Store-and-Forward Teledermatology Wound Checks Following Mohs Surgery: A Pilot Study.

Introduction: Store-and-forward telemedicine is a form of electronic transmission in which patient images or clinical information are transmitted to clinicians for asynchronous clinical decision making. This study evaluated the use, feasibility, savings, and patient satisfaction of postoperative store-and-forward wound checks following Mohs surgery. Methods: Select patients were asked to participate in a virtual postoperative wound check after receiving Mohs surgery. Participants sent photos of their wound site and subsequently completed an anonymous survey. Results: One hundred and ten patients were enrolled, mean age 68 (range 32-87). Patients saved an average of $14.16, 78.6 miles of travel, and 90 min of travel time. Ninety-eight percent of respondents felt their quality of care in teledermatology was "about the same" to "much better" than compared with traditional in-person care. Sixty-four of the respondents (90.1%) reported they would prefer their next Mohs wound check to be conducted through teledermatology. Conclusion: Store-and-forward telemedicine in patients undergoing Mohs micrographic surgery is a safe, effective, and efficient method for postoperative wound care.

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.

The utility of teledermatology in the evaluation of skin lesions.

INTRODUCTION: Past studies have shown mixed results about the accuracy of store-and-forward (SAF) teledermatology in the evaluation of skin lesions. The objective of this study is to determine the accuracy of SAF teledermatology in the diagnosis of skin lesions and biopsy decision compared to in-person clinical evaluation. METHODS: Histories and photographs of skin lesions gathered at clinic visits were sent as SAF consults to teledermatologists, whose diagnoses and biopsy decisions were recorded and compared statistically to the clinic data.Results and Discussion: We enrolled 206 patients with 308 lesions in the study. The study population was composed of 50% males (n = 104), and most patients were white (n = 179, 87%) and not Hispanic/Latino (n = 167, 81%). There was good concordance for biopsy decision between the clinic dermatologist (CD) and teledermatologist (TD) (Cohen's kappa (κ) = 0.51), which did not significantly differ when melanocytic lesions were excluded (κ = 0.54). The sensitivity and specificity of teledermatology based on biopsy decision was 0.71 and 0.85, respectively. Overall concordance in first diagnosis between the CD and TD was good (κ = 0.60). While there was no difference between CD and TD in proportion of correct diagnoses compared to histopathology, two skin cancers presentations were missed by TD. Study limitations included sample size, enrolment bias and differing amounts of teledermatologist case experience. Teledermatology has good concordance in diagnosis and biopsy decision when compared to clinic dermatology. Teledermatology may be utilized in the evaluation of skin lesions to expand access to dermatologic care.

Evaluation of a pediatric dermatology electronic consult program in a rural state with subanalysis of infantile hemangioma cases.

An electronic consultation (e-Consult) store-and-forward teledermatology program was implemented to improve access to dermatologic care in Maine. While initially designed to triage potential skin cancers, we found this program to be heavily used for pediatric patients, especially infants. Our findings suggest e-Consult expedites care for pediatric dermatology patients, particularly those with infantile hemangiomas. The addition of dermoscopy to e-Consult platforms has the potential to expand e-Consult effectiveness.

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.

Concordance and Accuracy of Teledermatology Using Mobile Phones in the Outpatient Clinic of Jose R Reyes Memorial Medical Center: Cross-sectional Study.

BACKGROUND: Dermatologists rely on visual findings; thus, teledermatology is uniquely compatible to providing dermatologic care. The use of mobile phones in a store-and-forward approach, where gathered data are sent to a distant health provider for later review, may be a potential bridge in seeking dermatologic care. OBJECTIVE: This study aimed to determine the agreement between face-to-face consultations and teledermatologic consultations through the store-and-forward approach using mobile phones and its accuracy compared to a histopathologic diagnosis. METHODS: The study design was a cross-sectional study of participants consecutively recruited from dermatology patients who presented with skin or mucosal complaint and without prior dermatologist consultation. Photographs were taken using a standard smartphone (iPhone 6s Plus), and a 4-mm skin punch biopsy was taken on each patient-the gold standard to which the study result was compared to. The photographs were sent to 3 consultant dermatologists using a store-and-forward approach, for independent diagnosis and treatment plan. RESULTS: A total of 60 patients were included, with a median age of 41 years. There was moderate-to-almost perfect agreement in terms of final diagnosis between the face-to-face dermatologic diagnosis and teledermatologic diagnoses. The third teledermatologist had the highest agreement with the clinical dermatologist in terms of final diagnosis (κ=0.84; P<.001). Among the 3 dermatologists, there was moderate-to-almost perfect agreement as well. Agreement between pairs of teledermatologists ranged from 0.45 to 0.84. The 3 teledermatologists had moderate-to-substantial agreement with the biopsy results, with the third teledermatologist having the highest accuracy (κ=0.77; P<.001). Overall, there was a moderate agreement in the diagnosis of patients across raters. CONCLUSIONS: Teledermatology is a viable alternative to face-to-face consultations. Our results show moderate-to-substantial agreement in diagnoses from a face-to-face consultation and store-and-forward teledermatology.

Real-world outcomes of melanoma surveillance using the MoleMap NZ telemedicine platform.

BACKGROUND: MoleMap NZ is a novel New Zealand-based store-and-forward telemedicine service to detect melanoma. It uses expert review of total body photography and close-up and dermoscopic images of skin lesions that are suspicious for malignancy. OBJECTIVE: The purpose of this study was to assess the effectiveness of MoleMap NZ as a melanoma early detection program. METHODS: We conducted a review of 2108 melanocytic lesions recommended for biopsy/excision by MoleMap NZ dermoscopists between January 2015 and December 2016. RESULTS: Pathologic diagnoses were available for 1571 lesions. Of these, 1303 (83%) lesions were benign and 260 (17%) lesions were diagnosed as melanoma, for a melanoma-specific benign:malignant ratio of 5.0:1. The number needed to biopsy to obtain 1 melanoma was 6. Among melanomas with available tumor thickness data (n = 137), 92% were <0.8 mm (range in situ to 3.1 mm), with in situ melanomas comprising 74%. LIMITATIONS: Only lesions recommended for excision were analyzed. Pathology results were available for 75% of these cases. Tumor thickness data were available for 53% of melanomas diagnosed. CONCLUSIONS: This real-world study of MoleMap NZ, a community-based teledermoscopy program, suggests that it has the potential to increase patients' access to specialist expertise via telemedicine. Additional studies are needed to more accurately define its efficacy.

Use of teledermatology by dermatology hospitalists is effective in the diagnosis and management of inpatient disease.

BACKGROUND: Patient outcomes are improved when dermatologists provide inpatient consultations. Inpatient access to dermatologists is limited, illustrating an opportunity to use teledermatology. Little is known about the ability of dermatologists to accurately diagnose disease and manage inpatients with teledermatology, particularly when using nondermatologist-generated clinical data. METHODS: This prospective study assessed the ability of teledermatology to diagnose disease and manage 41 dermatology consultations from a large urban tertiary care center, using internal medicine referral documentation and photographs. Twenty-seven dermatology hospitalists were surveyed. Interrater agreement was assessed by the κ statistic. RESULTS: There was substantial agreement between in-person and teledermatology assessment of the diagnosis with differential diagnosis (median κ = 0.83), substantial agreement in laboratory evaluation decisions (median κ = 0.67), almost perfect agreement in imaging decisions (median κ = 1.0), and moderate agreement in biopsy decisions (median κ = 0.43). There was almost perfect agreement in treatment (median κ = 1.0), but no agreement in follow-up planning (median κ = 0.0). There was no association between raw photograph quality and the primary plus differential diagnosis or primary diagnosis alone. LIMITATIONS: Selection bias and single-center nature. CONCLUSIONS: Teledermatology may be effective in the inpatient setting, with concordant diagnosis, evaluation, and management decisions.

Definitions, survey methods, and findings of patient satisfaction studies in teledermatology: a systematic review.

Remote consultations likely will grow in importance if the COVID-19 pandemic continues. This review analyzes which methods of teledermatology patients prefer by categorizing how recent studies have defined satisfaction, conducted surveys and concluded patients respond to the different modalities of teledermatology. Using PubMed and Cochrane databases, we reviewed studies from April 5th, 2010 to April 5th, 2020 that included the search terms patient satisfaction and teledermatology. All studies that included patient satisfaction as an outcome were included, but studies not published in English were excluded. We examined domains of satisfaction, survey method, study characteristics (including patient population, country, age, study design and evidence score), findings and statistical comparisons. We thoroughly reviewed 23 studies. Definitions of satisfaction varied, but all concluded patients were satisfied with the live-interactive and store-and-forward modalities. The studies reveal that store-and-forward is appropriate for clinicians with established patients who require regular follow-up. Verified areas of care include treatment of chronic conditions, topical skin cancer therapy, wound monitoring, and post-procedural follow-up. Only four studies conducted statistical analyses. One of those studies compared patient preference for each modality of teledermatology with face-to-face dermatology. While this study reported high satisfaction with each mode of teledermatology, patients still preferred face-to-face. Favorable responses to remote diagnostic capabilities suggest that these offerings improve preference for teledermatology. With only one study evaluating preference between each modality and face-to-face dermatology, more studies should address the discrepancy. Surveys that cover all domains of satisfaction may improve assessments and identify where gaps in preference exist.

Implementation and Impact of a Store-and-Forward Teledermatology Platform in an Urban Academic Safety-Net Health Care System.

Background:Minority and low-income patients disproportionately experience dermatologic access challenges. Store-and-forward (SAF) teledermatology has emerged as a model of care delivery that may improve access. We sought to evaluate patterns of utilization and overall impact after SAF teledermatology implementation in a safety-net health care system. Methods:We performed a retrospective review of 3,285 teledermatology consultations from 2014 to 2017 in an urban academic safety-net health care system. Results:A total of 1,680 (51.2%) patients were referred for inflammatory/rash conditions and 967 (29.5%) for skin lesions. The teledermatologist recommended in-person evaluation in 1,199 encounters (36.5%). Median wait time for a subsequent appointment was 36 days (range 0-244 days). Of subsequent in-clinic visits, 237 patients (26.4%) underwent skin biopsy. No-show rate after referral was 11.8%. In comparison, median wait time for dermatology appointment through standard referral was 64 days, with a no-show rate of 18.6%. Biopsy rate of patients referred via teledermatology was 26.4%, in comparison to a rate of 10.9% of patients referred directly from primary care provider. Discussion:Implementation of SAF teledermatology in a safety-net health system resulted in avoidance of 63.5% potential dermatology visits. Consultation typically resulted in a change in suspected diagnosis or management plan. Rates of concordance between teledermatology consults and in-person evaluations were high. Median wait time was reduced by almost half, no-show rate was reduced ∼37%, and biopsy rate was more than double for teledermatology patients compared with standard referral. Conclusion:These findings suggest that SAF teledermatology may improve access to high-quality dermatologic care and increase clinic efficiencies for patients in safety-net health care systems.

Extending the Reach and Task-Shifting Ophthalmology Diagnostics Through Remote Visualisation.

Driven by the global increase in the size and median age of the world population, sight loss is becoming a major public health challenge. Furthermore, the increased survival of premature neonates in low- and middle-income countries is causing an increase in developmental paediatric ophthalmic disease. Finally, there is an ongoing change in health-seeking behaviour worldwide, with consequent demand for increased access to healthcare, including ophthalmology. There is therefore the need to maximise the reach of resource-limited ophthalmology expertise in the context of increasing demand. Yet, ophthalmic diagnostics critically relies on visualisation, through optical imaging, of the front and of the back of the eye, and teleophthalmology, the remote visualisation of diagnostic images, shows promise to offer a viable solution.In this chapter, we first explore the strategies at the core of teleophthalmology and, in particular, real-time vs store-and-forward remote visualisation techniques, including considerations on suitability for different tasks and environments. We then introduce the key technologies suitable for teleophthalmology: anterior segment imaging, posterior segment imaging (retinal imaging) and, briefly, radiographic/tomographic techniques. We highlight enabling factors, such as high-resolution handheld imaging, high data rate mobile transmission, cloud storage and computing, 3D printing and other rapid fabrication technologies and patient and healthcare system acceptance of remote consultations. We then briefly discuss four canonical implementation settings, namely, national service provision integration, field and community screening, optometric decision support and virtual clinics, giving representative examples. We conclude with considerations on the outlook of the field, in particular, on artificial intelligence and on robotic actuation of the patient end point as a complement to televisualisation.

Teledermatology and its Current Perspective.

Teledermatology is one of the most important and commonly employed subsets of telemedicine, a special alternative to face-to-face (FTF) doctor--patient consultation that refers to the use of electronic telecommunication tools to facilitate the provision of healthcare between the "seeker" and "provider." It is used for consultation, education, second opinion, and monitoring medical conditions. This article will review basic concepts, the integration of noninvasive imaging technique images, artificial intelligence, and the current ethical and legal issues.

Teledermatology Consultation Can Optimize Treatment of Cutaneous Disease by Nondermatologists in Under-Resourced Clinics.

Background: Access to dermatologists is limited for disadvantaged patients, who may receive suboptimal dermatologic care from nonspecialists. We assessed if teledermatology could improve primary care provider (PCP)-delivered care for cutaneous disease at a clinic serving uninsured patients. Materials and Methods: Utilizing the American Academy of Dermatology's free AccessDerm program, we offered store-and-forward teledermatology to PCPs, who initiated consultations at will during clinical care independent of the study. We retrospectively analyzed all consultations from 2013 to 2017 and collected patient age/sex, teledermatologist diagnosis, time to teledermatologist reply, time to next dermatology appointment, as well as PCP- and teledermatologist-proposed care plans. Results: Retrospective analysis of 131 consults revealed a 37-h mean teledermatology response-time versus a 14-day appointment wait (p < 0.00001). Teledermatologists provided a definitive care plan without in-person evaluation for 82 (65%) of completed consults and recommended interim treatments while awaiting appointments in 15 cases, thus accelerating care plan delivery in 97 cases (76%). The triage decision rate differed among diagnostic categories; deferral to in-person evaluation was more frequent for neoplasms (p < 0.0001). When PCPs specified preconsult treatment plans, 82% differed from teledermatologist-advised management. Following teledermatologist recommendations would have changed the clinical course in 70% of cases, potentially avoiding suboptimal care, including inappropriate corticosteroids, antimicrobials, and emergency room referrals. Conclusions: We found teledermatology can effectively guide PCPs in resource-limited settings by accelerating delivery of dermatologist-recommended care plans for uninsured patients. Expanding teledermatology for PCPs in under-resourced clinics has the potential to improve treatment of cutaneous disease by nonspecialists and to mitigate suboptimal care for disadvantaged patients.

Impact of dermatology eConsults on access to care and skin cancer screening in underserved populations: A model for teledermatology services in community health centers.

BACKGROUND: The clinical outcome of teledermatology with dermoscopy in large-scale primary care networks remains unclear. OBJECTIVE: We evaluate the impact of implementing a teledermatology consultation program with dermoscopy on a statewide scale, focusing on access to care and skin cancer screening for medically underserved populations. METHODS: Descriptive retrospective cohort study of 2385 dermatology referrals from primary care from June 2014 through November 2015. RESULTS: Before implementation of electronic consultations (eConsults), access to dermatology was limited; only 139 (11%) of 1258 referrals resulted in a confirmed appointment with a median wait time of 77 days. Post implementation, 499 of 1127 consults (44%) were sent electronically, and of those, 16% required a face-to-face visit with a median wait time of 28 days. Ten malignancies were identified via eConsults. Overall consult volume remained stable pre- and post-eConsult implementation. LIMITATIONS: We evaluated eConsults in medically underserved populations seeking care at community health centers. Results might not be generalizable to other populations or in other settings. CONCLUSION: eConsults increase access to dermatologic care and reduce wait times for patients receiving medical care at community health centers. Implementing dermoscopy into teledermatology could increase access to skin cancer screening and treatment for medically disadvantaged populations.

Diagnosis and Management of Malignant Melanoma in Store-and-Forward Teledermatology.

BACKGROUND: Published studies have led to concern that store-and-forward teledermatology (SFT) diagnosis and management of melanomas may be inferior to face-to-face (FTF) dermatology care. INTRODUCTION: To ascertain the frequency of correctly managed and diagnosed melanomas within a population of veterans in Veterans Integrated Service Network 20 SFT. MATERIALS AND METHODS: We conducted a retrospective chart review of 7,960 veterans seen by SFT between July 1, 2009 and December 31, 2011. RESULTS: Of the 61 veterans that met inclusion and exclusion criteria, 45 (74%) melanomas were correctly diagnosed and 57 (93%) were correctly managed. DISCUSSION: Diagnostic and management accuracy of SFT is comparable to FTF. Incorrect diagnosis or management of melanomas did not prove to have significant consequences for patient care. Cases subject to analysis of this study are not demographically representative of the general population. CONCLUSION: Diagnosis and management of melanoma in SFT is comparable to FTF care.

Validation of a Skin-Lesion Image-Matching Algorithm Based on Computer Vision Technology.

BACKGROUND: Melanoma incidence is increasing globally, but consistently accurate skin-lesion classification methods remain elusive. We developed a simple software system to classify potentially all types of skin lesions. In the current study, we evaluated the system's ability to identify melanomas with a diameter of 10 mm or larger. MATERIALS AND METHODS: The skin-lesion classification system is composed of a proprietary database of nearly 12,000 diagnosed skin-lesion images and a computer algorithm based on the principles of content-based image retrieval. The algorithm compares characteristics of new skin-lesion images with images in the database to identify the nearest-match diagnosis. RESULTS: Nearly all classification accuracy measures for this new system exceeded 90%, with results for sensitivity of 90.4% (95% confidence interval, 85.6-93.7%), specificity of 91.5% (85.4-95.2%), positive predictive value of 94.5% (90.4-96.9%), negative predictive value of 85.5% (78.7-90.4%), and overall classification accuracy of 90.8% (87.2-93.4%). CONCLUSIONS: The image-matching algorithm performed with high accuracy for the classification of larger melanomas. Furthermore, the system does not require a dermoscope or any other specialized hardware; any close-focusing camera will do. This system has the potential to be an inexpensive and accurate tool for the evaluation of skin lesions in ethnically and geographically diverse populations.

Interobserver reliability of store-and-forward teledermatology in a clinical practice setting.

INTRODUCTION AND OBJECTIVES: Although 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 METHODS: Patients 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. RESULTS: In 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). CONCLUSION: The 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.

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

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