Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease

Assessing quality of direct-to-consumer telemedicine in China: a cross-sectional study using unannounced standardised patients

Direct-to-onsumer telemedicine (DTCT) has become popular as an alternative to traditional care. However, uncertainties about the potential risks associated with the lack of comprehensive quality evaluation could influence its long-term development. This study aimed to assess the quality of care provided by DTCT platforms in China using unannounced standardised patients (USP) between July 2021 and January 2022. The study assessed consultation services on both hospital and enterprise-sponsored platforms using the Institute of Medicine quality framework. It employed 10 USP cases, covering conditions such as diabetes, asthma, common cold, gastritis, angina, low back pain, child diarrhoea, child dermatitis, stress urinary incontinence and postpartum depression. Descriptive and regression analyses were employed to examine platform characteristics and compare quality across platform types. The results showed that of 170 USP visits across 107 different telemedicine platforms, enterprise-sponsored platforms achieved a 100% success in access, while hospital-sponsored platforms had a success rate of only 47.5% (56/118). Analysis highlighted a low overall correct diagnosis rate of 45% and inadequate adherence to clinical guidelines across all platforms. Notably, enterprise-sponsored platforms outperformed in accessibility, response time and case management compared with hospital-sponsored platforms. This study highlights the suboptimal quality of DTCT platforms in China, particularly for hospital-sponsored platforms. To further enhance DTCT services, future studies should compare DTCT and in-person care, aiming to identify gaps and potential risks associated with using DTCT as alternatives or supplements to traditional care. The potential of future development in enhancing DTCT services may involve exploring the integration of hospital resources with the technology and market capabilities of enterprise-sponsored platforms.

The quality of telemedicine consultations for sexually transmitted infections in China

The burden of sexually transmitted infections (STIs) continues to increase in developing countries like China, but the access to STI care is often limited. The emergence of direct-to-consumer (DTC) telemedicine offers unique opportunities for patients to directly access health services when needed. However, the quality of STI care provided by telemedicine platforms remains unknown. After systemically identifying the universe of DTC telemedicine platforms providing on-demand consultations in China in 2019, we evaluated their quality using the method of unannounced standardized patients (SPs). SPs presented routine cases of syphilis and herpes. Of the 110 SP visits conducted, physicians made a correct diagnosis in 44.5% (95% CI: 35.1% to 54.0%) of SP visits, and correctly managed 10.9% (95% CI: 5.0% to 16.8%). Low rates of correct management were primarily attributable to the failure of physicians to refer patients for STI testing. Controlling for other factors, videoconference (vs SMS-based) consultation mode and the availability of public physician ratings were associated with higher-quality care. Our findings suggest a need for further research on the causal determinants of care quality on DTC telemedicine platforms and effective policy approaches to promote their potential to expand access to STI care in developing countries while limiting potential unintended consequences for patients.

Ethical issues in direct-to-consumer healthcare: A scoping review

An increasing number of health products and services are being offered on a direct-to-consumer (DTC) basis. To date, however, scholarship on DTC healthcare products and services has largely proceeded in a domain-specific fashion, with discussions of relevant ethical challenges occurring within specific medical specialties. The present study therefore aimed to provide a scoping review of ethical issues raised in the academic literature across types of DTC healthcare products and services. A systematic search for relevant publications between 2011-2021 was conducted on PubMed and Google Scholar using iteratively developed search terms. The final sample included 86 publications that discussed ethical issues related to DTC healthcare products and services. All publications were coded for ethical issues mentioned, primary DTC product or service discussed, type of study, year of publication, and geographical context. We found that the types of DTC healthcare products and services mentioned in our sample spanned six categories: neurotechnology (34%), testing (20%), in-person services (17%), digital health tools (14%), telemedicine (13%), and physical interventions (2%). Ethical arguments in favor of DTC healthcare included improved access (e.g., financial, geographical; 31%), increased autonomy (29%), and enhanced convenience (16%). Commonly raised ethical concerns included insufficient regulation (72%), questionable efficacy and quality (70%), safety and physical harms (66%), misleading advertising claims (56%), and privacy (34%). Other frequently occurring ethical concerns pertained to financial costs, targeting vulnerable groups, informed consent, and potential burdens on healthcare providers, the healthcare system, and society. Our findings offer insights into the cross-cutting ethical issues associated with DTC healthcare and underscore the need for increased interdisciplinary communication to address the challenges they raise.

Implementation of Direct-to-Patient Mobile Teledermatology in VA

BACKGROUND

Innovative technology can enhance patient access to healthcare but must be successfully implemented to be effective.

OBJECTIVE

We evaluated Department of Veterans Affairs' (VA's) implementation of My VA Images, a direct-to-patient asynchronous teledermatology mobile application enabling established dermatology patients to receive follow-up care remotely instead of in-person.

DESIGN /PARTICIPANTS/APPROACH

Following pilot testing at 3 facilities, the app was introduced to 28 facilities (4 groups of 7) every 3 months using a stepped-wedge cluster-randomized design. Using the Organizational Theory of Implementation Effectiveness, we examined the app's implementation using qualitative and quantitative data consisting of encounter data from VA's corporate data warehouse; app usage from VA's Mobile Health database; bi-monthly reports from facility representatives; phone interviews with clinicians; and documented communications between the operational partner and facility staff.

KEY RESULTS

Implementation policies and practices included VA's vision to expand home telehealth and marketing/communication strategies. The COVID-19 pandemic dominated the implementation climate by stressing staffing, introducing competing demands, and influencing stakeholder attitudes to the app, including its fit to their values. These factors were associated with mixed implementation effectiveness, defined as high quality consistent use. Nineteen of 31 exposed facilities prepared to use the app; 10 facilities used it for actual patient care, 7 as originally intended. Residents, nurse practitioners, and physician assistants were more likely than attendings to use the app. Facilities exposed to the app pre-pandemic were more likely to use and sustain the new process.

CONCLUSIONS

Considerable heterogeneity existed in implementing mobile teledermatology, despite VA's common mission, integrated healthcare system, and stakeholders' broad interest. Identifying opportunities to target favorable facilities and user groups (such as teaching facilities and physician extenders, respectively) while addressing internal implementation barriers including incomplete integration with the electronic health record as well as inadequate staffing may help optimize the initial impact of direct-to-patient telehealth. The COVID pandemic was a notable extrinsic barrier.

CLINICAL TRIALS REGISTRATION

NCT03241589.

Telehealth and digital health innovations: A mixed landscape of access

In the wake of emergent natural and anthropogenic disasters, telehealth presents opportunities to improve access to healthcare when physical access is not possible. Yet, since the beginning of the COVID pandemic, lessons learned reveal that various populations in the United States do not or cannot adopt telehealth due to inequitable access. We explored the Digital Determinants of Health (DDoHs) for telehealth, characterizing the role of accessibility, broadband connectivity and electrical grids, and patient intersectionality. In addition to its role as an existing Social Determinant of Health, Policies and Laws directly and indirectly affect these DDoHs, making access more complex for marginalized populations. Digital systems lack the flexibility, accessibility, and usability to inclusively provide the essential services patients need in telehealth. We propose the following recommendations: (1) design technology and systems using accessibility and value sensitive design principles; (2) support a range of technologies and settings; (3) support multiple and diverse users; and (4) support clear paths for repair when technical systems fail to meet users' needs. Addressing these requires change not only from providers but also from the institutions providing these systems.

Effect of Telemedicine Use on Medical Spending and Health Care Utilization: A Machine Learning Approach

Introduction

This study analyzes the effect of telemedicine use on healthcare utilization and medical spending for patients with chronic mental illness.

Methods

Using the IBM MarketScan Research database from 2009 to 2018, this study examined the timing of users' first telemedicine use and identified similar periods for non-users by using random forest and random forest proximity matching. A difference-in-differences approach, which tests whether there are differences in the study outcomes before and after the actual/predicted first use among the treated group (users) compared with the control group (non-users), was then used to assess the impact of telemedicine. Analyses were done in 2021.

Results

Comparing users with non-users after matching suggested that telemedicine use both increases the number of overall outpatient visits (0.461; 95% CI=0.280, 0.642; p<0.001) related to psychotherapy and evaluation and management services, and decreases the number of in-person visits (0.280; 95% CI= -0.446, -0.114; p=0.001) for patients with chronic mental health diagnoses. Total medical spending was not significantly affected. Additionally, no evidence was found of telemedicine use being associated with an increased probability of an emergency department visit or hospitalization.

Conclusions

The study findings suggest that telemedicine use is associated with an increase in outpatient care utilization for patients with chronic mental health diagnoses. No substantive changes in medical spending, the probability of an emergency department visit, or the probability of hospitalization were noted. Results provide insights into the effect of telemedicine use on spending and healthcare utilization for patients with chronic mental illness. These findings may inform research to guide future telemedicine policies and interventions.

An mHealth App (eSkinHealth) for Detecting and Managing Skin Diseases in Resource-Limited Settings: Mixed Methods Pilot Study

BACKGROUND

In sub-Saharan Africa, the disease burden from skin diseases, including skin-related neglected tropical diseases (skin NTDs), is extremely high. These diseases often are overlooked due to limited access to health care stemming from, for example, remote geographical locations and a lack of experts. To address these gaps, we developed a mobile health app, eSkinHealth, which is a field-adapted platform to serve as a portable electronic patient chart and for teledermatology.

OBJECTIVE

The purpose of the study is to evaluate the usability and effectiveness of the app in rural Côte d'Ivoire for diagnosing and managing skin NTDs and other skin diseases.

METHODS

A 2-arm trial with local health care providers and patients with skin diseases was implemented over a 3-month period. The providers were assigned to an intervention receiving the eSkinHealth app or control with usual care. Four nurses and 8 community health care workers participated in each arm. The training was provided on the use of the app to the intervention arm only, while both arms were trained on skin diseases. For the usability study, we evaluated our approach with the System Usability Scale (SUS) and in-depth interviews. For the effectiveness study, our primary outcome was to evaluate the detection and management of 5 skin NTDs as our targeted diseases, namely, Buruli ulcer, leprosy, lymphatic filariasis, scabies, and yaws, using the eSkinHealth app. Procedures of our methods were reviewed and approved by the institutional review board of the Ministry of Health and by Tulane University.

RESULTS

The mean age of our participants (providers) was 40.5 and 42.5 years for the intervention and control arms, respectively, and all were male (n=24). The average SUS scores taken from the intervention arm at baseline, the midpoint (6 weeks), and the end of study (12 weeks) were 72.3 (SD 11.5), 72.3 (SD 12.4), and 86.3 (SD 10.8), respectively. All participants interviewed, including 4 dermatologists and program managers, were satisfied with the app. Especially community health care workers felt empowered by being equipped with the tool. A total of 79 cases of skin NTDs were reported in the intervention arm as compared to 17 cases in the control arm (P=.002). Besides the skin NTDs, more skin diseases and conditions were reported from the control than from the intervention arm (P<.001). However, 100 cases (66%) were not given any particular diagnosis in the control arm and were documented only as a "dermatosis." In the intervention arm, 151 cases (72.9%) were diagnosed within the eSkinHealth platform, and the remaining were diagnosed on-site by dermatologists.

CONCLUSIONS

The study provided evidence for the usability and effectiveness of the eSkinHealth app embedded into our surveillance approach to improve the detection and management of skin NTDs and other skin diseases in Côte d'Ivoire and, furthermore, is expected to contribute to knowledge on mobile health approaches in the control of skin diseases in resource-limited settings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05300399; https://clinicaltrials.gov/ct2/show/NCT05300399.

Teledermatology Evaluation and Feedback Systems: A Tool for Improving Care

Chile is a country where teledermatology has been growing exponentially since the implementation of a single national asynchronous teledermatology platform for the public system in December 2018. To ensure the quality of care in teledermatology systems, it is crucial to evaluate the fulfillment of basic specifiers such as ICD-Diagnosis, therapeutic suggestions, and diagnostic suggestions, among others. This article aims to evaluate the teledermatology system of the Chilean public health service by analyzing 243 randomly extracted consultations, representative of the 20,716 electronic consultations performed during 2020. Compliance with basic specifiers is evaluated. From these, fulfillment of core teledermatology functions, such as diagnostic and therapeutic suggestions, is observed in most consultations. There are statistically significant relationships between the patient's destination (primary health center [PHC] or face-to-face referral), pharmacological prescription, coverage of the drug prescribed by the public system, and the education received by the consulting physician. If the consultation is resolved in the PHC, there is a higher chance for pharmacological prescription, prescribing mostly drugs that are covered by the government. This is less likely to occur when patients are referred for face-to-face evaluation. A targeted evaluation of education, pharmacological prescriptions, and their applicability is key to improving the quality of teledermatology systems.

Patient-reported treatment outcomes and safety of direct-to-consumer teledermatology for finasteride treatment in male androgenetic alopecia: A cross-sectional study

Objective

The use of direct-to-consumer (DTC) teledermatology platforms has increased, particularly for androgenetic alopecia (AGA). However, little is known about the efficacy and safety of these platforms. This study aimed to investigate the patient-reported treatment outcomes and safety of DTC teledermatology for the finasteride treatment of male AGA.

Methods

This retrospective, cross-sectional study used data from a German DTC platform for finasteride treatment between December 2021 and January 2023. Patient-reported outcomes were collected through voluntary follow-up questionnaires provided to the patients six weeks after the first prescription to assess treatment outcomes and safety.

Results

Data collection included 2269 patients. Of all patients who answered the follow-up questionnaire (n = 191), 79% (150 out of 191) self-reported positive changes in hair appearance, and 59% (113 out of 191) reported an improvement in self-esteem under treatment. Patients with self-reported positive changes in hair appearance were more likely to report improved self-esteem (P < 0.0001). Treatment-related adverse events occurred in 12% (22 out of 191) of the patients. Full treatment adherence was reported in 87% (167 out of 191) of patients.

Conclusion

From the patient's perspective, DTC teledermatology has the potential to improve hair appearance and self-esteem. Our results suggest that it may be an effective and safe treatment option for men with AGA, justifying low-threshold access. However, treatment-related adverse events should be closely monitored during follow-up. Further studies are required to evaluate the long-term effects of the DTC teledermatology treatment. By collecting real-world data, teledermatology platforms could be useful beyond their primary focus and could play an important role in the context of future research.

Early Detection and Case Management of Skin Diseases with a Mobile Health Application 'eSkinHealth': Protocol for a Mixed-Methods Pilot Study in Côte d'Ivoire

BACKGROUND

The prevalence of skin diseases is extremely high in sub-Saharan Africa, among which are skin neglected tropical diseases (skin NTDs) that could lead to life-long disabilities and deformities if not diagnosed and treated early. To achieve early detection and early treatment of these skin diseases, we developed a mobile health application (mHealth app): 'eSkinHealth.'

OBJECTIVE

This paper outlines a protocol for evaluating the effect of our eSkinHealth app in the early detection and effective management of skin diseases in Côte d'Ivoire.

METHODS

A mixed-methods pilot trial will be conducted in Côte d'Ivoire and will consist of 3 phases: phase 1, the development and improvement of the eSkinHealth app; phase 2, a pilot trial to evaluate the usability of the eSkinHealth app for local medical staff in Côte d'Ivoire; and phase 3, a pilot trial to evaluate the effectiveness of early detection and case management of targeted skin NTDs (Buruli ulcer, leprosy, yaws, and lymphatic filariasis) with the eSkinHealth app in Côte d'Ivoire. The pilot study will be implemented as a 2-arm trial with local healthcare providers and patients with skin NTDs over a 3-month follow-up period. The local healthcare providers will be assigned to an intervention group receiving the eSkinHealth app to be used in their daily practices or a control group. Training will be provided on the usage and implementation of the app and diagnostic pipeline to the intervention group only, while both groups will receive training on skin diseases. Our primary outcome is to evaluate the early detection and effective management of skin diseases using the eSkinHealth app in Côte d'Ivoire by number of cases diagnosed and managed. Additionally, we will evaluate the eSkinHealth app with validated questionnaires and in-depth interviews. Procedures of our methods have been reviewed and approved by the IRB of the Ministry of Health, Côte d'Ivoire and by Tulane University in 2021.

RESULTS

This study was funded in 2021. We started enrolment of patients in February 2022, and data collection is currently underway. We expect the first results to be submitted for publication in 2023.

CONCLUSIONS

Our 'eSkinHealth' is a field-adapted platform that could both provide direct diagnostic and management assistance to health workers in remote settings. The study will provide evidence for the usability and the effectiveness of the eSkinHealth app to improve the early detection and case management of skin NTDs in Côte d'Ivoire; and further, are expected to contribute to knowledge on mobile health approaches in the control of skin NTDs.

CLINICALTRIAL

2020-2054 (Clinicaltrials.gov).

Telemedicine System Applicability Using Drones in Pandemic Emergency Medical Situations

Drones have evolved significantly in recent years, acquiring greater autonomy and carrier capacity. Therefore, drones can play a substantial role in civil medicine, especially in emergency situations or for the detection and monitoring of disease spread, such as during the COVID-19 pandemic. The aim of this paper is to present the real possibilities of using drones in field rescue operations, as well as in nonsegregated airspace, in order to obtain solutions for monitoring activities and aerial work in support of the public health system in crisis situations. The particularity of our conceptual system is the use of a “swarm” of fast drones for aerial reconnaissance that operate in conjunction, thus optimizing both the search and identification time while also increasing the information area and the operability of the system. We also included a drone with an RF relay, which was connected to a hub drone. If needed, a carrier drone with medical supplies or portable devices can be integrated, which can also offer two-way audio and video communication capabilities. All of these are controlled from a mobile command center, in real time, connected also to the national dispatch center to shorten the travel time to the patient, provide support with basic but life-saving equipment, and offer the opportunity to access remote or difficult-to-reach places. In conclusion, the use of drones for medical purposes brings many advantages, such as quick help, shortened travel time to the patient, support with basic but life-saving equipment, and the opportunity to access remote or difficult-to-reach places.

Application of Smartphone Otoscope in Telemedicine in Rural Medical Consortium in Eastern China in the COVID-19 Era

Purpose

This study aimed to evaluate the effectiveness of smartphone otoscope telemedicine in the rural medical consortium in East China in the COVID-19 era.

Methods

This prospective study was conducted within a rural medical consortium that provides health care services by integrating medical resources in the same area. When a patient visited primary health care (PHC) for ear diseases, the PHC provider used a smartphone otoscope to examine the patient's external ear canal and eardrum, and then sent photos or videos of the patient's ear to the otolaryngologist at the lead hospital via WeChat group. The otolaryngologist provided remote diagnosis and management recommendations to the PHC provider. The following data were recorded: age and gender, outpatient diagnosis, disease duration, sides, duration of treatment, telemedicine visits, treatment outcomes, patient satisfaction, and PHC providers' self-evaluation score.

Results

A total of 83 patients were included in the study, including 43 males and 40 females, with a mean age of 44.6 ± 19.7 years (range 3–83 years). The duration of treatment for these patients was 14.0 (7,14) days. PHC visits were 2.2 ± 1.1 times (range: 1–7 times). Telemedicine visits ranged from 1 to 5, with a mean of 1.8 ± 0.9. Among of patients, 62 (74.7%) were cured, 21 (25.3%) improved, and 0 (0%) were ineffective. Sixty-five patients (78.3%) were very satisfied, 16 (19.3%) patients were somewhat satisfied, and two patients (2.4%) were dissatisfied. Based on the self-reported helpfulness, the primary health care providers assessed telemedicine as very helpful (n = 63, 75.9%), helpful (n = 20, 24.1%), and unhelpful (n = 0, 0%).

Conclusions

Smartphone otoscope telemedicine in the medical consortium can effectively improve the ability of rural PHC providers to diagnose and treat ear diseases, save time and costs for patients, and improve patient satisfaction.

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.

Access, charge and quality of tele-dermatology e-consults in China: A standardized patients study

OBJECTIVE

Direct-to-consumer telemedicine is rapidly changing the way that patients seek medical care. This study provided the first report on access, cost and quality of text- and image-based tele-dermatology e-consults, in China.

METHODS

We adopted the Standardized Patients approach to evaluate the services of tele-dermatology e-consults in two metropolitan cities, that is, Beijing and Hangzhou, in China. We measured quality from four dimensions: service process, diagnosis accuracy, prescription and treatment comprehensiveness, based on China's national clinical guidelines. We performed logistic regressions to investigate factors that were associated with high-quality care.

RESULTS

For 114 physicians eligible for inclusion, we succeeded in 87 (76%) validated visits. The median waiting time was 100 minutes (IQR 19-243 minutes) and the median length of consultation was 636 minutes (about 10 hours, IQR 188-1528 minutes). Per visit costs varied from $0 to $38, with a median of $8 (IQR 4-9). Among all, 15% of visits showed high quality in service process, 84% arrived in the correct diagnosis, 24% provided high-quality prescriptions and 71% provided comprehensive treatment. Providing images was associated with high quality in service process (OR 7.22, 95% CI 1.49-34.88). Visits in metropolitan Beijing and on non-work days had better prescription quality than that in metropolitan Hangzhou (OR 6.05, 95% CI 1.75-20.95) and that on workdays (OR 3.75, 95%CI 1.27-11.04), respectively.

CONCLUSIONS

Tele-dermatology e-consults seem to be easy to access and less expensive in China. However, great efforts are warranted to ensure that service processes and prescriptions adhere to clinical guidelines.

Telemedicine and artificial intelligence to support self-isolation of COVID-19 patients: Recent updates and challenges

Background

Asymptomatic and high-risk COVID-19 patients are advised to self-isolate at home. However, patients may not realize that the condition is deteriorating until too late.

Objective

This study aims to review various artificial intelligence-based telemedicine research during the COVID-19 outbreak and proposes a framework for developing telemedicine powered by artificial intelligence to monitor progression in COVID-19 patients during isolation at home. It also aims to map challenges using artificial intelligence-based telemedicine in the community.

Methods

A systematic review was performed for the related articles published in 2019-2021 and conducted in the PubMed and ScienceDirect database using the keywords "telemedicine," "artificial intelligence," and "COVID-19". The inclusion criteria were full-text articles and original research written in the English language.

Results

Thirteen articles were included in this review to describe the current application of artificial intelligence-based telemedicine during the COVID-19 pandemic. Various current applications have been implemented, such as for early diagnosis and tracing of contact for the users, to monitor symptoms and decision-making treatment, clinical management, and virtual and remote treatment. We also proposed the framework of telemedicine powered by artificial intelligence for support the self-isolation of COVID-19 patients based on the recent update in technology. However, we identified some challenges for using digital health technologies because of the ethical and practical use, the policy and regulation, and device use both for healthcare workers and patients.

Conclusion

Artificial intelligence promises to improve the practice of medicine in various ways. However, practical applications still need to be explored, and medical professionals also need to adapt to these advances for better healthcare delivery to the public.

Exploration of implementation, financial and technical considerations within allied health professional (AHP) telehealth consultation guidance: a scoping review including UK AHP professional bodies' guidance

OBJECTIVES

The COVID-19 pandemic has resulted in a shift to remote consultations, but telehealth consultation guidelines are lacking or inconsistent. Therefore, a scoping review was performed to chart the information in the articles exploring telehealth for the UK allied health professionals (AHPs) and compare them with the UK AHP professional bodies' guidelines.

DESIGN

Scoping review following Aksey and O' Malley methodological framework.

DATA SOURCES

CINHAL and MEDLINE were searched from inception to March 2021 using terms related to 'telehealth', 'guidelines' and 'AHPs'. Additionally, the UK AHP professional bodies were contacted requesting their guidelines.

STUDY SELECTION

Articles exploring telehealth for patient consultations, written in English and published in peer-reviewed journal or guidelines available from UK AHP professional bodies/their websites were considered eligible for review.

DATA EXTRACTION

One reviewer extracted data concerning three overarching domains: implementation, financial and technological considerations.

RESULTS

2632 articles were identified through database searches with 21 articles eligible for review. Eight guidelines were obtained from the UK AHP professional bodies with a total of 29 included articles/guidelines. Most articles were published in the last two years; there was variety in telehealth terminology, and most were developed for occupational therapists, physiotherapists and speech and language therapists. Information was lacking about the assessment of telehealth use and effectiveness, barriers and limitations, the logistical management, the family's and caregiver's roles and the costs. There was lack of clarity on the AHPs' registration requirements, costs and coverage, and legal aspects.

CONCLUSION

This study identified gaps in current guidelines, which showed similarities as well as discrepancies with the guidance for non-AHP healthcare professionals and revealed that the existing guidelines do not adequately support AHPs delivering telehealth consultations. Future research and collaborative work across AHP groups and the world's leading health institutions are suggested to establish common guidelines that will improve AHP telehealth services.

Documentary quality versus veracity of information of the websites on syphilis and gonorrhea

Objective: Analyze the possible relation between the documentary quality (DQ) versus the veracity of information (VI) on the syphilis and gonorrhea web pages. Methods: Descriptive cross-sectional study of websites containing information about syphilis and gonorrhea, by accessing this population through a Google. The quality was studied by using 8 variables belonging to DQ and 7 variables of the VI. Results: A total of 440 active websites mainly belonging to mass media and private entities was assessed. The fulfillment of DQ gave the following results: Mean 3.46 ± 0.07, median 4 and range from 0 to 7. The VI result was: median 4.07 ± 0.09, median 4 and range from 0 to 7. According to the search athwart syphilis or gonorrhea, the contrast of the median of the two indicators was: 3.55 vs 3.37 p = 0.181 and 4.14 vs 4.00 p = 0.442. No correlation was verified amid the data of DQ and VI (R = 0.04); p = 0.368. Similarly, no significance was observed when segregating data by disease, in the case of syphilis R = -0.03; p = 0.625 and on gonorrhea R = 0.12; p = 0.064. Conclusions: The DQ and VI bestowed low outcomes, which implies poor quality of syphilis and gonorrhea websites. According to infection (syphilis or gonorrhea), there were no meaningful differences amid the median values of the two indicators. Being acquainted with the authorship and affiliation of a website and the fact that it is tied to a prestigious web may be a factor to be deemed when predicting the VI of a website. The correlation amid the two indicators did not demonstrate an association, thus, knowing the DQ does not imply having the security of an adequate VI.

The policy dimensions, regulatory landscape, and market characteristics of teledermatology in the United States

The COVID-19 pandemic has spurred healthcare systems across the world to rapidly redesign their models of care delivery. As such, this pandemic has accelerated the adoption of teledermatology in the United States. However, it remains unknown whether this momentum will be maintained after the pandemic. The future of teledermatology in the United States will be significantly influenced by a complex set of policy, legal, and regulatory frameworks. An understanding of these frameworks will help dermatologists more effectively adopt and implement teledermatology platforms. In this article, we review the current state of teledermatology in the United States, including policy dimensions, the regulatory landscape, market characteristics, and future directions.

A Review of Patient Satisfaction and Experience with Telemedicine: A Virtual Solution During and Beyond COVID-19 Pandemic

Aim: This article reviews the studies examining patients' perspective toward telemedicine and their preference for virtual health care services. Methods: An electronic literature search using PubMed was conducted to identify relevant research studies published between December 2019 and August 2020. Twenty-five studies were selected out of 1,041 studies based on inclusion and exclusion criteria, which highlight patients' satisfaction and experience with the use of telemedicine during the pandemic. Results: The findings based upon 48,144 surveyed patients and 146 providers in 12 different countries revealed high satisfaction with virtual encounters across a spectrum of diseases. Telemedicine was found satisfactory on various outcome measures, such as addressing patients' concerns, communication with health care providers, usefulness, and reliability. Most common advantages were time saved due to lesser traveling and waiting time, better accessibility, convenience, and cost efficiency. Age and sex did not significantly impact the satisfaction levels. Physicians and patients both showed a strong preference for continued usage and agreed upon telemedicine's potential to complement the regular health care services even after the pandemic. Technical challenges (reported in 10 studies) and lack of physical examination (reported in 13 studies) were the main limitations encountered in virtual visits. Conclusion: Long-term sustainability of telemedicine for all socioeconomic classes requires closer scrutiny of issues such as technology, training, reimbursement, data privacy, legal guidelines, and framework. Telemedicine must be adopted as a proactive strategy and scaled-up even beyond emergency usage due to its immense potential in complementing conventional health care services, such as diagnosis, treatment, follow-up, surveillance, and infection control.

Acceptance of Teledermatological Practices: A Cross-Sectional Study of Practicing Saudi Dermatologists

Background: The increase in demand for Telemedicine globally has continued to rise in recent months, showing remarkable success in a variety of medical fields. As dermatology shows one of the most prolific rates of success, having a clear national picture of practitioner opinion on the subject is important. In this study we aimed to quantify the overall level of acceptance and satisfaction of Saudi dermatologists towards the practice of teledermatology.

Design and setting: Data was collected by means of a survey which included demographic data and level of exposure and overall satisfaction towards Telemedicine in their field. 

Results: A total of 102 questionnaires were returned of which 57.8% had engaged in at least one teleconsultation. Of these, 71.2% showed support for the technology, with negative responses being associated with poor infrastructure or implementation in the workplace.

Conclusion: The acceptance of dermatologists to teledermatology consultations in Saudi Arabia shows a positive tendency, with the majority of those who engaged in the practice saying they would do so again and find it satisfactory. Creating more reliable and robust tools and greater training in their use would be beneficial for its further incorporation.

Patient preferences for telehealth services in a large multispecialty practice

INTRODUCTION

Telehealth service provision has accelerated during the Coronavirus disease 2019 (COVID-19) pandemic. As the pandemic continues, clinical practices have discovered ways to resume operations. Opportunities exist to understand patient preferences for telehealth clinical services and to tailor offerings to different demographic groups.

METHODS

We conducted a survey of patients receiving telehealth services through our outpatient practice to understand the types of healthcare services for which patients report preferences for telehealth.

RESULTS

We received 551 survey responses (response rate = 20.8%; 551/2650). More than half of patients indicated being 'very likely' to use telehealth services to refill medication(s) (67.3%), prepare for an upcoming visit (66.1%), review test results (60.3%), or receive education (54.2%). Males had lower odds of preferring telehealth services for reviewing test results (odds ratio (OR) = 0.57; 95% confidence interval (CI): 0.34-0.94) or mental health issues (OR = 0.54; 95% CI: 0.38-0.77). Respondents who received a video visit were significantly more likely than those who received a telephone visit to report preferences for using telehealth for education, care plan discussions, long-term health issues, and mental health.

DISCUSSION

Patient preferences for telehealth services vary by services provided and respondent demographics. Experience with telehealth increases the likelihood for future use of these services.

Telemedicine in the United States: An Introduction for Students and Residents

Telemedicine refers to the delivery of medical care and provision of general health services from a distance. Telemedicine has been practiced for decades with increasing evidence proving its potential for enhanced quality of care for patients, reduction in hospital readmissions, and increase in savings for both patients and providers. The COVID-19 pandemic has resulted in a significant increase in the reliance on telemedicine and telehealth for provision of health care services. Developments in telemedicine should be structured as complements to current health care procedures, not with the goal of completely digitizing the entire health care system, but rather to use the power of technology to enhance areas that may not be working at their full potential. At the same time, it is also clear that further research is needed on the effectiveness of telemedicine in terms of both financial and patient benefits. We discuss the current and rapidly increasing knowledge about the use of telemedicine in the United States, and identify the gaps in knowledge and opportunities for further research. Beginning with telemedicine’s origins in the United States to its widespread use during the COVID-19 pandemic, we highlight recent developments in legislation, accessibility, and acceptance of telemedicine.

Use of Mobile Applications in Dermatology

Smartphones and applications related to the same are ubiquitous now. As dermatologists, we have a wide array of smartphone apps at our disposal which we can use to improve our practice in all aspects—clinical, academic, research, and administrative. This article provides an overview of available apps, tips on using apps—both general and specific for dermatology, as well as discusses the scientific validity of some of these apps and the future of smartphone apps in the context of dermatology.

Dermatological consultations in the COVID-19 era: is teledermatology the key to social distancing? An Egyptian experience

BACKGROUND

Coronavirus disease 2019 (COVID-19) has received marked attention globally. A worldwide call for social distancing occurred. Although the reduction of face-to-face consultation is required in order to reduce the risk of infection, dermatological services must be maintained in action and 'teledermatology' should be the solution.Materials & methods: We introduce a cross sectional observational study, demonstrating the patients' behavior regarding dermatological consultations in Cairo, Egypt in both private and Public practice. Synchronous (live interaction via What's app and Zoom) and asynchronous (What's app, emails) teledermatology models were used. After the end of the teleconsultation, patients were asked to fill a questionnaire adapted from the Telehealth Usability Questionnaire (TUQ).

RESULTS

There was an overall satisfaction and future use score among the interviewed patients that received Teledermatology services of 91.0%, a usefulness score of 93.7%, interface and interaction quality scores of 85.9% and 87.0%, ease and use learnability score of 87.8% and reliability score of 86.7%.

CONCLUSION

Teledermatology was efficient in triaging and treatment, hence, decreasing risk of COVID-19 exposure for the physician, the patient and the paramedical personel in heavily populated third world countries. Legislation is needed to sanction physician compensation for tele dermatology where this does not exist.

Reorganising dermatology care: predictors of the substitution of secondary care with primary care

Background

The substitution of healthcare is a way to control rising healthcare costs. The Primary Care Plus (PC+) intervention of the Dutch ‘Blue Care’ pioneer site aims to achieve this feat by facilitating consultations with medical specialists in the primary care setting. One of the specialties involved is dermatology. This study explores referral decisions following dermatology care in PC+ and the influence of predictive patient and consultation characteristics on this decision.

Methods

This retrospective study used clinical data of patients who received dermatology care in PC+ between January 2015 and March 2017. The referral decision following PC+, (i.e., referral back to the general practitioner (GP) or referral to outpatient hospital care) was the primary outcome. Stepwise logistic regression modelling was used to describe variations in the referral decisions following PC+, with patient age and gender, number of PC+ consultations, patient diagnosis and treatment specialist as the predicting factors.

Results

A total of 2952 patients visited PC+ for dermatology care. Of those patients with a registered referral, 80.2% (N = 2254) were referred back to the GP, and 19.8% (N = 558) were referred to outpatient hospital care. In the multivariable model, only the treating specialist and patient’s diagnosis independently influenced the referral decisions following PC+.

Conclusion

The aim of PC+ is to reduce the number of referrals to outpatient hospital care. According to the results, the treating specialist and patient diagnosis influence referral decisions. Therefore, the results of this study can be used to discuss and improve specialist and patient profiles for PC+ to further optimise the effectiveness of the initiative.

A review of literature supporting the development of practice guidelines for teledermatology in Australia

Despite the potential of teledermatology to increase access to dermatology services and improve patient care, it is not widely practised in Australia. In an effort to increase uptake of teledermatology, Australian-specific practice guidelines for teledermatology are being developed by the Australasian College of Dermatologist. This paper reports finding from literature reviews that were undertaken to inform the development of these guidelines. Results cover the following sections: Modalities of teledermatology; Patient selection and consent; Imaging; Quality and safety; Privacy and security; Communication; and Documentation and retention. The document educates providers about the benefits and limitations of telehealth while articulating how to enhance patient care and reduce risk when practicing teledermatology.

Skin Doctor Consultations Using Mobile Teledermoscopy: Exploring Virtual Care Business Models

Background: Technological advances have given rise to virtual health care services, resulting in a shift in how traditional health care services are being delivered. Consumers are increasingly demanding efficient access to health care information and services irrespective of time and distance, which is further driving the digitization of health care. This digital economy has created new opportunities for innovative new business models to meet the needs of these new markets. This study explores several in-use business models of virtual health care service platforms that incorporate mobile teledermoscopy (MTD) technologies. By comparing the different building blocks of these commercial ventures, we provide insights on business model choices and discuss the elements that contribute to economically sustainable and viable service offerings incorporating MTD applications. Materials and Methods: We searched the literature on teledermatology, complemented by searches using Google and other mobile app store platforms, and identified seven commercial ventures using teledermoscopy. We analyzed the building blocks of each business model by using an adapted version of Ash Maurya's Lean Canvas and Alexander Osterwalder's Business Model Canvas. Results: We identified three business elements that support the viability, sustainability, and growth of online dermatology services: developing key partnerships, clinician involvement in the design and implementation process, and managing the medico-legal risks and liabilities that are relevant for each country. Conclusions: Leveraging mobile technologies to deliver virtual health care present new business opportunities for health care providers. A better understanding of the business features associated with existing commercial ventures may increase uptake and improve financial viability of MTD applications as a complementary tool to traditional patient care models.

Direct to Consumer Telemedicine

PURPOSE OF REVIEW

Telemedicine uses technology to connect patients and data with providers at a distance. Direct to consumer telemedicine is a rapidly growing segment of the industry.

RECENT FINDINGS

The telehealth market has skyrocketed in recent years, making it a multi-billion dollar industry. Direct to consumer telehealth, dominated by the for-profit private sector, is the most popular form. Direct to consumer telemedicine is a subset of telehealth that shows promise in increasing access to and engagement in medical care. Quality assurance, reimbursement, and regulatory oversight are important factors in assuring appropriate widespread adoption.

Online Care Versus In-Person Care for Improving Quality of Life in Psoriasis: A Randomized Controlled Equivalency Trial

This 12-month, pragmatic, randomized controlled equivalency trial evaluated whether an online, collaborative connected-health model results in equivalent improvements in quality of life compared with in-person care for psoriasis. Overall, 296 adults with physician-diagnosed psoriasis from ambulatory clinics were randomly assigned to either online or in-person care; all were analyzed for outcomes. In the online group, patients and primary care providers sought dermatologists' care directly and asynchronously online. The in-person group sought care face to face. Interventions did not allow blinding of participants; investigators were blinded during analysis. Across 12 months, for the online group, the mean ± standard deviation decline in Skindex-16 from baseline across follow-up visits was 9.02 ± 20.67 compared with 10.55 ± 23.50 for the in-person group. The difference in Skindex-16 between the two groups was -0.83 (95% confidence interval = -5.18 to 3.51), and this was within the equivalence margin (±7.0). For the online group, the mean ± standard deviation decline in Dermatology Life Quality Index was 1.64 ± 4.34 compared with 1.18 ± 4.77 for the in-person group. The difference in Dermatology Life Quality Index between the two groups was -0.45 (95% confidence interval = -1.29 to 0.38) and was within the equivalence margin (±2.5). In conclusion, the online model was as effective as in-person care in improving quality of life among psoriasis patients. This study was funded by the Patient-Centered Outcomes Research Institute and is registered on clinicaltrials.gov (NCT02358135).

Implementation and evaluation of Stanford Health Care store-and-forward teledermatology consultation workflow built within an existing electronic health record system

Introduction

Teledermatology services that function separately from patients’ primary electronic health record (EHR) can lead to fragmented care, poor provider communication, privacy concerns and billing challenges. This study addresses these challenges by developing PhotoCareMD, a store-and-forward (SAF) teledermatology consultation workflow built entirely within an existing Epic-based EHR.

Methods

Thirty-six primary care physicians (PCPs) from eight outpatient clinics submitted 215 electronic consults (eConsults) for 211 patients to a Stanford Health Care dermatologist via PhotoCareMD. Comparisons were made with in-person referrals for this same dermatologist prior to initiation of PhotoCareMD.

Results

Compared to traditional in-person dermatology clinic visits, eConsults decreased the time to diagnosis and treatment from 23 days to 16 hours. The majority (73%) of eConsults were resolved electronically. In-person referrals from PhotoCareMD (27%) had a 50% lower cancellation rate compared with traditional referrals (11% versus 22%). The average in-person visit and documentation was 25 minutes compared with 8 minutes for an eConsult. PhotoCareMD saved 13 additional clinic hours to be made available to the dermatologist over the course of the pilot. At four patients per hour, this opens 52 dermatology clinic slots. Over 96% of patients had a favourable experience and 95% felt this service saved them time. Among PCPs, 100% would recommend PhotoCareMD to their colleagues and 95% said PhotoCareMD was a helpful educational tool.

Discussion

An internal SAF teledermatology workflow can be effectively implemented to increase access to and quality of dermatologic care. Our workflow can serve as a successful model for other hospitals and specialties.

Leprosy Diagnosed via Teledermatology in a U. S. Urban Academic Health Center Highlights Potential Benefits and a Pitfall of Existing Telemedicine Services

Purpose: Teledermatology has emerged as an important tool to extend the reach of dermatologists. As utilization of teledermatology services increases, careful attention should be given to the design of the system for consulting dermatologists. Methodology: In this case study, we report how access to a patient's entire medical history in a teledermatology consultation was vital for an accurate diagnosis. Results: This case emphasizes the importance of full access to patients' medical records for improving diagnostic accuracy. We believe that full-access systems will lower the risk of misdiagnosis and will help to maximize the potential of teledermatology.

Recent trends in teledermatology and teledermoscopy

Teledermatology is a useful alternative where specialized dermatological assistance is not available and has been used successfully to support health professionals in a wide range of settings worldwide, in either an asynchronous store-and-forward format or a real-time video conferencing format. Teledermoscopy, which includes dermoscopic images in the teleconsultation, is another addition that improves remote assessments of pigmented lesions. A more recent variant is mobile teledermoscopy, which uses a smartphone to deliver the same type of service.

Teledermoscopy’s greatest strength may be as a triage and monitoring tool, as it can reduce the number of unnecessary referrals, wait times, and the cost of providing and receiving dermatological care. While face-to-face (FTF) care remains the gold standard for diagnosis, drawbacks of not using FTF care as the primary method can be mitigated if teleconsultants are willing to refer to FTF care whenever there is uncertainty. Teledermatology has generally been well accepted by patients and practitioners alike.

Barriers to the large-scale use of teledermatology remain. Assigning medicolegal responsibility and instituting a reimbursement system are critical to promoting widespread use by medical professionals, while privacy and security features and a mechanism to link teleconsultations to patients’ existing health records are essential to maximize patient benefit. Direct-to-consumer services also need attention from regulators to ensure that consumers can enjoy the benefits of telemedicine without the dangers of unregulated or untested platforms.

Teledermatology: A Review and Update

Telemedicine is slowly transforming the way in which healthcare is delivered and has the potential to improve access to subspecialty expertise, reduce healthcare costs, and improve the overall quality of care. While many subspecialty fields within medicine today have either experimented with or begun to implement telemedicine platforms to enable remote consultation and care, dermatology is particularly suited for this care system as skin disorders are uniquely visible to the human eye. Through teledermatology, diagnostic images of skin disorders with accompanying clinical histories can be remotely reviewed by teledermatologists by any number of modalities, such as photographic clinical images or live video teleconferencing. Diagnoses and treatment recommendations can then be rendered and implemented remotely. The evidence to date supports both its diagnostic and treatment accuracy and its cost effectiveness. Administrative, regulatory, privacy, and reimbursement policies surrounding this dynamic field continue to evolve. In this review, we examine the history, evidence, and administrative landscape surrounding teledermatology and discuss current practice guidelines and ongoing controversies.

Telemedicine utilisation in a paediatric sports medicine practice: decreased cost and wait times with increased satisfaction

Objectives

Telemedicine is the use of telecommunication to provide healthcare remotely. We sought to quantify time/cost savings and satisfaction between a cohort of telemedicine and inperson visits in a tertiary paediatric orthopaedic clinic.

Methods

Time for clinical visits and wait times were compared between telemedicine and inperson visits. Costs to patients and department were also calculated for both visit types. Parents completed a five-item satisfaction survey regarding their telemedicine experience.

Results

Visit times (15 vs 68 min, P<0.001) and wait times (2 vs 33 min, P<0.001) were shorter for telemedicine visits. Families saved 85 miles of driving and $50 in costs per telemedicine visit. Labour cost saved for a telemedicine visit was $24/patient. More than 90% of patients were satisfied with the telemedicine service.

Conclusion

Telemedicine can be used in a sports medicine setting to provide care that reduces costs while maintaining high levels of patient satisfaction.

Level of evidence

Level III.

Teledermatology in the United States: An Update in a Dynamic Era

BACKGROUND

Teledermatology is rapidly advancing in the United States. The last comprehensive survey of U.S. teledermatology programs was conducted in 2011.

INTRODUCTION

This article provides an update regarding the state of teledermatology programs in the United States.

MATERIALS AND METHODS

Active programs were identified and surveyed from November 2014 to January 2017. Findings regarding practice settings, consult volumes, payment methods, and delivery modalities were compared to those from the 2011 survey. Findings from the Veterans Affairs (VA) were reported as an aggregate.

RESULTS

There were 40 active nongovernmental programs, amounting to a 48% increase and 30% discontinuation rate over five years. Academia remained the most common practice setting (50%). Median annual consultation volume was comparable with 263 consultations, but maximum annual consultation volume increased (range: 20-20,000). The most frequent payment method was self-pay (53%). Store-and-forward continued to be the most common delivery modality. In Fiscal Year 2016, the VA System consisted of 62 consultation sites and performed a total of 101,507 consultations.

DISCUSSION

The limitations of this study were that consult volume and payment methods were not available from all programs.

CONCLUSION

U.S. teledermatology programs have increased in number and annual consultation volume. Academia is the most prevalent practice setting, and self-pay is the dominant accepted payment method. Innovative platforms and the provision of direct-to-patient care are changing the practice of teledermatology.

Diagnostic Accuracy of Pediatric Teledermatology Using Parent-Submitted Photographs: A Randomized Clinical Trial

Importance

Advances in smartphone photography (both quality and image transmission) may improve access to care via direct parent-to-clinician telemedicine. However, the accuracy of diagnoses that are reliant on parent-provided photographs has not been formally compared with diagnoses made in person.

Objective

To assess whether smartphone photographs of pediatric skin conditions taken by parents are of sufficient quality to permit accurate diagnosis.

Design, Setting, and Participants

A prospective study was conducted among 40 patient-parent dyads at a pediatric dermatology clinic at the Children's Hospital of Philadelphia from March 1 to September 30, 2016, to assess concordance between diagnoses made by an independent pediatric dermatologist based on in-person examination and those based on parental photographs. Half of the patient-parent dyads were randomized for a secondary analysis to receive instructions on how best to take photographs with smartphones. Clinicians were blinded to whether parents had received photography instructions.

Exposures

Half of the patient-parent dyads received a simple, 3-step instruction sheet on how best to take photographs using a smartphone (intervention group); the other half did not (control group).

Main Outcomes and Measures

Concordance between photograph-based vs in-person diagnosis in the intervention vs control groups, as quantified using Cohen κ, a measure of interrater agreement that takes into account the possibility of agreement occurring by chance.

Results

Among the 40 patient-parent dyads (22 female children and 18 male children; mean [SD] age, 6.96 [5.23] years), overall concordance between photograph-based vs in-person diagnosis was 83% (95% CI, 71%-94%; κ = 0.81). Diagnostic concordance was 89% (95% CI, 75%-97%; κ = 0.88) in a subgroup of 37 participants with photographs considered of high enough quality to make a diagnosis. No statistically significant effect of photography instructions on concordance was detected (group that received instructions, 85%; group that did not receive instructions, 80%; P = .68). In cases of diagnostic disagreement, appropriate follow-up was suggested.

Conclusions and Relevance

Parent-operated smartphone photography can accurately be used as a method to provide pediatric dermatologic care.

Trial Registration

clinicaltrials.gov Identifier: NCT03246945.

Smartphone-Based Applications for Skin Monitoring and Melanoma Detection

With the advancement of mobile technologies, smartphone applications (apps) have become widely available and gained increasing attention as a novel tool to deliver dermatologic care. This article presents a review of various apps for skin monitoring and melanoma detection and a discussion of current limitations in the field of dermatology. Concerns regarding quality, transparency, and reliability have emerged because there are currently no established quality standards or regulatory oversight of mobile medical apps. Only a few apps have been evaluated clinically. Further research is needed to evaluate the utility and efficacy of smartphone apps in skin cancer screening and early melanoma detection.