and future perspectives

Born in 1995, teledermatology (TD) turns 25 years old today. Since then, TD evolved according to patients and physicians needs. The present review aimed to summarize all the efforts and experiences carried out in the field of TD and its subspecialties, the evolution and the future perspectives. A literature search was conducted in PubMed and Google Scholar. The state of the art of the "tele-dermo research" included TD and clinical trials, TD/TDS web platforms, TDS and artificial intelligence studies. Finally, the future perspective of TD/TDS in the era of social distancing was discussed. Using TD in specific situations adds several benefits including time-effectiveness of intervention and reduction in the waiting time for the first visit, reduced travel-costs, reduced sanitary costs, equalization of access from patient to specialistic consult. The communication technologies devices currently available can adequately support the growing needs of tele-assistance. A main limit is the current lack of a common clear European regulation for practicing TD, encompassing privacy issues and data management. The pandemic lockdown of 2020 has highlighted the importance of performing TD for all those patient, elderly and/or fragile, where the alternative would be no care at all. Many efforts are needed to develop efficient workflows and TD programs to facilitate the interplay among the different TD actors, along with practice guidelines or position statements.

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.

Factors Contributing to Diagnostic Discordance Between Store-and-Forward Teledermatology Consultations and In-Person Visits: Case Series

BACKGROUND

Use of asynchronous store-and-forward (SAF) teledermatology can improve access to timely and cost-effective dermatologic care and has increased during the COVID-19 pandemic. Previous research has found high diagnostic concordance rates between SAF teledermatology and face-to-face clinical diagnosis, but to our knowledge, none have used specific cases to illustrate factors contributing to diagnostic discordance.

OBJECTIVE

To identify and illustrate characteristics that may have contributed to diagnostic discordance between store-and-forward teledermatology and in-person clinical diagnosis in a series of patients.

METHODS

We identified 7 cases of diagnostic discordance between teledermatology and in-person visits where the favored diagnosis of the in-person dermatologist was not included in the differential diagnosis formulated by the teledermatologist. Cases were identified from a previously published retrospective chart review of 340 SAF teledermatology consultations, which was previously performed at an academic community health care system in the greater Boston area, Massachusetts, from January 1, 2014, through December 31, 2017. Of 99 patients who completed an in-person dermatology appointment after their teledermatology consultation, 7 had diagnostic disagreement between the teledermatologist and in-person dermatologist where the diagnosis in the in-person consultation was not included in the differential diagnosis in the original teledermatology consult. These 7 cases were examined by 2 author reviewers to identify factors that may have contributed to diagnostic discordance.

RESULTS

Factors contributing to diagnostic discordance between SAF teledermatology consultations and in-person visits included poor image quality, inadequate history or diagnostic workup, inability to evaluate textural characteristics, diagnostic uncertainty due to atypical presentations, and evolution in appearance of skin conditions over time.

CONCLUSIONS

We identified multiple factors that contributed to diagnostic discordance. Recognition and mitigation of these factors, when possible, may help to improve diagnostic accuracy and reduce the likelihood of misdiagnosis. Continuing education of referring providers and implementation of standardized guidelines for referrals may also be helpful in reducing the risk of misdiagnosis due to inherent limitations of teledermatology services.

A process modelling approach to assess the impact of teledermatology deployment onto the skin tumor care pathway

BACKGROUND

Teledermatology was raised as a potential answer to increase access and decrease delay for skin cancer management. However, its influence on non-melanoma skin cancer (NMSC) care pathway has never been studied.

OBJECTIVES

To compare conventional care pathway to teledermatology (TD) in NMSC care pathways using a process modelling approach.

PATIENTS AND METHODS

A period study including three groups was conducted in a department of dermatology. During the first period from January till February 2013 a NMSC care pathway was mapped for a group a prior TD integration. During the second period from September 2016 till October 2018, the NMSC care pathway was determined for patients managed by a conventional care process and after TD diagnosis. Patients characteristics, type of tumors and processes were compared using time as a key performance indicator. Mean were reported with their ± SD. Linear regression was performed using time between multidisciplinary consultation and surgery as outcome adjusted on sex, age and cancer type.

RESULTS

During the first period (prior to TD) 89 NMSC patients were managed (mean age = 76 yr old ± 13) during the second period, 36 patients NMSC were managed after TD, mean age of 89 years old ± 6 and 954 patients in a conventional process, mean age of 78 years old ±12. In comparison between the two periods patient's age, sex and cancer distribution significantly differed while the rate of surgery was not significantly different (p = 0.967). Linear multivariate regression using time between multidisciplinary consultation and surgery as outcome adjusted on sex age and cancer type displayed that during the second period patients in the TD group spent 17.6 days more [0.98,34.25] while patient in the conventional care process group had 9.8 days [1.85,17.74] more than patient in the study period 1, (p = 0.04, p = 0.02) without significant difference for age and sex (p = 0.29, p = 0.51). Patients with a SCC had a decreased time between multidisciplinary consultation and surgery of -12.97 days [-17.43, -8.5], p < 10^-3.

CONCLUSION

Interestingly, patients managed by TD were significantly older than those managed using a conventional care pathway. Unexpectedly their total time spent in the process was not shorter. The results of this analysis illustrated the interest of using process modelling approach to assess the impact of a healthcare innovation integration and to further rethink coordination and care pathways for NSMC post TD.

Teleoncology: The Youngest Pillar of Oncology

The core pillars of multimodal care of patients with cancer are surgical, radiation, and medical oncology. The global pandemic of coronavirus disease 2019 (COVID-19) has suddenly resurrected a new pillar in oncology care: teleoncology. With oncologists reaching out to patients through telemedicine, it is possible to evaluate and fulfill patients’ needs; triage patients for elective procedures; screen them for influenza-like illness; provide them with guidance for hospital visits, if needed; and bridge oral medications and treatments when a hospital visit is not desirable because of any high risk-benefit ratio. Teleoncology can bring great reassurance to patients at times when reaching an oncology center is challenging, and more so in resource-constrained countries. Evidence-based treatment protocols, dispensable by teleoncology, already exist for many sites of cancer and they can provide a bridge to treatment when patients are unable to reach cancer centers for their standard treatment. The young pillar of teleoncology is going to remain much longer than COVID-19.