Store-and-forward teledermatology: assessment of validity in a series of 2000 observations

Background and objectivesThe aim of this study was to assess the validity of store-and-forward teledermatology as a tool to support physicians in primary care and hospital emergency services and reduce the requirement for face-to-face appointments. Diagnostic validity and the approach chosen for patient management (face-to-face vs teledermatology) were compared according to patient origin and diagnostic group.Material and methodsDigital images from 100 patients were assessed by 20 different dermatologists and the diagnoses offered were compared with those provided in face-to-face appointments (gold standard). The proposed management of the different groups of patients was also compared.ResultsThe percentage complete agreement was 69.05% (95% confidence interval [CI], 66.9%–71.0%). The aggregate agreement was 87.80% (95% CI, 86.1%–89.0%). When questioned about appropriate management of the patients, observers elected face-to-face consultation in 60% of patients (95% CI, 58%–61%) and teledermatology in 40% (95% CI, 38%–41%). Diagnostic validity was higher in patients from primary care (76.1% complete agreement and 91.8% aggregate agreement) than those from hospital emergency services (61.8% complete agreement, 83.4% aggregate agreement) (p < 0.001) and teledermatology was also chosen more often in patients from primary care compared with those from emergency services (42% vs 38%; p = 0.003). In terms of diagnostic group, higher validity was observed for patients with infectious diseases (73.3% complete agreement and 91.3% aggregate agreement) compared to those with inflammatory disease (70.8% complete agreement and 86.4% aggregate agreement) or tumors (63.0% complete agreement and 87.2% aggregate agreement) (p <0.001). Teledermatology was also chosen more often in patients with infectious diseases (52%) than in those with inflammatory disease (40%) or tumors (28%) (p <0.001).ConclusionsStore-and-forward teledermatology has a high level of diagnostic validity, particularly in those cases referred from primary care and in infectious diseases. It can be considered useful for the diagnosis and management of patients at a distance and would reduce the requirement for face-to-face consultation by 40%.     

Accuracy and reliability of store-and-forward teledermatology: preliminary results from the St George Teledermatology Project

Teledermatology is the practice of dermatology across distances (and time) and involves the transfer of electronic information. To be effective and safe, the teledermatology process needs to demonstrate an acceptable level of accuracy and reliability. Accuracy is reflected by the degree of concordance (agreement) between the teledermatology and face-to-face diagnoses. Reliability is dependent on how consistently a set of results can be reproduced across different operators. Mean concordance (primary diagnoses) achieved by four dermatologists studying 53 store-and-forward diagnostic cases, originating from 49 referred patients, was 79% (range 73-85%). When the differential diagnoses were taken into account, the variation across individual dermatologists narrowed further, with a mean of 86% (range 83-89%). In contrast, the mean general practitioner (GP; n=11) concordance (GP face-to-face vs reference dermatologist store-and-forward diagnoses) was 49%. An interim review of all 49 teledermatology patients showed no adverse outcome at the end of 3 months. The ability to request face-to-face visits by dermatologists, combined with GPs maintaining primary care of the referred patient, serve as additional safeguards for patients using a telemedicine system. Our results indicate that teledermatology management of referred skin complaints is both accurate and reliable.     

Teledermatology: an intraobserver diagnostic correlation study,part I

Many studies have been published recently on the effectiveness of teledermatology as a diagnostic tool; however, much of the data comes from live 2-way video teleconferencing consultations and very little comes from more readily available "store and forward" consultations. Moreover, most published studies compare the diagnoses of 2 different dermatologists (interobserver comparison). Given the lack of data on baseline interdermatologist diagnostic variability, the interpretation of currently available diagnostic correlation data is somewhat difficult. The objective of this study is to measure the degree of diagnostic concordance between a dermatologist seeing a patient via a teledermatology consult system and the same dermatologist seeing the same patient face-to-face in a dermatology clinic at a tertiary medical center. A random sample of 404 patients was selected from patients who had routine appointments at our dermatology clinic.     

Teledermatology. Review of 917 teleconsults

IntroductionTeledermatology is been currently introduced as a diagnostic tool in the daily practice of the dermatologist. Many published works regarding teleconsult show the high sensitivity and economic saving of this technique as a diagnostic method.Material and methodsIn this article we report our experience with nearly 1,000 teleconsults carried out in a period of two years, from October 2004 to October 2006.ResultsThe majority of the 917 teleconsults performed were for benign lesions, notably seborrheic keratosis in 201 cases; among malignant lesions actinic keratosis appeared in 161 cases and melanoma was diagnosed in 5 cases. Fifty-eight percent of teleconsults have been arranged for a face-to-face consult in order to perform adequate treatment, in 90 % of cases, or to confirm diagnosis or carry out complementary exams, in 10 % of cases.ConclusionThe image is the gold standard for dermatological diagnosis. Currently, digital phototography gives us such a high image quality that, based on our experience, it can be stated that a neoplastic lesion that cannot be diagnosed by a high quality digital image with the available technology, rarely could be diagnosed in a face-to-face consult without the aid of complementary exams.     

Fiabilidad de la teledermatología de almacenamiento en un escenario real

Introduction and objectivesAlthough many studies have evaluated the diagnostic reliability of store-and-forward (SF) teledermatology, the reliability of the technique for the diagnosis of general skin conditions in a clinical practice setting has never been demonstrated. We evaluated the reliability of SF teledermatology in clinical practice by analyzing the diagnostic agreement achieved in a subgroup of patients from the DERMATEL-2 study.Material and methodsPatients referred from primary care settings were randomized to 3 groups: SF, a combination of videoconferencing and SF technology (VC-SF), and a control group. This article focuses on the SF group. Clinical data were recorded and photographs taken by primary care physicians, who forwarded the data electronically. Each SF consultation package was assessed by 3 dermatologists (D1,D2,D3). Subsequently all the patients were assessed by a single dermatologist (D1) in a face-to-face consultation. Finally, 2 other dermatologists (D4,D5) assessed the agreement between the diagnoses obtained by SF and FF.ResultsIn total, 457 patients (200 males and 257 females) aged between 2 months and 86 years were randomized (192 to SF, 176 to VC-SF, and 89 to the control group). The diagnostic categories were as follows: tumors (49.4%), inflammatory (25.7%), adnexal (11%), infectious (9.4%) and other processes (4.4%) Since 170 patients had consultations deemed valid for analysis, the study included a total of 510 SF assessments. Most of the images and clinical records were of high quality (71.2% and 91.2% respectively), and diagnostic confidence was high in 81.4% of the cases studied.In 58.4% of cases the condition was managed exclusively by teledermatology. Levels of complete and aggregate interobserver agreement between SF and face-to-face evaluators were 0,72 and 0.90, respectively, for diagnosis and 0.61 and 0.80 for treatment. Diagnostic agreement correlated with the image quality (P  <  .001), diagnostic confidence (P < .001), felt need for conventional consultation (P < .001), and the quality of the clinical record (P = .013).ConclusionThe interobserver reliability of SF diagnosis in clinical practice is good. Dermatologists are able to predict errors in diagnosis by analyzing their own diagnostic confidence and evaluating the quality of the images.     

Teledermatology: an intraobserver diagnostic correlation study,Part II

This is part II of an intraobserver diagnostic correlation study comparing teledermatology with traditional face-to-face evaluation. Part I discussed the methodology and diagnostic correlation results between teledermatology and in-person consultation (Cutis. 2003;71:399-403). This second part reports the diagnostic certainty level between the 2 groups, which are shown to be significantly different (teledermatology, 7/10; in-person, 9/10). This difference held true in every category of skin condition evaluated (P < or = .0065). Unlike other studies, we found that teledermatologists recommended biopsies 10% more frequently than clinic-based evaluators. We discuss the reasons for the lower diagnostic certainty level of teledermatologists, as well as the limitations of this study. Despite the limitations, we conclude that teledermatology appears to be an effective method of delivering dermatologic care in the appropriate setting.     

Teledermatology: diagnostic reliability in 383 children

Background

There are few studies of teledermatology focused on the pediatric age group. The aim of this study was to assess the validity and reliability of store-and-forward teledermatology (STD) as a diagnostic tool for pediatricians and to reduce face-to-face consultations.

Materials and Methods

A retrospective, observational study of 383 children and adolescents under 15 years of age, referred from primary care to Dermatology Department of University Hospital of La Coru?na, Spain, between 2011 and 2013, using a STD consult system.

Results

Diagnoses concordance between pediatricians and teledermatologists was 39.2% of cases and partial concordance 16.7%. Agreement for global diagnosis was κ = 0.78 (p = 0.000) and for specific diagnosis was κ = 0.73 (p = 0.000). Management was concordant in 28.7% and partially concordant in 15.4%. Lower reliability was statistically associated with modification of the lesions by inappropriate treatments, incomplete clinical data or bad-quality photographic images included in the referral consultation, diagnosis of infectious diseases and rare dermatoses. The filtering percentage (as the percentage of avoided clinic-based evaluations)was 64.5%. The mean response time of the consultant dermatologistswas 3.62 days. Referrals for live consultations due to poor clinical information or insufficient quality of pictures were necessary in only 10% of the cases.

Conclusions

The degree of diagnostic accuracy for the pediatric population using STD as a diagnostic tool was similar to that achieved in adults. Its usefulness for filtering dermatologic referral was also demonstrated in the study, so it could be suitable for integration into the routine practice of pediatricians.

     

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.     

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.     

Teledermatología. Capacidad para reducir consultas presenciales según el grupo de enfermedad

IntroductionTeledermatology was initially considered useful and cost-effective, especially when distances to the reference hospital were significant. It is currently gaining importance as a more specific tool that can evaluate the need for a rapid referral or to decrease medical costs. The aim of this study was to assess the capacity of teledermatology for resolving cases in different groups of disease.Material and methodsTeleconsultations received in our Department of Dermatology between May 2011 and April 2014 were evaluated according to the virtual diagnosis, the indication given by the dermatologist who evaluated the teleconsultation (discharge/referral), reasons for attending to hospital, reasons for more than one virtual consultation, final face-to-face diagnosis, and diagnostic agreement between the virtual and face-to-face diagnoses.ResultsAn assessment was made on 1163 virtual consultations. Inflammatory diseases were the most frequent diagnosis group (45%). A total of 50.82% of virtual consultations were discharged. The highest resolution rate was achieved by the infectious diseases group, followed by inflammatory diseases (78.4% and 62.8%, respectively). Malignant lesions were referred in nearly all cases (96.7%). The main reason for a referral was the need for diagnostic confirmation or complementary studies (59.8% of all cases). A total of 102 patients received more than one teleconsultation, principally due to incomplete clinical data or poor-quality images. The agreement rate between virtual and face-to-face diagnosis was 88.95%.ConclusionTeledermatology avoids around 50% of the primary care referrals. The highest resolution rate is achieved in the infectious diseases group, followed by the inflammatory diseases group and, secondly, by benign tumours and benign melanocytic lesions.     

Geriatric teledermatology: store‐and‐forward vs. face‐to‐face examination

Background Telemedicine could be useful in countries like Italy to meet the needs of elderly patients and in particular in those in precarious general conditions, for whom travelling even short distances can pose considerable practical and economical difficulties. Objective The aim of this study was to determine the efficacy of store‐and‐forward teledermatology vs face‐to‐face consultations in elderly patients. Methods A total of 130 geriatric patients with skin diseases requiring dermatological examination were enrolled. The patients examined, consisting of 60 men (46.15%) and 70 women (53.85%), were aged between 66 and 97 years (mean age 80.58 years). Three dermatologists of the department, with equal experience took turns in face‐to‐face examination and teledermatology (store‐and‐forward). To compare face‐to‐face dermatological examinations with the asynchronous store‐and‐forward approach of teledermatology, we considered diagnostic agreement (ICD‐9 code), therapeutic agreement and concordance of diagnostic confidence. Results One hundred and fourteen of 130 patients were diagnosed with the same ICD‐9 code, making a total observed agreement of 87.7% with a Cohen’s κ estimated of 0.863. Agreement between therapies was 69.6% (Cohen’s κ = 0.640). As it concerns diagnostic confidence, dermatologists appeared generally slightly less certain of their diagnosis by telemedicine. Conclusions Store‐and‐forward teledermatology can improve diagnostic and therapeutic care for skin disease in elderly who lack easy and/or direct access to dermatologists.     

Correlation between face-to-face assessment and telemedicine for the diagnosis of skin disease in case conferences

BackgroundIn Panama, weekly case conferences are held in which all dermatologists from throughout the country agree on a second opinion for the diagnosis of complicated cases. Unfortunately, patients from the interior of the country may have difficulty attending these case conferences. An alternative in such situations is the use of telemedicine. To date, however, no studies have been undertaken on the effectiveness of this approach in Panama. The aim of this study was to assess the degree of correlation between the diagnoses obtained in case conferences involving face-to-face examination and those involving telemedicine.Material and methodA quasi-experimental nonblinded analysis of correlation was carried out in which dermatologists were randomly assigned to 2 groups: face-to-face examination and telemedicine. Both groups were asked to assess 30 cases and the degree of correlation (Cohen κ coefficient) between the diagnoses made by each group was assessed.ResultsThe patient group included 19 women (63.3%) and 9 patients (30%) were aged between 50 and 59 years. There was a good correlation (κ = 0.6512) between the results of teledermatology and face-to-face examination. Significant differences in the diagnostic skills of the 2 groups were ruled out.ConclusionsTeledermatology can be used effectively to facilitate diagnosis in case conferences involving patients who cannot attend in person (gold standard).     

Randomized controlled trial comparing store‐and‐forward teledermatology alone and in combination with web‐camera videoconferencing

Background. Studies on the reliability of teledermatology have shown considerable variability in results. Only one study has compared asynchronous and synchronous methods. Objectives. This report describes DERMATEL, a prospective, randomized diagnostic‐concordance study that sought to evaluate the relative advantages, in terms of reliability, of two remote consultation techniques. Methods. Patients referred by 18 general practitioners were randomized (4 : 4 : 2) to three study groups: store and forward (SF), hybrid videoconferencing‐SF (VC–SF), and a control group. In total, 457 patients were assigned: 192 to the SF group, 176 to the VC–SF group and 89 to the control group. High‐quality still images were used throughout, with additional use of standard web‐camera (webcam) videoconferencing in the VC–SF group. All patients were also seen by the same dermatologist in a face‐to‐face (FTF) consultation, considered the practical reference standard. Two different dermatologists assessed concordances between the teledermatology and FTF consultations. Results. There were no significant differences in age, gender or diagnostic category between the three groups, and the images (82%), clinical history (91%) and diagnostic confidence (89%) were high‐quality. Online management was possible for 70% of cases. Agreement between teledermatology and the FTF consultation was high for both diagnosis (> 0.85) and treatment (> 0.78). Concordance in diagnosis was influenced by image quality (P < 0.001), confidence in diagnosis (P < 0.001) and need for conventional consultation (P < 0.001), rather than by quality of clinical history (P = 0.58) or method of teleconsultation (P = 0.340). Conclusions. Intraobserver reliability is very high in teledermatology. When history taking and training in digital photography are standardised, a hybrid system with audio is no better than SF alone.     

Evaluation eines telemedizinischen Pilotprojekts

Background and Objective. Rapid progress in computer and information technologies has led to an increased interest in the use of telemedicine during the past few years. Thus it should be clarified, whether teledermatology can achieve comparable results to conventional specialist examination and advice. Patients/Methods. We initiated a pilot study, comparing teledermatology with conventional examination in a dermatology outpatient setting. 60 patients were included. Results. Out of 60 teledermatological examinations, remote clinicians were in agreement with face-to-face clinicians in 90%. Teledermatology was unable to make a useful diagnosis in 6 patients, however further diagnostic procedures were ordered, enabling teledermatologists to achieve correct diagnoses. Regarding need for further diagnostic tests, there was no difference between teledermatology and conventional examination. Conclusions. Teledermatology appears suitable to transfer a dermatologist's expertise over large distances.     

The additive value of second opinion teleconsulting in the management of patients with challenging inflammatory,neoplastic skin diseases: a best practice model in dermatology?

BACKGROUND: Telemedicine is the practice of healthcare using interactive processes of communication to facilitate healthcare delivery, including diagnosis, consultation and treatment, as well as education and transfer of medical data. The aim of teledermatology, just as telemedicine, is to promote best practice procedures and to improve the consistency and competence of health care. AIM: To investigate the diagnostic additive value of second opinion teleconsulting in patients with challenging dermatoses, among dermatologists working in two different dermatology departments. SETTING: Thirty-three cases of patients with challenging inflammatory and neoplastic skin diseases at the University of L'Aquila Department of Dermatology were sent for teleconsultation to the Department of Dermatology, Medical University of Graz, Austria. METHODS: All cases were selected in the outpatient service in L'Aquila. After face-to-face consultation with a local colleague had been completed, images were sent using a store-and-forward (SAF)-based system (http://www.telederm.org) to Graz. Histopathological examination together with follow-up of the patient represents the diagnostic gold standard for this study. RESULTS: Telediagnosis was correct in 26 of 33 (78.8%) cases. Sixteen of 33 cases (48.5%) had already been diagnosed face-to-face by at least one of the two dermatologists in L'Aquila. In 10 of 33 cases (30.3%), the correct diagnosis was made in teleconsultation only. CONCLUSIONS: Second opinion teleconsulting may represent an additive value in the diagnosis of numerous challenging inflammatory and neoplastic skin diseases. It may be particularly useful as a best practice model for smaller departments in order to discuss and/or to confirm diagnoses and also for the management of patients with unusual difficult dermatoses.     

Comparison of teleconsultations and face-to-face consultations: preliminary results of a United Kingdom multicentre teledermatology study

The objective of this multicentre study was to undertake a systematic comparison of face-to-face consultations and teleconsultations performed using low-cost videoconferencing equipment. One hundred and twenty-six patients were enrolled by their general practitioners across three sites. Each patient underwent a teleconsultation with a distant dermatologist followed by a traditional face-to-face consultation with a dermatologist. The main outcome measures were diagnostic concordance rates, management plans and patient and doctor satisfaction. One hundred and fifty-five diagnoses were identified by the face-to-face consultations from the sample of 126 patients. Identical diagnoses were recorded from both types of consultation in 59% of cases. Teledermatology consultations missed a secondary diagnosis in 6% of cases and were unable to make a useful diagnosis in 11% of cases. Wrong diagnoses were made by the teledermatologist in 4% of cases. Dermatologists were able to make a definitive diagnosis by face-to-face consultations in significantly more cases than by teleconsultations (P = 0.001). Where both types of consultation resulted in a single diagnosis there was a high level of agreement (κ = 0.96, lower 95% confidence limit 0.91–1.00). Overall follow-up rates from both types of consultation were almost identical. Fifty per cent of patients seen could have been managed using a single videoconferenced teleconsultation without any requirement for further specialist intervention. Patients reported high levels of satisfaction with the teleconsultations. General practitioners reported that 75% of the teleconsultations were of educational benefit. This study illustrates the potential of telemedicine to diagnose and manage dermatology cases referred from primary care. Once the problem of image quality has been addressed, further studies will be required to investigate the cost-effectiveness of a teledermatology service and the potential consequences for the provision of dermatological services in the U.K.     

Patient satisfaction with teledermatology is related to perceived quality of life

BACKGROUND: There is a lack of good data about patient satisfaction with teledermatology and about its potential interaction with quality-of-life factors. OBJECTIVES: To assess the association between perceived skin-related quality of life and patient satisfaction with a nurse-led teledermatology service. METHODS: In a mobile nurse-led teledermatology clinic located in four inner city general practices in Manchester, the teledermatology service used digital cameras to capture and store images of skin conditions for remote diagnosis by dermatologists. One hundred and twenty-three adult patients, non-urgent dermatology referrals from primary care, completed the Dermatology Life Quality Index (DLQI) and a 15-item patient satisfaction questionnaire. RESULTS: In common with other studies of patient satisfaction, subjects reported highly favourable views of 'hotel' aspects of the service (93%) and found it 'convenient' (86%). However, 40% of patients would have preferred to have had a conventional face-to-face consultation with a dermatologist, and 17% felt unable to speak freely about their condition. Patient satisfaction with the service was related to quality of life. Patients reporting lower quality of life as measured by the DLQI were more likely to prefer a face-to-face encounter with a dermatologist (r = 0.216, P < 0.05), and to evince anxiety about being photographed (r = 0.223, P < 0.05). CONCLUSIONS: Patient acceptance and satisfaction with telemedicine services is complicated by patients' subjective health status. Telehealthcare providers need to recognize that patients with poor quality of life may want and benefit from face-to-face interaction with expert clinicians.