Successful melanoma triage by a virtual lesion clinic (teledermatoscopy)

From diagnosis to intervention: a review of telemedicine's role in skin cancer care

Skin cancer treatment is a core aspect of dermatology that relies on accurate diagnosis and timely interventions. Teledermatology has emerged as a valuable asset across various stages of skin cancer care including triage, diagnosis, management, and surgical consultation. With the integration of traditional dermoscopy and store-and-forward technology, teledermatology facilitates the swift sharing of high-resolution images of suspicious skin lesions with consulting dermatologists all-over. Both live video conference and store-and-forward formats have played a pivotal role in bridging the care access gap between geographically isolated patients and dermatology providers. Notably, teledermatology demonstrates diagnostic accuracy rates that are often comparable to those achieved through traditional face-to-face consultations, underscoring its robust clinical utility. Technological advancements like artificial intelligence and reflectance confocal microscopy continue to enhance image quality and hold potential for increasing the diagnostic accuracy of virtual dermatologic care. While teledermatology serves as a valuable clinical tool for all patient populations including pediatric patients, it is not intended to fully replace in-person procedures like Mohs surgery and other necessary interventions. Nevertheless, its role in facilitating the evaluation of skin malignancies is gaining recognition within the dermatologic community and fostering high approval rates from patients due to its practicality and ability to provide timely access to specialized care.

A country-wide teledermatoscopy service in Estonia shows results comparable to those in experimental settings in management plan development and diagnostic accuracy: A retrospective database study

Background

Teledermatoscopy accuracy has been examined in experimental settings and is recommended for primary care despite lacking real-world implementation evidence. A teledermatoscopy service has been provided in Estonia since 2013, where lesions are evaluated based on the patient's or general practitioner's suggestion.

Objective

The management plan and diagnostic accuracy of a real-world store-and-forward teledermatoscopy service for melanoma diagnosis were evaluated.

Methods

A retrospective study analyzed 4748 cases from 3403 patients using the service between October 16, 2017 and August 30, 2019 by matching country-wide databases. Management plan accuracy was calculated as the percentage of melanoma found that was managed correctly. Diagnostic accuracy parameters were sensitivity, specificity, and positive and negative predictive values.

Results

Management plan accuracy for melanoma detection was 95.5% (95% CI, 77.2-99.9). Diagnostic accuracy showed a sensitivity of 90.48% (95% CI, 69.62-98.83) and a specificity of 92.57% (95% CI, 91.79-93.31).

Limitations

Matching the lesions was limited to SNOMED CT location standard precision. Diagnostic accuracy was calculated based on a combination of diagnosis and management plan data.

Conclusion

Teledermatoscopy for detecting and managing melanoma in real-world clinical practice displays results comparable with those in experimental setting studies.

Teledermatology for Enhancing Skin Cancer Diagnosis and Management: Retrospective Chart Review

BACKGROUND

Skin cancer rates are at all-time highs, but the shortage of dermatologists compels patients to seek medical advice from general practitioners. A new referral pathway called the Suspected Skin Cancer (SSC) service was established to provide general practitioners in Waikato, New Zealand, with rapid diagnosis and treatment advice for lesions suspicious for skin cancer.

OBJECTIVE

The aim of this study was to assess the quantity, quality, and characteristics of referrals to the SSC teledermatology service during its first 6 months.

METHODS

A retrospective chart review of all referrals sent to the SSC teledermatology service during the first 6 months of its operation was conducted. Time to advice, diagnoses, diagnostic discordance, adherence to advice, and time to treatment were recorded. Diagnostic discordance between general practitioners, dermatologists, and pathologists was calculated.

RESULTS

The SSC service received 340 referrals for 402 lesions. Dermatologists diagnosed 256 (63.7%) of these lesions as benign; 56 (13.9%) were histologically confirmed as malignant, including 19 (4.7%) melanomas. The overall discordance between referrer and dermatologist on specific and broad (ie, benign or malignant) diagnoses for 402 lesions was 47% and 26% (κ=0.58, SD 0.07), respectively; 44% and 26% (κ=0.61, SD 0.15) between referrer and pathologist; and 18% and 12% (κ=0.82, SD 0.12) between dermatologist and pathologist. The mean time between referral submission and receiving advice was 1.02 days. The average time to action (eg, excision) was 64.8 days.

CONCLUSIONS

An electronic referral system can be an effective form of teledermatology for providing prompt diagnosis and management advice for benign and malignant skin lesions.

Store-and-Forward Teledermatology for Assessing Skin Cancer in 2023: Literature Review

BACKGROUND

The role of teledermatology for skin lesion assessment has been a recent development, particularly, since the COVID-19 pandemic has impacted the ability to assess patients in person. The growing number of studies relating to this area reflects the evolving interest.

OBJECTIVE

This literature review aims to analyze the available research on store-and-forward teledermatology for skin lesion assessment.

METHODS

MEDLINE was searched for papers from January 2010 to November 2021. Papers were searched for assessment of time management, effectiveness, and image quality.

RESULTS

The reported effectiveness of store-and-forward teledermatology for skin lesion assessment produces heterogeneous results likely due to significant procedure variations. Most studies show high accuracy and diagnostic concordance of teledermatology compared to in-person dermatologist assessment and histopathology. This is improved through the use of teledermoscopy. Most literature shows that teledermatology reduces time to advice and definitive treatment compared to outpatient clinic assessment.

CONCLUSIONS

Overall, teledermatology offers a comparable standard of effectiveness to in-person assessment. It can save significant time in expediting advice and management. Image quality and inclusion of dermoscopy have a considerable bearing on the overall effectiveness.

Lead Time from First Suspicion of Malignant Melanoma in Primary Care to Diagnostic Excision: a Cohort Study Comparing Teledermatoscopy and Traditional Referral to a Dermatology Clinic at a Tertiary Hospital

INTRODUCTION

The increasing use of teledermatoscopy in clinical practice has led to demands to evaluate the effects of this new technology on traditional healthcare systems.

OBJECTIVES

To study lead times from first consultation in primary care to diagnostic excision of suspected malignant melanoma lesions in traditional referrals to a tertiary hospital-based dermatology clinic compared with mobile teledermatoscopy referrals.

METHODS

A retrospective cohort study design was used. Data on sex, age, pathology, caregivers, clinical diagnosis, date for first visit to primary care unit, and date for diagnostic excision were collected from medical records. Patients managed through traditional referral (n=53) were compared with patients managed at primary care units using teledermatoscopy (n=128) regarding lead time from first visit to diagnostic excision.

RESULTS

Mean time from date of first visit at primary care unit to diagnostic excision did not differ between the traditional referral and teledermatoscopy groups (16.2 vs. 15.7 days, median 10 vs. 13 days, p=0.657). Lead times from date of referral to diagnostic excision did not significantly differ (15.7 vs. 12.8 days, median 10 vs. 9 days, p=0.464).

CONCLUSIONS

Our study indicates that lead time to diagnostic excision for patients with suspected malignant melanoma managed by teledermatoscopy was comparable and not inferior to that of the traditional referral pathway. If teledermatoscopy is used at first consultation in primary care, it could potentially be more efficient than traditional referral.

A 9-Year Teledermoscopy Service in New Zealand: Retrospective Service Review

BACKGROUND

A teledermoscopy service was established in January 2010 wherein patients attended nurse-led clinics for the imaging of lesions of concern and remote diagnosis by a dermatologist.

OBJECTIVE

This study aims to review the number of visits, patient characteristics, the efficiency of the service, and the diagnoses made.

METHODS

We evaluated the waiting times and diagnoses of skin lesions for all patient visits from January 1, 2010, to May 31, 2019. The relationships between patient characteristics and the diagnosis of melanoma were specifically analyzed.

RESULTS

The teledermoscopy clinic was attended by 6479 patients for 11,005 skin lesions on 8805 occasions. Statistically significant risk factors for the diagnosis of melanoma and melanoma in situ were male sex (P<.001), European ethnicity (P=.001), an age of 65 to 74 years (P=.001), and Fitzpatrick skin type 2 (P=.001). Attendance was maximal during 2015 and 2016. The seasonal variations in visits from 2011 to 2018 revealed a consistent peak at the end of summer and a dip at the end of winter. In the year 2010, a total of 306 patients attended the clinic; 76.1% (233/306) of these patients were discharged to primary care, and 23.9% (73/306) were referred to a hospital for a specialist assessment. For patients who were diagnosed with suspected melanoma by a dermatologist from January 1, 2010, to May 31, 2019, the median waiting time for an imaging appointment was 44.5 (mean 57.9; range 8-218) days. The most common lesions diagnosed were benign naevus (2933/11,005, 26.7%), benign keratosis (2576/11,005, 23.4%), and keratinocytic cancer (1707/11,005, 15.5%); melanoma was suspected in 4.6% (507/11,005) of referred lesions. The positive predictive value of melanoma and melanoma in situ was 61.1% (320 true positives and 203 false positives). The number needed to treat (ie, the ratio of the total number of excisions to the number with a histological diagnosis of melanoma or melanoma in situ) was 2.02.

CONCLUSIONS

A teledermoscopy service offered by nurse-led imaging clinics can provide efficient and convenient access to dermatology services by streamlining referrals to secondary care and prioritizing patients with skin cancer for treatment.

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.

Emergency Use and Efficacy of an Asynchronous Teledermatology System as a Novel Tool for Early Diagnosis of Skin Cancer during the First Wave of COVID-19 Pandemic

Background: After the outbreak of the corona virus disease-19 (COVID-19) pandemic, teledermatology was implemented in the Hungarian public healthcare system for the first time. Our objective was to assess aggregated diagnostic agreements and to determine the effectiveness of an asynchronous teledermatology system for skin cancer screening. Methods: This retrospective single-center study included cases submitted for teledermatology consultation during the first wave of the COVID-19 pandemic. Follow-up of the patients was performed to collect the results of any subsequent personal examination. Results: 749 patients with 779 lesions were involved. 15 malignant melanomas (9.9%), 78 basal cell carcinomas (51.3%), 21 squamous cell carcinomas (13.8%), 7 other malignancies (4.6%) and 31 actinic keratoses (20.4%) were confirmed. 87 malignancies were diagnosed in the high-urgency group (42.2%), 49 malignancies in the moderate-urgency group (21.6%) and 16 malignancies in the low-urgency group (4.6%) (p < 0.0001). Agreement of malignancies was substantial for primary (86.3%; κ = 0.647) and aggregated diagnoses (85.3%; κ = 0.644). Agreement of total lesions was also substantial for primary (81.2%; κ = 0.769) and aggregated diagnoses (87.9%; κ = 0.754). Conclusions: Our findings showed that asynchronous teledermatology using a mobile phone application served as an accurate skin cancer screening system during the first wave of the COVID-19 pandemic.

Virtual lesion clinic - Evaluation of a teledermatology triage system for referrals for suspected melanoma

INTRODUCTION

The Virtual Lesion Clinic (VLC) of Waitematā District Health Board (WDHB) improves melanoma assessment and treatment using teledermatology. The VLC is reserved for pigmented lesions referred as suspected melanoma from primary care but indeterminate at the initial triage.

OBJECTIVES

To assess the efficacy of the VLC diagnosis of melanoma.

METHODS

A retrospective audit of suspected melanoma referrals (1 January 2012 to 31 December 2016) was conducted. Lesions were referred to the VLC if diagnostic uncertainty remained at the initial triage. VLC patients attended MoleMap imaging centres, a dermatologist reviewed history and images remotely and suggested a diagnosis and management plan. Post VLC provisional diagnosis of melanoma, all lesions subsequently excised were reviewed. A positive predictive value (PPV) was calculated using concordance between VLC diagnosis of melanoma and histopathological diagnosis of melanoma. Number needed to excise (NNE) for melanoma was derived, as well as an invasive to in-situ melanoma ratio (IM:MIS) and false negative rate (FNR).

RESULTS

The VLC received 1874 referrals for 3546 lesions during the 5-year study period. Six hundred and seventy-nine lesions were recommended excision/biopsy or specialist face-to-face assessment, and 504 lesions were subsequently excised. The PPV was 62%, NNE 1.62 and IM:MIS 0.76 for lesions suspected to be melanoma at VLC assessment. The VLC had a melanoma-specific FNR of 7%.

CONCLUSIONS

The VLC is effective in early diagnosis of melanoma with a high positive predictive value, low number needed to excise and low false negative rate amongst lesions referred as suspected melanoma.

Remote Skin Cancer Diagnosis: Adding Images to Electronic Referrals Is More Efficient Than Wait-Listing for a Nurse-Led Imaging Clinic

Simple Summary

Skin cancer is a significant cause of death and disability, particularly in New Zealand. Expert diagnosis reduces unnecessary excision of benign lesions, reduces patient anxiety, and allows early identification of skin cancer, particularly of melanoma. The study assessed an electronic referral pathway for teledermatology—diagnosing skin lesions remotely using a standardised template with regional, close-up, and dermoscopic images—and compared this to scheduled nurse-led teledermoscopy clinics. A dermatology opinion was reached more rapidly with comparable efficacy when referrals include good quality images, compared to nurse-led imaging clinics.

Abstract

We undertook a retrospective comparison of two teledermatology pathways that provide diagnostic and management advice for suspected skin cancers, to evaluate the time from referral to diagnosis and its concordance with histology. Primary Care doctors could refer patients to either the Virtual Lesion Clinic (VLC), a nurse-led community teledermoscopy clinic or, more recently, to the Suspected Skin Cancer (SSC) pathway, which requires them to attach regional, close-up, and dermoscopic images. The primary objective of this study was to determine the comparative time course between the SSC pathway and VLC. Secondary objectives included comparative diagnostic concordance, skin lesion classification, and evaluation of missed skin lesions during subsequent follow-up. VLC referrals from July to December 2016 and 2020 were compared to SSC referrals from July to December 2020. 408 patients with 682 lesions in the VLC cohort were compared with 480 patients with 548 lesions from the 2020 SSC cohort, matched for age, sex, and ethnicity, including histology where available. Median time (SD) from referral to receipt of teledermatology advice was four (2.8) days and 50 (43.0) days for the SSC and VLC cohorts, respectively (p < 0.001). Diagnostic concordance between teledermatologist and histopathologist for benign versus malignant lesions was 70% for 114 lesions in the SSC cohort, comparable to the VLC cohort (71% of 122 lesions). Referrals from primary care, where skin lesions were imaged with variable devices and quality resulted in faster specialist advice with similar diagnostic performance compared to high-quality imaging at nurse-led specialist dermoscopy clinics.

Shared Care and Virtual Clinics for Glaucoma in a Hospital Setting

Glaucoma patients require lifelong management, and the prevalence of glaucoma is expected to increase, resulting in capacity problems in many hospital eye departments. New models of care delivery are needed to offer requisite capacity. This review evaluates two alternative schemes for glaucoma care within a hospital, i.e., shared care (SC) and virtual clinics (VCs), whereby non-medical staff are entrusted with more responsibilities, and compares these schemes with the “traditional” ophthalmologist-led outpatient service (standard care). A literature search was conducted in three large bibliographic databases (PubMed, Embase, and Trip), and the abstracts from the prior five annual meetings of the Association for Research in Vision and Ophthalmology were consulted. Twenty-nine were included in the review (14 on SC and 15 on VCs). Patients with low risk of vision loss were considered suitable for these approaches. Among the non-medical staff, optometrists were the most frequently involved. The quality of both schemes was good and improved with the non-medical staff being trained in glaucoma care. No evidence was found on patients feeling disadvantaged by the lack of a doctor visit. Both schemes increased the hospital’s efficiency. Both SC and VCs are promising approaches to tackle the upcoming capacity problems of hospital-based glaucoma care.

An Australian tertiary hospital analysis of outpatient dermatology clinical and demographic characteristics

OBJECTIVES

Literature on dermatology outpatient demographic and clinical data is limited, and the few studies on this topic are mainly conducted overseas, with medical systems and case mix different to Australia. This study presents demographic data relating to dermatology public outpatient referrals to a tertiary hospital in Brisbane, Australia, and determines what additional structured data should be collected to formulate and evaluate initiatives to address service issues such as referral quality, triage process and wait times.

METHODS

A four-year retrospective audit was undertaken, summarising all referrals (n = 7140) and clinical dermatology encounters (n = 53 844) between January 2016 and December 2019 at Princess Alexandra Hospital (PAH), the largest hospital in Metro South Health (MSH), serving a population of one million. PAH has one of the two largest public dermatology clinics in Queensland and is the only dermatology service within MSH.

RESULTS

Patient demographic data, wait time by triage category, referral rates over time and encounter durations were collected. Structured diagnostic data (e.g. ICD-10 coding) of the provisional diagnosis, comorbidities, medications and the final diagnosis are not collected in a structured format and would be a valuable addition.

CONCLUSIONS

The clinical burden of public dermatology is increasing. Both collection and analysis of structured data pertaining to the referrals and encounters are important to help formulate, implement and evaluate initiatives that aim to improve health service provision in this area.

Development of a Checklist Tool to Assess the Quality of Skin Lesion Images Acquired by Consumers Using Sequential Mobile Teledermoscopy

BACKGROUND

Mobile teledermoscopy is an emerging technology that involves imaging and digitally sending dermoscopic images of skin lesions to a clinician for assessment. High-quality, consistent images are required for accurate telediagnoses when monitoring lesions over time. To date there are no tools to assess the quality of sequential images taken by consumers using mobile teledermoscopy. The purpose of this study was to develop a tool to assess the quality of images acquired by consumers.

METHODS

Participants imaged skin lesions that they felt were concerning at baseline, 1-, and 2-months. A checklist to assess the quality of consumer sequential imaging of skin lesions was developed based on the International Skin Imaging Collaboration guidelines. A scale was implemented to grade the quality of the images: 0 (low) to 18 (very high). Intra- and inter-reliability of the checklist was assessed using Bland-Altman analysis. Using this checklist, the consistency with which 85 sets of images were scored by 2 evaluators were compared using Kappa statistics. Items with a low Kappa value <0.4 were removed.

RESULTS

After reliability testing, 5 of the items were removed due to low Kappa values (<0.4) and the final checklist included 13 items surveying: lesion selection; image orientation; lighting; field of view; focus and depth of view. Participants had a mean age of 41 years (range 19-73), and 67% were female. Most participants (84%, n = 71/85) were able to select and image the correct lesion over time for both the dermoscopic and overview images. Younger participants (<40 years old) scored significantly higher (8.1 ± 2.1) on the imaging checklist compared to older participants (7.1 ± 2.4; p = 0.037). Participants had most difficulty with consistent image orientation.

CONCLUSIONS

This checklist could be used as a triage tool to filter images acquired by consumers prior to telediagnosis evaluation, which would improve the efficiency and accuracy of teledermatology and teledermoscopy processes. It may also be used to provide feedback to the consumers to improve image acquisition over time.

High-Frequency Ultrasonography-Possibilities and Perspectives of the Use of 20 MHz in Teledermatology

High-frequency ultrasonography (HF-USG) is a non-invasive and in vivo method of visualization of the skin and upper part of subcutaneous tissue based on ultrasounds above 20 MHz. Although initially HF-USG was introduced to measure skin thickness, it currently gained widespread acceptance in dermato-oncology, primarily when used to determine skin tumor margins. Moreover, its application in different dermatology fields is known, particularly as a rapidly evolving method in the objective evaluation of the severity of various chronic skin diseases. Among different specialties, teledermatology belongs to leading and continually developing areas of successful telemedicine applications. Various skin conditions are visible to the human eye, which makes them particularly suitable for telemedicine. However, HF-USG enables specialists to look into deeper skin layers, thus extending diagnostic options. On the other hand, teledermatology creates the possibility of sending images for consultation and facilitates the therapeutic decision as HF-USG can be used in an asynchronous store and forward manner. It seems that HF-USG and teledermatology may be regarded as a truly matched pair. The aim of this work is to present current applications of 20-MHz ultrasonography in dermatology, including skin neoplasms and chronic skin diseases. Moreover, the authors aimed to analyze the possibilities of HF-USG use as a valuable tool in teledermatology, especially in diagnosing and monitoring patients suffering from long-lasting skin conditions.

A retrospective review of cutaneous vascular lesions referred to a teledermatology clinic

INTRODUCTION Most cutaneous vascular lesions are benign and do not require treatment. Many are referred to specialist dermatologists from primary care. AIM This study aimed to investigate the characteristics of cutaneous vascular lesions and the reasons for their referral from primary care. METHODS Lesions diagnosed as cutaneous vascular abnormalities or dermatoses were retrospectively selected from a database of patients attending the Waikato Virtual Lesion Clinic. Demographic data, diagnosis and clinic outcome were recorded for each imaged lesion. Primary care referrals were reviewed to determine the reasons for referral. RESULTS In total, 229 referrals for vascular lesions were received between January 2010 and February 2019. Patient ages ranged from 6 to 95 years and 64.2% of patients were female. Nearly half the lesions (47.2%) were located on the head and neck; 64.1% had a dermatological diagnosis of a vascular tumour and 18.7% had a malformation. The most common reason for referral was pigmentation (45.7%) and bleeding was least common (8.2%). No diagnosis was given in 34.2% of referrals and less than one-quarter had a correct diagnosis. Malignancy was suspected in 40.2% of referrals; however, the dermatologists found that 95.2% of patients did not require further treatment. Half of excisions (n=2) were for bleeding and all were histologically benign. DISCUSSION Diagnostic uncertainty and suspected malignancy commonly result in referral of benign cutaneous vascular lesions to public dermatology services. This study highlights the usefulness of teledermatology in the timely access of specialist input, minimising the need for intervention or excision.

Diagnostic Concordance in Tertiary (Dermatologists-to-Experts) Teledermoscopy: A Final Diagnosis-Based Study on 290 Cases

Background

Teledermoscopy (TDS) improves diagnostic accuracy and decreases the number of unnecessary consultations.

Objectives

To determine the diagnostic concordance in tertiary (dermatologist-to-experts) TDS with histopathology/follow-up-based diagnosis.

Methods

A descriptive retrospective cohort study including 290 requests.

Results

Perfect diagnostic concordance was found in 202 (69.7%) cases and partial agreement in 29 (10%). Disagreement was found in 59 (20.3%) cases. Perfect concordance on the benign/malignant nature of the lesion was found in 227 (78.3%) cases and disagreement in 63 (21.7%). In onychology, diagnostic concordance was perfect in 43 (76.8%) cases, partial in 7 (12.5%), and there was disagreement in 6 (10.7%). Final concordance on the benign/malignant nature of the lesion was perfect in 48 (85.7%) and there was disagreement in 8 (14.3%) nail cases. For pediatric requests, diagnostic concordance was perfect in 29 (65.9%) cases, partial in 5 (11.4%), and there was disagreement in 10 (22.7%). Final concordance on the benign/malignant nature of the lesion was observed in 34 (77.3%) cases, disagreement in 10 (22.7%).

Conclusions

This study confirms that tertiary TDS improves diagnostic accuracy of pigmented skin lesions. Moreover, it shows encouraging results in unusual conditions such as ungual and pediatric skin tumors. The main limitation was the retrospective nature and the "real-life" setting of our study that could have created a selection bias toward inclusion of the most difficult cases.

E-referrals and teledermatoscopy grading for melanoma: a successful model of care

BACKGROUND/OBJECTIVES

An e-referral system was developed at a tertiary care hospital in Auckland, New Zealand in 2014 for suspected cutaneous malignancy. E-referrals include patient information, a description of the lesion(s), biopsy results and/or attached photograph(s). Experienced surgical oncologists prioritised the referrals and selected a management option or referred them for a teledermatoscopy opinion. Our aim was to review the efficacy of e-referrals for improving diagnostic accuracy for melanoma.

METHODS

Referrals received in 2016 including images and categorisation as confirmed, likely or suspected melanoma by the triage specialist were evaluated. Concordance of the pathological diagnosis with the triage diagnosis and teledermatoscopy diagnosis was determined for each referral.

RESULTS

809 of 3470 e-referrals for skin cancer were categorised as confirmed, likely or suspected melanoma. 230 (28.4%) of these included a referral histopathology confirming melanoma/melanoma in situ. Of the remaining 579 referrals, 315 were sent for urgent diagnostic excision and 264 were referred for teledermatoscopy. 120 of the 315 sent for urgent excision were confirmed as melanoma (53) or melanoma in situ (67) on histopathology: a positive predictive value (PPV) of 38.1% and number needed to excise (NNE) of 2.6. Less than 10% of referrals triaged for teledermatoscopy were confirmed as melanoma (24/264). Almost half of all referrals (374/809, 45.6%) included melanoma/melanoma in situ. The melanoma: melanoma in situ ratio was 1: 1.18.

CONCLUSIONS

The e-referral and teledermatoscopy service for suspected melanoma has proven fewer unnecessary excisions of benign lesions than previously reported.

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.

Teledermoscopy for Skin Cancer Prevention: a Comparative Study of Clinical and Teledermoscopic Diagnosis

Introduction

The number of newly diagnosed skin cancers per year is greater than the sum of the four most common cancers: breast, prostate, lung, and colon. The implementation of primary and secondary prevention measures, over the last 2 to 3 decades, has made a major contribution to successful treatment.

Aim

Evaluate the accuracy and reliability of teledermoscopic versus clinical diagnosis for skin cancers when diagnostic algorithms are used, and when GPs and surgical specialties are involved in the clinical procedure.

Methods

Digital dermoscope (TS-DD, by Teleskin company) was used for the acquisition of teledermoscopic photographs and specialized teledermoscopic software was used for clinical examination and teledermoscopic consultation. The teledermoscopic procedure itself was performed in two steps. The first step was a clinical examination using the ABCDE rule with digital dermoscopic photography of the suspected lesion. The second step was a 2-step dermoscopic evaluation using the second step ABCD algorithm for the second step. Accuracy and diagnostic reliability were calculated for: teledermoscopic diagnosis versus histopathological diagnosis; clinical diagnosis versus histopathological diagnosis and teledermoscopic diagnosis versus clinical diagnosis.

Results

The study included 120 patients with 121 Pigmented Skin Lesions, of which 75 (62%) were benign and 46 (38%) were malignant lesions (6 melanomas and 40 NonMelanoma Skin Cancers). Diagnostic accuracy between teledermoscopic and histopathologic diagnosis was 90.91% and reliability k=0.81; between clinical and histopathological diagnosis the diagnostic accuracy was 82.64% and the reliability k=0.64 and between the clinical and teledermoscopic diagnosis the diagnostic accuracy was 81.82% and the reliability k=0.62.

Conclusion

The achieved diagnostic accuracy between clinical and teledermoscopic diagnosis, when using diagnostic algorithms, establishes a feasible screening path for skin cancers and indicates that general practitioners and specialized surgeons may equally be involved in prevention.

Consumer Preferences for Skin Cancer Screening Using Mobile Teledermoscopy: A Qualitative Study

BACKGROUND

Mobile teledermoscopy is a rapidly advancing technology that promotes early detection and management of skin cancers. Whilst the use of teledermoscopy has proven to be effective and has a role in the detection of skin cancers, patients' attitudes towards the multiple ways in which this technology can be utilised has not been explored.

METHODS

Data were obtained from a large randomised controlled trial comparing mobile teledermoscopy-enhanced skin self-examinations (SSEs) with naked-eye SSE. A semi-structured interview guide was developed by the investigators with questions focusing on people's previous skin screening behaviours and 2 of the major pathways which can be utilised in mobile teledermoscopy: (i) direct-to-consumer and (ii) doctor-to-doctor. All interviews were tape-recorded and transcribed verbatim. Thematic analysis was undertaken by 2 independent researchers.

RESULTS

Twenty-eight participants were interviewed. Eighty-six percent of participants (n = 24/28) had previously had a clinical skin examination. Only 18% of participants (n = 5/28) visited the same doctor for each clinical skin examination. Five main themes were identified in the interviews that affected how people felt about the integration of mobile teledermoscopy into skin screening pathways: history of clinical skin examinations, continuity of the doctor-patient relationship, convenience of the direct-to-consumer teledermoscopy, expedited review enhancing the doctor-to-doctor setting and mobile teledermoscopy as a partner-assisted task.

CONCLUSIONS

Overall mobile teledermoscopy was viewed positively for both direct-to-consumer and doctor-to-doctor interaction. Continuity of care in the doctor-patient relationship was not found to be a priority for clinical skin examination with most participants visiting several doctors throughout their clinical skin examination history.

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.

Cost-effectiveness of Skin Cancer Referral and Consultation Using Teledermoscopy in Australia

Importance

International literature has shown that teledermoscopy referral may be a viable method for skin cancer referral; however, no economic investigations have occurred in Australia.

Objective

To assess the cost-effectiveness of teledermoscopy as a referral mechanism for skin cancer diagnosis and management in Australia.

Design, Setting, and Participants

Cost-effectiveness analysis using a decision-analytic model of Australian primary care, informed by publicly available data.

Interventions

We compared the costs of teledermoscopy referral (electronic referral containing digital dermoscopic images) vs usual care (a written referral letter) for specialist dermatologist review of a suspected skin cancer.

Main Outcomes and Measures

Cost and time in days to clinical resolution, where clinical resolution was defined as diagnosis by a dermatologist or excision by a general practitioner. Probabilistic sensitivity analysis was performed to examine the uncertainty of the main results.

Results

Findings from the decision-analytic model showed that the mean time to clinical resolution was 9 days (range, 1-50 days) with teledermoscopy referral compared with 35 days (range, 0-138 days) with usual care alone (difference, 26 days; 95% credible interval [CrI], 13-38 days). The estimated mean cost difference between teledermoscopy referral (A$318.39) vs usual care (A$263.75) was A$54.64 (95% CrI, A$22.69-A$97.35) per person. The incremental cost per day saved to clinical resolution was A$2.10 (95% CrI, A$0.87-A$5.29).

Conclusions and Relevance

Using teledermoscopy for skin cancer referral and triage in Australia would cost A$54.64 extra per case on average but would result in clinical resolution 26 days sooner than usual care. Implementation recommendations depend on the preferences of the Australian health system decision makers for either lower cost or expedited clinical resolution. Further research around the clinical significance of expedited clinical resolution and its importance for patients could inform implementation recommendations for the Australian setting.

Teledermatology for diagnosing skin cancer in adults

BACKGROUND

Early accurate detection of all skin cancer types is essential to guide appropriate management and to improve morbidity and survival. Melanoma and squamous cell carcinoma (SCC) are high-risk skin cancers which have the potential to metastasise and ultimately lead to death, whereas basal cell carcinoma (BCC) is usually localised with potential to infiltrate and damage surrounding tissue. Anxiety around missing early curable cases needs to be balanced against inappropriate referral and unnecessary excision of benign lesions. Teledermatology provides a way for generalist clinicians to access the opinion of a specialist dermatologist for skin lesions that they consider to be suspicious without referring the patients through the normal referral pathway. Teledermatology consultations can be 'store-and-forward' with electronic digital images of a lesion sent to a dermatologist for review at a later time, or can be live and interactive consultations using videoconferencing to connect the patient, referrer and dermatologist in real time.

OBJECTIVES

To determine the diagnostic accuracy of teledermatology for the detection of any skin cancer (melanoma, BCC or cutaneous squamous cell carcinoma (cSCC)) in adults, and to compare its accuracy with that of in-person diagnosis.

SEARCH METHODS

We undertook a comprehensive search of the following databases from inception up to August 2016: Cochrane Central Register of Controlled Trials, MEDLINE, Embase, CINAHL, CPCI, Zetoc, Science Citation Index, US National Institutes of Health Ongoing Trials Register, NIHR Clinical Research Network Portfolio Database and the World Health Organization International Clinical Trials Registry Platform. We studied reference lists and published systematic review articles.

SELECTION CRITERIA

Studies evaluating skin cancer diagnosis for teledermatology alone, or in comparison with face-to-face diagnosis by a specialist clinician, compared with a reference standard of histological confirmation or clinical follow-up and expert opinion. We also included studies evaluating the referral accuracy of teledermatology compared with a reference standard of face-to-face diagnosis by a specialist clinician.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data using a standardised data extraction and quality assessment form (based on QUADAS-2). We contacted authors of included studies where there were information related to the target condition of any skin cancer missing. Data permitting, we estimated summary sensitivities and specificities using the bivariate hierarchical model. Due to the scarcity of data, we undertook no covariate investigations for this review. For illustrative purposes, we plotted estimates of sensitivity and specificity on coupled forest plots for diagnostic threshold and target condition under consideration.

MAIN RESULTS

The review included 22 studies reporting diagnostic accuracy data for 4057 lesions and 879 malignant cases (16 studies) and referral accuracy data for reported data for 1449 lesions and 270 'positive' cases as determined by the reference standard face-to-face decision (six studies). Methodological quality was variable with poor reporting hindering assessment. The overall risk of bias was high or unclear for participant selection, reference standard, and participant flow and timing in at least half of all studies; the majority were at low risk of bias for the index test. The applicability of study findings were of high or unclear concern for most studies in all domains assessed due to the recruitment of participants from secondary care settings or specialist clinics rather than from primary or community-based settings in which teledermatology is more likely to be used and due to the acquisition of lesion images by dermatologists or in specialist imaging units rather than by primary care clinicians.Seven studies provided data for the primary target condition of any skin cancer (1588 lesions and 638 malignancies). For the correct diagnosis of lesions as malignant using photographic images, summary sensitivity was 94.9% (95% confidence interval (CI) 90.1% to 97.4%) and summary specificity was 84.3% (95% CI 48.5% to 96.8%) (from four studies). Individual study estimates using dermoscopic images or a combination of photographic and dermoscopic images generally suggested similarly high sensitivities with highly variable specificities. Limited comparative data suggested similar diagnostic accuracy between teledermatology assessment and in-person diagnosis by a dermatologist; however, data were too scarce to draw firm conclusions. For the detection of invasive melanoma or atypical intraepidermal melanocytic variants both sensitivities and specificities were more variable. Sensitivities ranged from 59% (95% CI 42% to 74%) to 100% (95% CI 48% to 100%) and specificities from 30% (95% CI 22% to 40%) to 100% (95% CI 93% to 100%), with reported diagnostic thresholds including the correct diagnosis of melanoma, classification of lesions as 'atypical' or 'typical, and the decision to refer or to excise a lesion.Referral accuracy data comparing teledermatology against a face-to-face reference standard suggested good agreement for lesions considered to require some positive action by face-to-face assessment (sensitivities of over 90%). For lesions considered of less concern when assessed face-to-face (e.g. for lesions not recommended for excision or referral), agreement was more variable with teledermatology specificities ranging from 57% (95% CI 39% to 73%) to 100% (95% CI 86% to 100%), suggesting that remote assessment is more likely recommend excision, referral or follow-up compared to in-person decisions.

AUTHORS' CONCLUSIONS

Studies were generally small and heterogeneous and methodological quality was difficult to judge due to poor reporting. Bearing in mind concerns regarding the applicability of study participants and of lesion image acquisition in specialist settings, our results suggest that teledermatology can correctly identify the majority of malignant lesions. Using a more widely defined threshold to identify 'possibly' malignant cases or lesions that should be considered for excision is likely to appropriately triage those lesions requiring face-to-face assessment by a specialist. Despite the increasing use of teledermatology on an international level, the evidence base to support its ability to accurately diagnose lesions and to triage lesions from primary to secondary care is lacking and further prospective and pragmatic evaluation is needed.

Tele-expertise for diagnosis of skin lesions is cost-effective in a prison setting: A retrospective cohort study of 450 patients

CONTEXT

The prevalence of skin diseases among prisoners is higher than in the general population. Diagnosing and treating these lesions require a dermatologic advice. A tele-expertise network in dermatology for prisoners including 8 health facilities in prison and 2 hospital dermatological departments was developed to improve access to dermatologists' expertise in correctional facilities. Our objective was to evaluate the effectiveness and costs of tele-expertise in dermatology for prisoners.

METHODS

We carried out a retrospective cohort study on data collected by the information system of the tele-expertise network. We used the MAST (Model for ASsessment of Telemedicine) model to perform a multidimensional assessment including the proportion of patients with a completed treatment plan for the skin lesions, the proportion of technical problems, the quality of the pictures, the investment and operating costs and the satisfaction of the professionals.

RESULTS

Mean patient age was 34.2 years with 90% men. 511 requests for 450 patients were initiated. The delay from the connection to the tele-expertise software to the validation of the request was inferior to 7 min for 50% of the requests and inferior to 30 min for 85% of the requests. Overall, with tele-expertise, 82% of the patients had a completed treatment plan for the skin lesions, with 2.9% of all patients requiring a later face-to-face appointment or hospitalization, to be compared to a proportion of 35% of patients with a completed treatment plan when tele-expertise was not available. The most frequent lesions were acnea (22%) and atopic dermatitis (18%). The mean cost for one completed treatment plan was €184 by tele-expertise and €315 without tele-expertise. Tele-expertise was well accepted among physicians with all responders (n = 9) willing to continue using it.

CONCLUSION

Tele-expertise is a dominant intervention in comparison to a face-to face consultation taking into account the cost of transportation and the proportion of canceled appointments and is acceptable for physicians.

TRIAL REGISTRATION

NCT02309905.

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.

Telemedicine in dermatology: findings and experiences worldwide - a systematic literature review

Telemedicine has become an important element of health care in many countries and profited from the technological progress of the last two decades. Due to the visual character of the dermatological specialty, teledermatology in particular participated in that development and is becoming a major tool in dermatological consultation. The objective of this article was to identify the use of teledermatology across the world based on published original articles. A systematic literature search of the MEDLINE and Embase databases for eligible publications (predefined inclusion and exclusion criteria) and a cross-validation search were conducted. Search results were reviewed systematically. The search resulted in 204 publications meeting the inclusion criteria for analysis. The highest number of published studies on teledermatology was performed in the United States, followed by the United Kingdom, Spain, the Netherlands, Italy and Austria. The majority of dermatological indications for telemedical consultations were not specified or included various kinds of skin diseases, followed by skin cancer and wounds. Research questions predominantly focused on concordance, effectiveness and cost-effectiveness to determine the value. Teledermatology proved to be a reliable consultation tool in the majority of studies. If specified, telemedicine was used in daily dermatological routine for patient management purposes, to consult patients in peripheral locations, or for medical support in nursing homes or home care settings. The application of teledermatology worldwide is highest in North American and European countries, while countries with poor geographical distribution of physicians seem to be under-represented in teledermatological use, as concluded from publication output. Regarding indications, comparison with classic consultation and area of application, most studies were of general nature. For precise determination of the value, systematic studies would be needed. However, teledermatology is already accepted as a valid tool.

More Medicine, Fewer Clicks: How Informatics Can Actually Help Your Practice

In the information age, we expect data systems to make us more effective and efficient-not to make our lives more difficult! In this article, we discuss how we are using data systems, such as electronic health records (EHRs), to improve care delivery. We illustrate how US Oncology is beginning to use real-world evidence to facilitate trial accrual by automatic identification of eligible patients and how big data and predictive analytics will transform the field of oncology. Some information systems are already being used at the point of care and are already empowering clinicians to improve the care of their patients in real time. Telehealth platforms are being used to bridge gaps that currently exist in expertise, geography, and technical capability. Optimizing virtual collaboration, such as through virtual tumor boards, is empowering communities that are geographically disparate to coordinate care. Informatics methods can provide solutions to the challenging problems of how to manage the vast amounts of data confronting the practicing oncologist, including information about treatment regimens, side effects, and the influence of genomics on the practice of oncology. We also discuss some of the challenges of clinical documentation in the modern era, and review emerging efforts to engage patients as digital donors of their EHR data.