Teledermatology as a tool for communication between general practitioners and dermatologists

Acceptance of Telemedicine Compared to In-Person Consultation From the Providers' and Users' Perspectives: Multicenter, Cross-Sectional Study in Dermatology

BACKGROUND

Teledermatology is currently finding its place in modern health care worldwide as a rapidly evolving field.

OBJECTIVE

The aim of this study was to investigate the acceptance of teledermatology compared to in-person consultation from the perspective of patients and professionals.

METHODS

This multicenter, cross-sectional pilot study was performed at secondary and tertiary referral centers of dermatology in Switzerland from August 2019 to January 2020. A customized questionnaire addressing demographics and educational data, experience with telemedicine, and presumed willingness to replace in-patient consultations with teledermatology was completed by dermatological patients, dermatologists, and health care workers in dermatology.

RESULTS

Among a total of 664 participants, the ones with previous telemedicine experience (171/664, 25.8%) indicated a high level of overall experience with it (patients: 73/106, 68.9%, dermatologists: 6/8, 75.0%, and health care workers: 27/34, 79.4%). Patients, dermatologists, and health care workers were most likely willing to replace in-person consultations with teledermatology for minor health issues (353/512, 68.9%; 37/45, 82.2%; and 89/107, 83.2%, respectively). We observed a higher preference for telemedicine among individuals who have already used telemedicine (patients: P<.001, dermatologists: P=.03, and health care workers, P=.005), as well as among patients with higher educational levels (P=.003).

CONCLUSIONS

This study indicates that the preference for teledermatology has a high potential to increase over time since previous experience with telemedicine and a higher level of education were associated with a higher willingness to replace in-patient consultations with telemedicine. We assume that minor skin problems are the most promising issue in teledermatology. Our findings emphasize the need for dermatologists to be actively involved in the transition to teledermatology.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04495036; https://classic.clinicaltrials.gov/ct2/show/NCT04495036.

Patient and Provider Satisfaction with Teledermatology

BACKGROUND

There is little research comparing dermatologist and patient satisfaction with in-person, store-and-forward, and live interactive examinations.

OBJECTIVE

To compare satisfaction with in-person examinations to store-and-forward and live interactive consultations having two types of video.

METHODS

A controlled study was conducted where patients referred for dermatology consultations were examined in-person, by video, and by store-and-forward methods. Video changed between compressed and uncompressed on alternate clinics. Patients and dermatologists rated encounters after each examination. Dermatologists doing store-and-forward evaluations rated the quality of information provided. After experiencing all methods patients ranked their preferences. Dermatologists ranked their preferences at the end of the study.

RESULTS

In-person examinations were preferred by both patients and dermatologists. Overall, satisfaction with teledermatology was still high. Patients were evenly divided in preferring store-and-forward workups or live interactive video. Dermatologists were also divided on store-and-forward and uncompressed video, but tended toward the latter. Compressed video was the least preferred method among dermatologists.

LIMITATIONS

Dermatology residents took store-and-forward photos and their quality was likely superior to those normally taken in practice.

CONCLUSIONS

Patients and dermatologists prefer in-person examinations and diverge on preferring store-and-forward and live interactive when video is not compressed. The amount of video compression that can be applied without noticeable image degradation is a question for future research.

Trial of low-cost teledermatology in primary care

We examined the feasibility of a low-cost, store-and-forward teledermatology service for general practitioners (GPs) in regional Queensland. Digital pictures and a brief case history were transmitted by email. A service coordinator carried out quality control checks and then forwarded these email messages to a consultant dermatologist. On receiving a clinical response from the dermatologist, the service coordinator returned the message to the referring GP. The aim was to provide advice to rural GPs within one working day. Over six months, 63 referrals were processed by the teledermatology service, covering a wide range of dermatological conditions. In the majority of cases the referring doctors were able to treat the condition after receipt of email advice from the dermatologist; however, in 10 cases (16%) additional images or biopsy results were requested because image quality was inadequate. The average time between a referral being received and clinical advice being provided to the referring GPs was 46 hours. The number of referrals in the present study, 1.05 per month per site, was similar to that reported in other primary care studies. While the use of low-cost digital cameras and public email is feasible, there may be other issues, for example remuneration, which will militate against the widespread introduction of primary care teledermatology in Australia.

Practice Guidelines for Teledermatology

Previous American Telemedicine Association (ATA) Teledermatology Practice Guidelines were issued in 2007. This updated version reflects new knowledge in the field, new technologies, and the need to incorporate teledermatology practice in a variety of settings, including hospitals, urgent care centers, Federally Qualified Health Centers, school-based clinics, public health facilities, and patient homes.

Impact of a store-and-forward teledermatology intervention versus usual care on delay before beginning treatment: A pragmatic cluster-randomized trial in ambulatory care

Introduction

In France, 66% of patients forego getting specialized care by dermatologists because of difficulty obtaining appointments. Store-and-forward teledermatology could improve how promptly treatment begins by reducing the delay in obtaining a specialist’s opinion. In this study, we compared the delay before care between general practitioners (GPs) using a store-and-forward teledermatology intervention and GPs addressing their patients with a standard referral letter.

Methods

We performed an open-label, pragmatic cluster-randomized controlled trial with two parallel arms. GP clinics in Paris (France) were randomly assigned to use either teledermatology referral (use of electronics to send clinical images taken using a mobile phone) or conventional referral (using standard letters) to care for patients for whom a dermatologist’s advice was needed for the diagnosis or treatment of skin lesions. Dermatologists integrated responses to teledermatology requests in their usual schedule. Patients were followed up for three months. Primary outcome was the delay, in days, between the GP’s consultation and a reply by the specialist allowing treatment to begin. Analyses were adjusted for clustering of GPs and identities of dermatologists.

Results

Between February and June 2014, 103 patients were included in the study (53 patients of 20 GPs in the intervention group). The median delay between the initial GP’s consultation and the reply allowing for treatment to begin was four days in the intervention group and 40 days in the control group (adjusted hazard ratio = 2.55; p < 0.011).

Discussion

We showed that a simple store-and-forward teledermatology intervention significantly reduced the delay before beginning care (ClinicalTrials.gov identifier: NCT02122432).

Teledermatology

This article provides an overview of teledermatology with an emphasis on the evidence most relevant to referring clinicians, who are often primary care clinicians. Discussion includes the different modalities used for teledermatology and their diagnostic reliability, diagnostic accuracy, impact on in-person dermatology visits, clinical outcomes, and user satisfaction.

Teledermatology as an educational tool for teaching dermatology to residents and medical students

Although teledermatology (TD) is regarded as a tool to improve patient access to specialty healthcare, little has been done to evaluate its role in medical education. We describe the TD program at the Denver (CO) Department of Veterans Affairs Medical Center and evaluate its use as an educational tool for teaching dermatology to dermatology residents and medical students. Dermatology residents manage TD consultations and review all cases with a faculty preceptor; medical students participate as observers when possible. This study assessed dermatology resident (n=14) and medical student (n=16) perceptions of TD and its usefulness in teaching six core clinical competencies. Both residents (79%) and medical students (88%) "strongly agree" or "agree" that TD is an important educational tool. In general, medical students were slightly more satisfied than residents across all of the core competencies assessed except for patient care. Medical students and residents were most satisfied with the competencies of practice-based learning and improvement and medical knowledge, whereas they were least satisfied with those of interpersonal and communication skills and professionalism. Overall, TD is valued as a teaching tool for dermatology in the areas of patient care, medical knowledge, practice-based learning and improvement, and systems-based practice.

Teledermatology applied following patient selection by general practitioners in daily practice improves efficiency and quality of care at lower cost

BACKGROUND

Teledermatology, the application of telemedicine in the field of dermatology, has similar accuracy and reliability as physical dermatology. Teledermatology has been widely used in daily practice in the Netherlands since 2005 and is fully reimbursed.

OBJECTIVES

This study prospectively investigated the effect of teledermatology on efficiency, quality and costs of care when integrated in daily practice and applied following patient selection by the general practitioner (GP).

METHODS

Teledermatology consultations between GP and regional dermatologist were performed in daily GP practice in the Netherlands. Efficiency of care was measured by the decrease in the number of physical referrals to the dermatologist. Quality of care was measured by the percentage of teleconsultations for second opinion, physical referrals resulting from these teleconsultations, the response time of the dermatologists and educational effect experienced by the GP. Costs of conventional healthcare without teledermatology were compared with costs with teledermatology.

RESULTS

One thousand, eight hundred and twenty GPs and 166 dermatologists performed teledermatology, and 37,207 teleconsultations performed from March 2007 to September 2010 were included. In the group of patients where the GP used teleconsultation to prevent a referral (n =26,596), 74% of physical referrals were prevented. In the group of patients where the GP used teleconsultation for a second opinion (n =10,611), 16% were physically referred after teleconsultation. The prevented referral rate in the total population was 68%. The mean response time of dermatologists was 4·6 h (median 2·0). GPs indicated that there was a beneficial educational effect in 85% of the teleconsultations. The estimated cost reduction was 18%.

CONCLUSIONS

Teledermatology can lead to efficient care probably at lower cost. We are therefore of the opinion that teledermatology following GP selection should be considered as a possible pathway of referral to secondary care.

Pilot study on the acceptance of mobile teledermatology for the home monitoring of high-need patients with psoriasis

BACKGROUND/OBJECTIVES

The willingness to be educated is one of the highest desires among patients with psoriasis. Therefore, a collaborative model of management would appear to be essential in enhancing patient satisfaction in this challenging condition. The present study aimed at examining the applicability of a mobile teledermatology service in this regard and assessing the association between patient acceptance and perceived health-related quality of life.

METHODS

High-need patients with psoriasis performed visits over 12 weeks transmitting clinical images together with some relevant clinical information via mobile phones to teledermatologists, who provided treatment instructions. Ten patients and two teledermatologists completed 20-item patient (weeks 6 and 12) and 10-item physician (at week 12) acceptance questionnaires. In addition, patients answered the dermatology life quality index (DLQI) at weeks 0, 6 and 12.

RESULTS

Both patients and teledermatologists were pleased with the service with high acceptance rates (patients: 81.0% at week 6 and 82.9% at week 12; teledermatologists: 74.0%). In addition, 80% of the patients considered the service an alternative to in-person consultation and 90% felt they were in good hands but had achieved a more flexible and empowered lifestyle. No significant correlations were found between patient acceptance and DLQI. Both teledermatologists found the service a convenient and reliable tool for patient monitoring. Neither patients nor teledermatologists thought further in-person consultations necessary.

CONCLUSION

Mobile teledermatology is a valuable tool for the home monitoring of patients with psoriasis that makes a meaningful difference in their lives. It is well accepted by both patients and the physicians involved.

Teledermatology in pharmacies: a pilot study

We investigated community pharmacists' management of skin conditions in order to identify a need for further educational support. Twenty community pharmacists in Queensland completed a questionnaire regarding their management of skin conditions and their opinions regarding the usefulness of a potential teledermatology service. The pharmacists' accuracy in managing skin conditions was tested by a dermatologist who reviewed the pharmacists' advice in 33 cases obtained by 14 pharmacists. Overall agreement between the pharmacists and the dermatologist was moderate, with a kappa statistic of 0.58 (P < 0.05) The uptake of a potential teledermatology service was investigated in one pharmacy over one month. Five patients were offered the teledermatology service. Of these, two patients consented and three refused. All pharmacists (n = 20) indicated a desire for further education and supported the idea of a teledermatology service.

Teledermatology: a tool for remote supervision of a general practitioner with special interest in dermatology

BACKGROUND

Teledermatology (TD) has been developed as an alternative to face-to-face (FTF) dermatology care in remote areas.

AIM

To assess the feasibility of TD in remote supervision and education of a general practitioner with special interest (GPwSI), to reduce FTF consultations with the consultant dermatologist, and to provide appropriate diagnosis and care. Our secondary aim was to evaluate patient satisfaction with this mode of consultation.

METHODS

A TD service in Aberdeen was set up to augment supervision of a remote rural GP training in dermatology. This service was audited over a 2-year period to assess its usefulness in the education of the remote GP.

RESULTS

Prospective data on 230 selected referrals was analysed. Store-and-forward TD provided a high level of patient satisfaction, and was effective in remote supervision and education of a GPwSI in dermatology. FTF consultations with the consultant were avoided in 69% of consultations, and diagnostic agreement was considered high (61%). Educational feedback was given to the GP in 66% of consultations.

CONCLUSIONS

TD can supplement infrequent specialist dermatology service in remote areas, as in this case. We conclude that for selected patients, TD was a useful training tool for supervising the GPwSI, and ensuring clinical governance and quality assurance in clinics in a remote rural area. However, this model of care was limited by cost and the inherent limitations of TD.

Teledermatology consultations provide specialty care for farmworkers in rural clinics

CONTEXT

Rural patients have limited access to dermatologic care. Farmworkers have high rates of skin disease and limited access to care.

PURPOSE

This exploratory study assessed whether teledermatology consultations could help meet the needs of health care providers for farmworkers in rural clinics.

METHODS

Dermatologists provided 79 consultations, using store-and-forward teledermatology, to farmworkers who presented with a skin disease to rural North Carolina clinics. Clinic providers rated the value of the consultation.

FINDINGS

Most requests for consultations (94%) came from family nurse practitioners or physician assistants. Twelve percent of consultations were rated somewhat helpful, and the remainder helpful or very helpful. After receiving the consultation, providers changed the diagnosis in 13% of cases. The consultation led providers to contact or attempt to contact 21% of patients to change treatment recommendations.

CONCLUSIONS

Access to expert dermatologic services is needed by rural health care providers. Teledermatology consultations may be a helpful tool to meet this need.

Pediatric teledermatology--a survey of current use

Demand for pediatric dermatologic care far exceeds the supply of pediatric dermatologists. Teledermatology has been proposed as a solution to improve access to care, however, data regarding teledermatology use for pediatric patients are lacking. Surveys assessing use and experience with teledermatology were administered to pediatric dermatologists attending the 2006 Society for Pediatric Dermatology Annual Meeting and to programs offering teledermatology identified in the American Telemedicine Association's 2003 Teledermatology Survey. Over half of the 76 pediatric dermatologists responding to the survey had previous experience with teledermatology and nearly half currently use some form of teledermatology. For most, this represents nonreimbursed, store-and-forward consultations. Respondents noted that teledermatology allows more accurate triage of dermatology patients, decreases travel and outpatient clinic visits, and provides an avenue for ongoing support and education for primary care physicians. While difficulties exist, overcoming obstacles to the use of pediatric teledermatology and reimbursement for such services could improve access to expert pediatric dermatologic care.

Evaluation of general practitioner's time investment during a store-and-forward teledermatology consultation

BACKGROUND/OBJECTIVE

Introduction of teledermatology in general practice changes responsibilities and workloads of general practitioners (GPs) and dermatologists. We investigated the time investment of GPs as well as the relative share of the separate teledermatology activities during a store-and-forward teledermatology consultation.

METHODS

Sixty-four teledermatology consultations (eight GPs x eight patients) were conducted in a laboratory setting. The starting and ending time of each consultation and of five separate teledermatology activities were recorded by independent observers. The impact of several GP, patient and consultation characteristics on the calculated durations was investigated with repeated measurements analysis.

RESULTS

The mean duration of a teledermatology consultation was 11:32 min (range 7:02-26:44 min). The activity 'filling out electronic referral form' was the most time consuming teledermatology activity (3:12 min; 28%). Most time was spent on non-TD related consultation activities, e.g. taking medical history (4:43 min; 41%). The first of the eight consultations (p<0.001) and consultations with female patients (p=0.032) took on average more time than subsequent consultations (first consultations 13:42 min (male patients) and 17:03 min (female patients), and subsequent consultations 9:56 min (male patients) and 11:08 min (female patients)).

CONCLUSIONS

Usage of store-and-forward teledermatology increases the average duration of a GP consultation with at least three and a half minutes. Further integration of teledermatology applications and electronic patients' records may reduce the total duration of a consultation and increase acceptance of teledermatology in general practice.

Maturity of teledermatology evaluation research: a systematic literature review

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Teledermatology research review

Teledermatology consultations can be performed using either store-and-forward or real-time technology. The best-studied aspect of teledermatology is diagnostic reliability, also known as diagnostic agreement. A good level of diagnostic reliability is achieved by dermatologists using both store-and-forward and real-time modalities and is comparable to that found between clinic-based examiners. Less information is available regarding diagnostic accuracy. Current data suggest that teledermatologists reviewing store-and-forward consults achieve accuracy comparable to that of clinic-based dermatologists. When store-and-forward consult systems are used, approximately one in four in-person clinic appointments are averted. Real-time consult systems avoid the need to schedule approximately one in two clinic visits. Store-and-forward technology results in timelier interventions for patients when compared to a conventional referral process. To date, surveys of both store-and-forward and real-time teledermatology consult modalities suggest that patients, referring clinicians, and dermatologists are all highly satisfied with teledermatology consults. Very little has been published about the economic impact of store-and-forward teledermatology, whereas several studies have evaluated real-time modalities. Teledermatology has ranged from a cost-saving strategy to an intervention that incurs greater costs than conventional care, depending on the health care setting and economic perspective. Future research focusing on diagnostic accuracy, clinical outcomes using clinical course or disease status as outcome measures, development of reliable and valid teledermatology-specific survey instruments, and economic analyses that assess cost-effectiveness will help guide future teledermatology program assessments and policy.

Telemedicine in wound healing

Better care for patients and improved health care depends on the availability of good information which is accessible when and where it is needed. The development of technology, more specifically the Internet, has expanded the means whereby information can be acquired and transmitted over large distances enabling the concept of telemedicine to become a reality. Telemedicine, defined as the practise of medicine at a distance, encompasses diagnosis, education and treatment. It is a technology that many thought would expand rapidly and change the face of medicine. However, this has not happened and during the last decade although certain telemedicine applications, such as video-consulting and teleradiology, have matured to become essential health care services in some countries, others, such as telepathology, remain the subject of intensive research effort. Telemedicine can be used in almost any medical specialty although the specialties best suited are those with a high visual component. Wound healing and wound management is thus a prime candidate for telemedicine. Development of a suitable telemedical system in this field could have a significant effect on wound care in the community, tertiary referral patterns and hospital admission rates.

Operational teledermatology in Broken Hill, rural Australia

From January 2001 to January 2002, Broken Hill, New South Wales, served as a trial site for teledermatology as one method of access to dermatologists. Fourteen participating general practitioners referred 46 patients making up 48 teledermatology cases. The mean diagnostic agreement between general practitioners and dermatologists was 35% and 50% for primary and differential diagnoses, respectively. Teledermatology patients formed 12% of the collectively referred dermatology patients (outpatients and teledermatology). In this project, high patient and general practitioner acceptability and positive medical outcomes confirm the value of rural teledermatology. However, this project also revealed unexpected barriers and pitfalls in the effective operation of rural teledermatology. Lack of education of participants, inertia among potential users and patient inconvenience are issues that may adversely affect the effective implementation of rural teledermatology.

Teledermatologia: passado, presente e futuro

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

Teledermatologie versus Konsildiagnosen — eine vergleichende Untersuchung von 120 Konsilen

Dermatology fulfills the prerequisites for telemedicine. An important application of telemedicine might be the field of dermatologic consultations. In this comparative study images of skin disease were taken of 120 patients hospitalized in the University Hospitals of Tuebingen to answer the following questions: (1) are the preconditions in daily routine given for teledermatology, (2) is there adequate agreement between the diagnoses reached in dermatologic consultations and with teledermatology, and (3) can the images be utilized for teaching purposes. Patient acceptance was very good and the images captured with a digital camera were easily obtained. The results of intraobserver analysis for the two teledermatologists without any knowledge of the patients' history were 70.2% and 46.4%, respectively, and with knowledge of the history 76.6% and 64.3%. The results of interobserver analysis without any knowledge of the patients' history were 46.4% and 57.2% and with knowledge of the history 64.3% and 66%, respectively. With the reduction of the image quality, reduced reliability of the diagnoses was observed. Seven of ten images could be used for teaching purposes. It was demonstrated that in dermatology telemedicine is applicable in many, but not in all patients who are referred for dermatologic consultations.

Wound teleconsultation in patients with chronic leg ulcers

BACKGROUND

The treatment of chronic leg ulcers requires frequent assessments of local wound status and adjustment of therapy. The availability of reasonably priced photographic equipment and quick electronic transfer of high-quality digital images should make it possible that the assessment of wound status can be made by remote experts.

OBJECTIVE

This study examines the feasibility of using teledermatology for wound assessment and therapeutic suggestions for patients with chronic leg ulcers.

METHODS

One hundred ten chronic leg ulcers of different origins were examined in face-to-face consultations. The examining doctor assessed the wound, made therapeutic recommendations and took 1-4 photographs of the wound using a digital camera. The digital images and relevant clinical information were then transmitted via a web application to an expert in wound care, who provided an independent teledermatological assessment of wound status and therapeutic recommendations.

RESULTS

In our study, a high accordance between direct consultations and electronic consultations was found in the assessment of chronic leg ulcers, especially for important features like slough (concordance: 84.6%), necrosis (concordance: 98.2%) and granulation tissue formation (concordance: 76.4%). Furthermore, the teledermatologist generally felt confident in recommending further treatment strategies and in planning further wound assessments via the internet.

CONCLUSIONS

Our results suggest that teledermatology offers great potential for the future in chronic wound care. By reducing the need to travel long distances to the hospital or to consult a physician with expertise in wound care, wound teleconsultation might lower health care costs and improve the quality of life for patients with chronic wounds, while still maintaining a high quality of wound care.

Assessment of patients' acceptance of and satisfaction with teledermatology

Teledermatology refers to the use of information and communication technologies (such as videoconferencing or transmission of digital images) to enable the practice of diagnostic dermatology between participants separated by geographic distance. The objective of this study was to critically review the quality of evidence about patient satisfaction with teledermatology applications. Sample size, reporting of validity and reliability, used instrument and its underlying constructs were determined for all studies where information was available. Fourteen studies were identified, five refer to store-and-forward applications, the remaining ones describe video-based systems. The systematic review demonstrated that methodological deficiencies in the published research impact the generalizability of findings. The two types of teledermatology (video-based and store-and-forward) require different satisfaction instruments as they are based on different contexts of care delivery, with video-mediated communication being key in the former and patients' absence from the diagnostic process in the latter mode of care delivery.

Patient and Clinician Satisfaction with a Store-and-Forward Teledermatology Consult System

The aim of this study was to assess satisfaction with and acceptance of a store and forward teledermatology consult system among patients, referring primary-care clinicians, and consultant dermatologists. As part of a randomized clinical trial that compared the clinical and economic outcomes of store and forward teledermatology to a conventional referral process, we conducted satisfaction assessments among participating patients, referring primary-care clinicians, and consultant dermatologists. Survey questions included issues related to the timeliness of each consult process, the confidence participants displayed in each consult modality, and assessments of overall satisfaction and preferences. A majority of referring clinicians (92%) and dermatologist consultants (75%) reported overall satisfaction with the teledermatology consult process. Ninety-five percent of referring clinicians reported that teledermatology resulted in more timely referrals for their patients. This finding was validated by the observation that teledermatology patients reached a point of initial intervention significantly sooner than did patients in usual care (41 days versus 127 days, p = 0.0001). Teledermatology patients reported satisfaction with the outcome of their teledermatology consultation 82% of the time. However, patients did not express a clear preference for a consult method. A total of 41.5% of patients preferred teledermatology, 36.5% preferred usual care, and 22% were neutral. Our study showed a high level of satisfaction among all users of a store-and-forward teledermatology consult system, and, in some cases, our survey results could be validated with observed clinical outcomes.

To Telemedically Err Is Human

BACKGROUND

As telemedicine alters the process of health care and introduces new technology, the extent to which it introduces new errors or allows for the occurrence of familiar errors needs to be examined. TELEMEDICINE'S IMPACT ON PATIENT SAFETY FEATURES OF TRADITIONAL CARE: The accuracy of diagnostic decisions reached via telemedicine can be directly affected by the technology's limitations and the care providers' lack of training. Telemedicine could increase the risk of familiar types of patient-provider communication failure and introduce the possibility of cumulative errors. TELEMEDICINE'S IMPACT ON NEW CARE FEATURES AND CONCEPTS: Telemedical applications that use the Internet to enhance disease management and detection and monitoring of symptoms may place the privacy and confidentiality of individual health information at risk, which imposes a possible barrier to communication. In addition, home care patients' functional limitations need to be addressed by human factors engineering.

RECOMMENDATIONS

Patient safety should be integrated in organizational readiness and budget planning for telemedical interventions in hospitals, academic settings, nursing homes, home care agencies, and other health care settings. Specific recommendations are proposed for the development and diffusion of standards in telemedical care, risk management and reduction, and continuous quality improvement.

SUMMARY AND CONCLUSIONS

To address patient safety and provide high-quality care, a framework for addressing and examining telemedical errors needs to be established.

A comparison of in-person examination and video otoscope imaging for tympanostomy tube follow-up

The objective of this study was to determine if video otoscope still images (640 x 480 pixel resolution) of the tympanic membrane following surgical placement of tympanostomy tubes are comparable to an in-person microscopic examination. Forty patients having undergone tympanostomy tube placement in both ears were independently examined in-person by two otolaryngologists and imaged using a video otoscope and telemedicine software package. The two physicians later reviewed images at 6 and 12 weeks. Physical examination findings and diagnosis were documented and compared for their concordance using kappa statistics. For both physicians, the intraprovider concordance between the in-person examination and the corresponding image review was high for each of the physical examination findings: Tube In 93-94% (K 0.85-0.87), Tube Patent 86-93% (K 0.74-0.85), Drainage 94-98% (K 0.42-0.66), Perforation 85-98% (K 0.40-0.84), Granulation 95-99% (K -0.01 to 0.00), Middle Ear Fluid 89-91% (K -0.03 to 0.50), and Retracted 89-94% (K 0.13-0.43). These agreement rates are similar to the normal interprovider concordance observed when two physicians independently examined the same patient in-person for physical exam findings: Tube In 96% (K 0.93), Tube Patent 94% (K 0.88), Drainage 96% (K 0.56), Perforation 90% (K 0.60), Granulation 96% (K 0.39), Middle Ear Fluid 88% (K 0.14), and Retracted 91% (K 0.43). For both physicians, the intraprovider diagnostic concordance between the in-person examination and the corresponding image review was high 79-85% (K 0.67-0.76). The interprovider diagnostic concordance for the in-person exam was 88% (K 0.81). The interprovider diagnostic concordance when two physicians independently reviewed all images was 84% (K 0.74), and 89% (K 0.80) when poor images were excluded. This study demonstrates that physician review of video otoscope images is comparable to an in-person microscopic examination. Store-and-forward video otoscopy may be an acceptable method of following patients post-tympanostomy tube placement.

Dermatoses associated with travel to Burkina Faso and diagnosed by means of teledermatology

BACKGROUND

The pattern of dermatoses occurring in travellers to tropical areas is poorly documented.

OBJECTIVES

To diagnose skin diseases in travellers to Burkina Faso by means of teledermatology; to assess the educational value of teledermatology for the local general practitioner (GP).

METHODS

Patients (Westerners and Burkinabese nationals) were included in the study if they presented with a cutaneous disease to the GP based in Ouagadougou, Burkina Faso. Images of the skin lesions were acquired with a point-and-shoot digital camera and sent via the Internet, together with the clinical history. Diagnostic concordance between dermatologists in France and the GP in Ouagadougou was analysed as a simple proportion of agreement and 95% confidence interval.

RESULTS

One hundred and twenty-four patients (M/F ratio 1.17; 80.6% Westerners) were included in the study. One hundred and thirty dermatoses were identified: 73 (56%) were of infectious origin, and 19 (15%) were related to eczematous dermatitis. The skin infections were mainly due to bacteria (18%), fungi (14%) or arthropods (13%). Parasitic dermatoses were observed only in Burkinabese nationals. Among Westerners, fungal dermatoses were observed only in long-term residents. The diagnostic agreement between the local GP and the remote dermatologists was 49% overall (95% confidence interval 41-58). Agreement between the GP and the dermatologists on the dermatological category improved significantly over time (P<0.05).

CONCLUSIONS

Telemedecine can improve the management of cutaneous diseases among Western travellers. Most dermatoses observed in Western travellers to Burkina Faso are of infectious origin. Teledermatology has educational value for local GPs.

Evaluation of an Internet-based teledermatology system

We established a Website which allowed clinical dermatology cases to be submitted, with digital images, through a simple online form. The case could then be managed within the public health service. A database containing 6000 drug interactions was also available on the Website to help clinical management. The Website was tested by 10 junior doctors, who examined dermatology patients, filled in the electronic form with their clinical observations and descriptions, and forwarded digital images. Five dermatologists then evaluated the 71 cases stored on the Website. The agreement between the virtual evaluation and the definitive diagnosis (on face-to-face examination) was 95%. The Website could be used in national health strategies, as a tool for promoting voluntary medical attendance, and for multicentre epidemiological surveillance.

Teledermatology and teledermatopathology

Teledermatology is in essence an application of clinical telemedicine that deals with the practice of dermatology via the latest communication and information technology. As with other telemedicine applications, the goal is to provide the highest quality of dermatologic care more efficiently by moving patient information rather than the patient. Teledermatopathology, on the other hand, is a nonclinical telemedicine application specifically relating to diagnosis of cutaneous histologic specimens. There are numerous articles evaluating diagnostic concordance of teledermatology. However, because of a lack of a "true" gold standard, most published studies have compared diagnostic capabilities of teledermatology to our traditional face-to-face evaluations. Although the diagnostic correlation varies from study to study, most experts agree that Store and Forward and real-time video teleconferencing teledermatology is as clinically effective as a face-to-face consultation, which is less than 100% accurate. Teledermatopathology is showing similar potential, but because of the limitations on sampling error and the high cost of the alternative, robotic remote telepathology units, its acceptance into our daily practice has been delayed. This article focuses mainly on Store and Forward Teledermatology given its significant advantage and reviews the literature on teledermatology and teledermatopathology's diagnostic concordance and acceptance.

Telemedicine: an innovative way of managing patients with leg ulcers

The optimal management of patients with leg ulcers requires a multidisciplinary approach, with contributions from both community and hospital specialists to identify, investigate and treat the underlying causes, provide patient education, assess healing and dress the wounds, monitor outcome and prevent recurrence. However, current practice is impaired by the limited communication between community and hospital specialists. There are inconsistencies in methods of transferring and updating patient records between the hospital and the community, and this can lead to confusion over the diagnosis and appropriate management. Telemedicine, the electronic exchange of medical information at a distance, would appear to offer a way to establish an efficient and effective communication link between hospital and community specialists involved in the care of patients with leg ulcers. The authors of this article believe that modern information technology and the existing NHSnet information infrastructure could be employed to create such a link via electronic patient records.