Teledermatology as a means to improve access to inpatient dermatology care

Many hospitals have limited inpatient dermatology consultation access. Most dermatologists are outpatient-based and may find the distance and time to complete inpatient consultations prohibitive. Teledermatology may improve access to inpatient dermatology care by reducing barriers of distance and time. We conducted a prospective two-phase pilot study at two academic hospitals comparing time needed to complete inpatient consultations after resident dermatologists initially evaluated patients, called average handling time (AHT), and time needed to respond to the primary team, called time to response (TTR), with and without teledermatology with surveys to capture changes in dermatologist opinion on teledermatology. Teledermatology was only used in the study phase, and patients were seen in-person in both study phases. Teledermatology alone sufficiently answered consultations in 10 of 25 study consultations. The mean AHT in the study phase (sAHT) was 26.9 min compared to the baseline phase (bAHT) of 43.5 min, a 16.6 min reduction ( p = 0.004). The 10 study cases where teledermatology alone was sufficient had mean study TTR (sTTR) of 273.3 min compared to a baseline TTR (bTTR) of 405.7 min, a 132.4 min reduction ( p = 0.032). Teledermatology reduces the time required for an attending dermatologist to respond and the time required for a primary team to receive a response for an inpatient dermatology consultation in a subset of cases. These findings suggest teledermatology can be used as a tool to improve access to inpatient dermatology care.

Primary care providers' perceptions of mobile store-and-forward teledermatology

INTRODUCTION

Although teledermatology offers promise as a tool to increase access to care, adoption has been limited. Understanding the perspectives and experiences of key stakeholders, such as primary care providers (PCPs) and patients, is important to identify opportunities to reduce barriers to adoption and to improve teledermatology programs. Although many studies have examined patients' experiences and satisfaction with teledermatology, few have examined referring PCPs' perspectives.

OBJECTIVE

To identify PCPs' perceptions on the strengths and limitations of teledermatology in order to identify opportunities to improve teledermatology programs.

METHODS

We distributed an anonymous, web-based survey to 30 PCPs involved in a two-year study evaluating a mobile app-based teledermatology platform.

RESULTS

100% (18/18) agreed or strongly agreed that teledermatology increases access to dermatologic care, improves patient care, and is acceptable to patients. 100% (18/18) agreed or strongly agreed that teledermatology provides educational benefit to the PCP. Only 6% (1/18) agreed that teledermatology increases medical liability and 11% (2/18) agreed that it increases risk of a breach in privacy or confidentiality.

CONCLUSIONS

Our findings highlight that PCPs are highly satisfied with mobile app-based, store-and-forward teledermatology and that they believe teledermatology offers synergistic educational benefit. We hope these results will help guide the development of teledermatology programs to increase access to timely, cost-effective care.

Using TV white space spectrum to practise telemedicine: A promising technology to enhance broadband internet connectivity within healthcare facilities in rural regions of developing countries

The following correspondence provides an overview of TV White Space (TVWS) technology, regulations, and potential applications to the health care sector. This report also introduces "Project Kgolagano," a Botswana-based initiative representing the first endeavour to utilize TVWS internet connection for practising telemedicine. TV "white space" refers to the previously unused, wasted spectrum within TV radiofrequency channels that can now be leveraged to obtain broadband internet access. TVWS represents a less costly, faster, and farther-reaching internet connection that is a promising option for connecting the previously unconnected populations of remote and underserved areas. The Botswana-University of Pennsylvania Partnership, Microsoft, Botswana Innovation Hub, Vista Life Sciences, and Global Broadband Solutions have partnered together to bring TVWS wireless broadband access to healthcare facilities in poorly connected regions of Botswana (Lobatse, Francistown, Maun, Gaborone) in order to improve healthcare delivery and facilitate telemedicine in dermatology, cervical cancer screening, and family medicine (HIV/AIDS, TB, general adult and pediatric medicine).

Scaling up a Mobile Telemedicine Solution in Botswana: Keys to Sustainability

Effective health care delivery is significantly compromised in an environment where resources, both human and technical, are limited. Botswana's health care system is one of the many in the African continent with few specialized medical doctors, thereby posing a barrier to patients' access to health care services. In addition, the traditional landline and non-robust Information Technology (IT) network infrastructure characterized by slow bandwidth still dominates the health care system in Botswana. Upgrading of the landline IT infrastructure to meet today's health care demands is a tedious, long, and expensive process. Despite these challenges, there still lies hope in health care delivery utilizing wireless telecommunication services. Botswana has recently experienced tremendous growth in the mobile telecommunication industry coupled with an increase in the number of individually owned mobile devices. This growth inspired the Botswana-UPenn Partnership (BUP) to collaborate with local partners to explore using mobile devices as tools to improve access to specialized health care delivery. Pilot studies were conducted across four medical specialties, including radiology, oral medicine, dermatology, and cervical cancer screening. Findings from the studies became vital evidence in support of the first scale-up project of a mobile telemedicine solution in Botswana, also known as "Kgonafalo." Some technical and social challenges were encountered during the initial studies, such as malfunctioning of mobile devices, accidental damage of devices, and cultural misalignment between IT and healthcare providers. These challenges brought about lessons learnt, including a strong need for unwavering senior management support, establishment of solid local public-private partnerships, and efficient project sustainability plans. Sustainability milestones included the development and signing of a Memorandum of Understanding (MOU) between the Botswana government and a private telecommunications partner, the publication and awarding of the government tender to a local IT company, and the development and signing of a Memorandum of Agreement between the Ministry of Health Clinical Services department and the local tender winner. The initial system scale-up is scheduled to occur in 2014 and to ensure the project's sustainability, the system is aligned with the national eHealth strategy and local ownership of the project remains at the forefront (1).

Tele-leprology: a literature review of applications of telemedicine and tele-education to leprosy

Global efforts to eliminate leprosy have brought about a steep decline in prevalence; however, new cases are continually detected. Without early diagnosis and appropriate management, these individuals are at risk of disability, disfigurement, and social stigma. Telemedicine and tele-education are increasingly utilised strategies to maintain access to expert healthcare for leprosy patients scattered in low-accessibility areas. However, an overview of tele-leprology, the application of these strategies specifically to leprosy, is currently unavailable. This review provides such an overview and discusses future directions for research and implementation.

The accuracy of mobile teleradiology in the evaluation of chest X-rays

We assessed the diagnostic accuracy of digital photographs of plain film chest X-rays (CXRs) obtained using a mobile phone. The study was a randomized, non-inferiority trial, in which physical plain film CXRs viewed on a light box were compared with digital photographs of plain film CXRs. CXRs were selected from a database of radiology studies to show common pathologies found in Botswana associated with pneumonia, lung carcinoma, tuberculosis, pneumothorax and interstitial disease, as well as normal findings. The pre-selected diagnoses were subsequently verified by a second radiologist. Seven radiologists were randomized to review 75 plain film CXRs on light boxes before viewing 75 digital photographs, or vice versa. Their responses were considered correct if they matched the pre-defined diagnosis. For both modalities, the correct diagnosis was provided in 79% of cases; for plain film CXRs, the correct diagnosis was provided in 82% of cases and for digital photographs the correct diagnosis was provided in 76% of cases. The difference in diagnostic accuracy was -5.7% (95% CI: -10.8% to -0.5%), which confirmed non-inferiority (P<0.001) for the primary outcome of diagnostic accuracy. A subgroup analysis demonstrated non-inferiority for lung carcinoma and pneumonia images, although non-inferiority was not achieved for pneumothorax, tuberculosis, interstitial disease or normal images. The study demonstrates that digital photographs of CXRs obtained via a mobile phone equipped with a digital camera are non-inferior to plain film CXRs.

Reliability and validity of mobile teledermatology in human immunodeficiency virus-positive patients in Botswana: a pilot study

IMPORTANCE

Mobile teledermatology may increase access to care.

OBJECTIVE

To determine whether mobile teledermatology in human immunodeficiency virus (HIV)-positive patients in Gaborone, Botswana, was reliable and produced valid assessments compared with face-to-face dermatologic consultations.

DESIGN, SETTING, AND PARTICIPANTS

Cross-sectional study conducted in outpatient clinics and public inpatient settings in Botswana for 76 HIV-positive patients 18 years and older with a skin or mucosal condition that had not been evaluated by a dermatologist.

MAIN OUTCOMES AND MEASURES

We calculated the κ coefficient for diagnosis, diagnostic category, and management for test-retest and interrater reliability. We also determined sensitivity and specificity for each diagnosis.

RESULTS

The κ coefficient for test-retest reliability ranged from 0.47 (95% CI, 0.35 to 0.59) to 0.78 (0.67 to 0.88) for the primary diagnosis, 0.29 (0.18 to 0.42) to 0.73 (0.61 to 0.84) for diagnostic category, and 0.17 (-0.01 to 0.36) to 0.54 (0.38 to 0.70) for management. The κ coefficient for interrater reliability ranged from 0.41 (95% CI, 0.31 to 0.52) to 0.51 (0.41 to 0.61) for the primary diagnosis, 0.22 (0.14 to 0.31) to 0.43 (0.34 to 0.53) for diagnostic category, and 0.08 (0.02 to 0.15) to 0.12 (0.01 to 0.23) for management. Sensitivity and specificity for the top 10 diagnoses varied from 0 to 0.88 and 0.84 to 1.00, respectively.

CONCLUSIONS AND RELEVANCE

Our results suggest that while the use of mobile teledermatology technology in HIV-positive patients in Botswana has significant potential for improving access to care, additional work is needed to improve the reliability and validity of this technology on a larger scale in this population.

The association between obesity and health-related quality of life among urban Latinos

OBJECTIVES

To examine differences in health-related quality of life (HRQL) by obesity status in a community-based sample of urban Latinos. To determine if sex moderates the relationship between HRQL and obesity status in this cohort.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional study of 202 foreign-born Latinos with low levels of acculturation, living in an urban setting.

MAIN OUTCOME MEASURE

Health-related quality of life by the Medical Outcomes Study Short-Form Health Survey (SF-12).

METHODS

Including the entire study cohort, t-tests were used to determine the unadjusted difference between obese and non-obese participants on SF-12 physical and mental functioning scores (PCS and MCS, respectively). Linear regression was used to estimate the adjusted difference in SF-12 scores between obese and non-obese participants after adjusting for potential confounders. The association between obesity status and HRQL summary scores were then assessed separately in men and women both with and without adjustment for potential confounders.

RESULTS

There was a small but statistically significant unadjusted difference between obese and non-obese participants in the physical functioning domain of HRQL (-2.2, 95% CI -4.0, -.4), which was no longer significant in multivariate analysis (difference -1.5, 95% CI -3.3, .3). There were no significant differences in mental functioning scores in unadjusted or adjusted analyses. Sex did not moderate the relationship between obesity status and HRQL scores in stratified analyses.

CONCLUSIONS

Our results in an under-studied population suggest that obesity may have little impact on HRQL in urban Latinos. Future studies with larger and more diverse Latino populations are needed to further investigate the relationship between obesity and HRQL, and explore how acculturation impacts the association between these two factors.