Implementation of Direct-to-Patient Mobile Teledermatology in VA.

BACKGROUND: Innovative technology can enhance patient access to healthcare but must be successfully implemented to be effective. OBJECTIVE: We evaluated Department of Veterans Affairs' (VA's) implementation of My VA Images, a direct-to-patient asynchronous teledermatology mobile application enabling established dermatology patients to receive follow-up care remotely instead of in-person. DESIGN /PARTICIPANTS/APPROACH: Following pilot testing at 3 facilities, the app was introduced to 28 facilities (4 groups of 7) every 3 months using a stepped-wedge cluster-randomized design. Using the Organizational Theory of Implementation Effectiveness, we examined the app's implementation using qualitative and quantitative data consisting of encounter data from VA's corporate data warehouse; app usage from VA's Mobile Health database; bi-monthly reports from facility representatives; phone interviews with clinicians; and documented communications between the operational partner and facility staff. KEY RESULTS: Implementation policies and practices included VA's vision to expand home telehealth and marketing/communication strategies. The COVID-19 pandemic dominated the implementation climate by stressing staffing, introducing competing demands, and influencing stakeholder attitudes to the app, including its fit to their values. These factors were associated with mixed implementation effectiveness, defined as high quality consistent use. Nineteen of 31 exposed facilities prepared to use the app; 10 facilities used it for actual patient care, 7 as originally intended. Residents, nurse practitioners, and physician assistants were more likely than attendings to use the app. Facilities exposed to the app pre-pandemic were more likely to use and sustain the new process. CONCLUSIONS: Considerable heterogeneity existed in implementing mobile teledermatology, despite VA's common mission, integrated healthcare system, and stakeholders' broad interest. Identifying opportunities to target favorable facilities and user groups (such as teaching facilities and physician extenders, respectively) while addressing internal implementation barriers including incomplete integration with the electronic health record as well as inadequate staffing may help optimize the initial impact of direct-to-patient telehealth. The COVID pandemic was a notable extrinsic barrier. CLINICAL TRIALS REGISTRATION: NCT03241589.

Organizational Readiness for Patient-Facing Mobile Teledermatology to Care for Established Veteran Patients in the United States.

Purpose: To improve patient access to skin care, the Department of Veterans Affairs (VA) developed a patient-facing asynchronous mobile teledermatology application (app), which allows patients to follow up remotely with dermatologists. To understand how the app would be received in VA, we examined Organizational Readiness for Change (ORC), an important prelude to effective implementation, which includes the shared resolve and collective ability of organizational members to implement a change. Methods: We used a mixed-methods multiple case study approach to assess ORC at three VA facilities. Data derived from a site process call, surveys, and semistructured telephone interviews of VA staff, field notes, and administrative data. Results: Participants at all three facilities supported the intervention and recognized the value of using the app to increase patients' access to dermatologists, but expressed concerns largely related to disruption of the pre-existing clinical workflow. Participants at the facility most actively using the app had the highest overall ORC score and reported the most facilitators. Facility leadership support when guided by a clinical champion minimized barriers by recognizing the complexities of health care provision at specialty clinics. Discussion: While provider buy-in remained a barrier, leadership, guided by the clinical champion, played a critical role instituting implementation strategies. The strong association between the ORC survey score and the presence of facilitators and barriers suggests that the ORC survey may be a rapid, convenient, and effective tool for health care systems to identify favorable sites for wider implementation of mobile telehealth care. Clinical Trials Identifier: NCT03241589.

Implementing remote triage in large health systems: A qualitative evidence synthesis.

Remote triage (RT) allows interprofessional teams (e.g., nurses and physicians) to assess patients and make clinical decisions remotely. RT use has developed widespread interest due to the COVID-19 pandemic, and has future potential to address the needs of a rapidly aging population, improve access to care, facilitate interprofessional team care, and ensure appropriate use of resources. However, despite rapid and increasing interest in implementation of RT, there is little research concerning practices for successful implementation. We conducted a systematic review and qualitative evidence synthesis of practices that impact the implementation of RT for adults seeking clinical care advice. We searched MEDLINE®, EMBASE, and CINAHL from inception through July 2018. We included 32 studies in this review. Our review identified four themes impacting the implementation of RT: characteristics of staff who use RT, influence of RT on staff, considerations in selecting RT tools, and environmental and contextual factors impacting RT. The findings of our systemic review underscore the need for a careful consideration of (a) organizational and stakeholder buy-in before launch, (b) physical and psychological workplace environment, (c) staff training and ongoing support, and (d) optimal metrics to assess the effectiveness and efficiency of implementation. Our findings indicate that preimplementation planning, as well as evaluating RT by collecting data during and after implementation, is essential to ensuring successful implementation and continued adoption of RT in a health care system.

Implementation of Mobile Teledermatology: Challenges and Opportunities.

Background: While teledermatology is well-established in the Department of Veterans Affairs (VA), its implementation is far from complete. To facilitate consultative teledermatology and extend its reach, VA introduced a mobile teledermatology application (app) at three VA sites. Methods: We evaluated the initial implementation process using a mixed-methods, multiple case study approach to assess organizational readiness for change (ORC), which included examining facilitators, barriers, and contextual factors that affected implementation. We conducted: (1) group interviews and bimonthly reports to understand site processes; (2) semistructured interviews and surveys of individual participants representing a range of implementation roles; and (3) a review of internal organizational documents. We identified themes from interviews using an iterative process, and computed an ORC score based on surveys. Results: Forty-three individuals participated in the study. Qualitative data from all sites, corroborated by survey data available from one site, revealed a high readiness for change with an ORC score of 4.2, where 5 = maximal readiness for change. Facilitators included support from leadership and clinical champions, active telehealth programs, and an understanding and appreciation of the program and the resources needed. At all sites, however, technical issues negatively affected adoption; these included a suboptimal information technology infrastructure, which led to the inoperability of the app at two sites, and technical inefficiencies related to users' unfamiliarity with new devices and inconsistent internet access. Conclusions: Although a strong commitment to change and a confidence to effect change existed, these alone were insufficient to surmount barriers to implementation effectiveness. Clinical Trials Registration: NCT03241589.

Effectiveness of Acute Care Remote Triage Systems: a Systematic Review.

BACKGROUND: Technology-based systems can facilitate remote decision-making to triage patients to the appropriate level of care. Despite technologic advances, the effects of implementation of these systems on patient and utilization outcomes are unclear. We evaluated the effects of remote triage systems on healthcare utilization, case resolution, and patient safety outcomes. METHODS: English-language searches of MEDLINE (via PubMed), EMBASE, and CINAHL were performed from inception until July 2018. Randomized and nonrandomized comparative studies of remote triage services that reported healthcare utilization, case resolution, and patient safety outcomes were included. Two reviewers assessed study and intervention characteristics independently for study quality, strength of evidence, and risk of bias. RESULTS: The literature search identified 5026 articles, of which eight met eligibility criteria. Five randomized, two controlled before-and-after, and one interrupted time series study assessed 3 categories of remote triage services: mode of delivery, triage professional type, and system organizational level. No study evaluated any other delivery mode other than telephone and in-person. Meta-analyses were unable to be performed because of study design and outcome heterogeneity; therefore, we narratively synthesized data. Overall, most studies did not demonstrate a decrease in primary care (PC) or emergency department (ED) utilization, with some studies showing a significant increase. Evidence suggested local, practice-based triage systems have greater case resolution and refer fewer patients to PC or ED services than regional/national systems. No study identified statistically significant differences in safety outcomes. CONCLUSION: Our review found limited evidence that remote triage reduces the burden of PC or ED utilization. However, remote triage by telephone can produce a high rate of call resolution and appears to be safe. Further study of other remote triage modalities is needed to realize the promise of remote triage services in optimizing healthcare outcomes. PROTOCOL REGISTRATION: This study was registered and followed a published protocol (PROSPERO: CRD42019112262).

Telehealth Interventions Designed for Women: an Evidence Map.

BACKGROUND: Telehealth employs technology to connect patients to the right healthcare resources at the right time. Women are high utilizers of healthcare with gender-specific health issues that may benefit from the convenience and personalization of telehealth. Thus, we produced an evidence map describing the quantity, distribution, and characteristics of evidence assessing the effectiveness of telehealth services designed for women. METHODS: We searched MEDLINE® (via PubMed®) and Embase® from inception through March 20, 2018. We screened systematic reviews (SRs), randomized trials, and quasi-experimental studies using predetermined eligibility criteria. Articles meeting inclusion criteria were identified for data abstraction. To assess emerging trends, we also conducted a targeted search of ClinicalTrials.gov . RESULTS: Two hundred thirty-four primary studies and three SRs were eligible for abstraction. We grouped studies into focused areas of research: maternal health (n = 96), prevention (n = 46), disease management (n = 63), family planning (n = 9), high-risk breast cancer assessment (n = 10), intimate partner violence (n = 7), and mental health (n = 3). Most interventions focused on phone as the primary telehealth modality and featured healthcare team-to-patient communication and were limited in duration (e.g., < 12 weeks). Few interventions were conducted with older women (≥ 60 years) or in racially/ethnically diverse populations. There are few SRs in this area and limited evidence regarding newer telehealth modalities such as mobile-based applications or short message service/texting. Targeted search of clinical.trials.gov yielded 73 ongoing studies that show a shift in the use of non-telephone modalities. DISCUSSION: Our systematic evidence map highlights gaps in the existing literature, such as a lack of studies in key women's health areas (intimate partner violence, mental health), and a dearth of relevant SRs. With few existing SRs in this literature, there is an opportunity for examining effects, efficiency, and acceptability across studies to inform efforts at implementing telehealth for women.

Users and nonusers of university-based dermatology services following a teledermatology encounter: a retrospective descriptive analysis.

OBJECTIVE: The aim of this study was to retrospectively describe hybrid technology teledermatology encounters performed by a statewide telehealth network. Consult outcomes were reviewed to describe the number of encounters that resulted in a visit to the university-based dermatology clinics and the features of those visits. MATERIALS AND METHODS: Teledermatology encounters were reviewed to determine encounter volume and the proportion of encounters that resulted in a university-based dermatology clinic visit. Additional information collected included demographics, the reason for the visit, management recommendations, and clinical diagnoses. After identifying those consults that resulted in a dermatology clinic visit, we reviewed a random sample of teledermatology encounters that did not result in a university-based dermatology clinic visit for a descriptive comparison. RESULTS: A total of 1,536 teledermatology encounters were completed by the network between 2001 and 2007. Of the 1,307 encounters reviewed, 56 patients were seen in the university-based dermatology clinic after the teledermatology encounter. The need for a procedure or clinic-based intervention was a reason for the visit in 79% of these encounters. When reviewing management recommendations, 46% of the patients who required a university-based clinic visit needed a procedural intervention compared with 8% of the group that did not need a clinic visit. Medical recommendations predominated in the telemedicine-only group (71%) compared with the clinic-based visit group (36%). CONCLUSIONS: Our study describes the features, such as demographics and case-mix, of users and nonusers of university-based dermatology clinics after teledermatology encounters that may be important considerations for future evaluations of teledermatology consult systems.

Economic analysis of telemedicine and the teledermatology paradigm.

Abstract Economic considerations are an important component in the planning and execution of a telemedicine program. The goal of this review is to familiarize readers with economic concepts relevant to the analysis of telemedicine programs. Economic perspectives, cost attribution, types of economic analysis, and commonly encountered problems will be discussed as they pertain to telemedicine. Societal perspectives, healthcare system perspectives, patient perspectives, fixed versus variable costs, labor costs, and distinctions between cost-effectiveness analyses and other types of economic analysis also will be examined. Examples from the teledermatology literature will be used as a paradigm to illustrate how these concepts are integrated into existing analyses of teledermatology systems. Teledermatology shows promise as a cost-saving healthcare delivery system with outcomes comparable to or better than those of conventional care processes. The literature also points out the importance of economic perspectives in the findings and interpretation of an analysis.

Cost minimization analysis of a store-and-forward teledermatology consult system.

The aim of this study was to perform a cost minimization analysis of store-and-forward teledermatology compared to a conventional dermatology referral process (usual care). In a Department of Defense (DoD) setting, subjects were randomized to either a teledermatology consult or usual care. Accrued healthcare utilization recorded over a 4-month period included clinic visits, teledermatology visits, laboratories, preparations, procedures, radiological tests, and medications. Direct medical care costs were estimated by combining utilization data with Medicare reimbursement rates and wholesale drug prices. The indirect cost of productivity loss for seeking treatment was also included in the analysis using an average labor rate. Total and average costs were compared between groups. Teledermatology patients incurred $103,043 in total direct costs ($294 average), while usual-care patients incurred $98,365 ($283 average). However, teledermatology patients only incurred $16,359 ($47 average) in lost productivity cost while usual-care patients incurred $30,768 ($89 average). In total, teledermatology patients incurred $119,402 ($340 average) and usual-care patients incurred $129,133 ($372 average) in costs. From the economic perspective of the DoD, store-and-forward teledermatology was a cost-saving strategy for delivering dermatology care compared to conventional consultation methods when productivity loss cost is taken into consideration.

VA Telederm study: protocol for a stepped-wedge cluster randomised trial to compare access to care for a mobile app versus a workstation-based store-and-forward teledermatology process.

INTRODUCTION: Teledermatology has emerged as an important strategy to enhance access to high-quality skin care. VA Telederm is a provider-facing, web-based mobile app designed to integrate into the existing teledermatology workflow in the US Veterans Health Administration (VHA). In this study, we will conduct a systematic evaluation of VA Telederm on access outcomes in VHA facilities using a pragmatic trial guided by clinical and operational leaders. METHODS AND ANALYSIS: The study is a prospective, stepped-wedge cluster randomised trial with cross-sectional exposure and outcome measurement via retrospective database analysis of administrative records. Each cluster is a VHA facility deemed eligible for the trial. We assign the intervention using a cluster-level balanced randomisation scheme based on facility size, baseline teledermatology uptake and geographic location. The trial will test whether patients receiving dermatological care at participating facilities will have better access compared with patients receiving care through the current standard process. The primary outcomes proxy for patient-level access to dermatology services, including (1) consult completion time for teledermatology consults; (2) appointment completion time for new dermatology consults; and (3) travel distance for dermatology services. As secondary outcomes, we will assess facility-level adoption outcomes, that is, the number of dermatology encounters and the proportion of teledermatology consults out of all dermatology encounters. To account for secular trends in outcomes and for correlation across individuals within clusters, we will assess the impact of the intervention using generalised linear mixed regression models. DISCUSSION: Streamlining the current practice for store-and-forward teledermatology in the VHA can improve access to expert dermatological care for US veterans. The lessons learnt in this trial could validate the use of mobile technology for consultative store-and-forward dermatology in a large healthcare organisation. The results may also be of interest to other medical specialties assessing the merits of implementing mobile telehealth. PROTOCOL VERSION: Version 3; 7 November 2018. TRIAL REGISTRATION NUMBER: NCT03241589; Pre-results.

Accuracy and reliability of teleophthalmology for diagnosing diabetic retinopathy and macular edema: a review of the literature.

Using teleophthalmology for the delivery of routine eye care for patients with diabetes mellitus is becoming an increasingly common practice. Paramount in the consideration of any new diagnostic test is an analysis of its diagnostic accuracy and reliability and how that compares with conventional care. This review summarizes existing data on the diagnostic accuracy and reliability of teleophthalmology and conventional clinic-based eye care for detecting diabetic retinopathy and diabetes mellitus. The sensitivity of ophthalmoscopy for detecting diabetic retinopathy performed by eye care clinicians has varied widely, with point estimates ranging from 0% to 96%. Alternatively, specificity has been universally high. The sensitivity of teleophthalmology for detecting diabetic retinopathy has been shown to be comparable, if not better, than clinic-based examinations. Sensitivity values have ranged from 50% to 93%. The specificity of teleophthalmology, like clinic-based examinations, has been consistently high. High levels of diagnostic reliability, analyzed by both simple agreement and kappa values, have been found between ophthalmoscopy and teleophthalmology for detecting and classifying diabetic retinopathy. Evaluating the accuracy of macular edema detection requires the use of dual gold standards, the clinical examination using slit-lamp biomicroscopy and stereoscopic photography. Teleophthalmology, compared with both gold standards, has, overall, been a highly sensitive and specific test. Reliability studies that compared the two gold standards with one another have found moderate to substantial levels of agreement. Based on existing data, teleophthalmology appears to be an accurate and reliable test for detecting diabetic retinopathy and macular edema.

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.

Quality of life: a research gap in teledermatology.

An important outcome in healthcare, and in particular for dermatologic healthcare, is quality of life. Whereas the literature is well represented by quality of life assessments in dermatology, very little information is available that specifically addresses teledermatology's impact on quality of life. This gap in our knowledge of teledermatology is noteworthy precisely because of the importance that quality of life plays in dermatologic disease and healthcare delivery. The goal of this review is to briefly outline the concept of quality of life and its importance to dermatology, describe the different type of instruments that are used to assess quality of life, and to review studies that implemented teledermatology interventions and made quality of life assessments. The available literature has shown that teledermatology interventions do result in improved quality of life, and those changes correlate with improvements in disease severity and clinical course. Integrating quality of life assessments in future evaluations of teledermatology interventions would be valuable to provide a more comprehensive depiction of teledermatology's impact on patients receiving dermatology care via telemedicine.

Cost and Utility Analysis of a Store-and-Forward Teledermatology Referral System: A Randomized Clinical Trial.

IMPORTANCE: The costs and utility of teledermatology are important features of implementation. Such an analysis requires a description of the perspective of the entity that will bear the cost. OBJECTIVE: To assess the costs and utility of a store-and-forward teledermatology referral process compared with a conventional referral process from the perspectives of the Department of Veterans Affairs (VA) and society. DESIGN, SETTING, AND PARTICIPANTS: Three hundred ninety-one randomized participants were referred from remote sites of primary care to the dermatology services of 2 VA medical facilities for ambulatory skin conditions from December 2008 through June 2010, and follow-up was completed in March 2011. The time trade-off utility measures and costs were collected during a 9-month period among participants in a 2-site parallel group randomized clinical trial. The perspectives of the VA and society were evaluated. The multiple imputation procedure or weighted means were used for missing data elements. Data were analyzed from January to July 2014. INTERVENTIONS: Referrals were managed using store-and-forward teledermatology or a conventional text-based referral process. MAIN OUTCOMES AND MEASURES: Total costs from the perspectives of the VA and society incurred during the 9-month follow-up were used to derive per-participant costs. Utility, using the time trade-off method, was the measure of effectiveness. RESULTS: From the VA perspective, the total cost for conventional referrals was $66 145 (minimum, $58 697; maximum, $71 635), or $338 (SD, $291) per participant (196 participants); the total cost for teledermatology referrals was $59 917 (mimimum, $51 794; maximum, $70 398), or $308 (SD, $298) per participant (195 participants). The $30 difference in per-participant cost was not statistically significant (95% CI, -$79 to $20). From the societal perspective, the total cost for conventional referrals was $106 194 (minimum, $98 746; maximum, $111 684), or $542 (SD, $403) per participant (196 participants); the total cost for teledermatology referrals was $89 523 (minimum, $81 400; maximum, $100 400) or $460 (SD, $428) per participant. This $82 difference in per-participant cost was statistically significant (95% CI, -$12 to -$152). From baseline to the 9-month follow-up, the time trade-off utility value improved by 0.02 in the conventional referral group and 0.03 in the teledermatology group. This difference was not statistically significant (P = .50). CONCLUSIONS AND RELEVANCE: Compared with conventional referrals, store-and-forward teledermatology referrals were performed at a comparable cost (VA perspective) or at a lower cost (societal perspective) with no evidence of a difference in utility as measured by the time trade-off method. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00488293.

Clinical course outcomes for store and forward teledermatology versus conventional consultation: a randomized trial.

We assessed the clinical course of patients after store and forward teledermatology in comparison with conventional consultations. Patients being referred from primary care to dermatology clinics were randomly assigned to teledermatology or a conventional consultation. A total of 392 patients were randomized; 261 patients completed the study and were included in the analysis. Their clinical course was rated on a five-point scale by a panel of three dermatologists, blinded to study assignment, who reviewed serial digital image sets. The clinical course was assessed by comparing images sets between baseline and first clinic visit (if one occurred) and between baseline and nine months. There was no evidence to suggest a difference between the two groups in either clinical course between baseline and nine months post-referral (P = 0.88) or between baseline and the first dermatology clinic visit (P = 0.65). Among teledermatology referrals, subsequent presentation for an in-person dermatology clinic visit was significantly correlated with clinical course (P = 0.023). Store and forward teledermatology did not result in a significant difference in clinical course at either of two post-referral time periods.

Effect of store and forward teledermatology on quality of life: a randomized controlled trial.

IMPORTANCE: Although research on quality of life and dermatologic conditions is well represented in the literature, information on teledermatology's effect on quality of life is virtually absent. OBJECTIVE: To determine the effect of store and forward teledermatology on quality of life. DESIGN: Two-site, parallel-group, superiority randomized controlled trial. SETTING: Dermatology clinics and affiliated sites of primary care at 2 US Department of Veterans Affairs medical facilities. PARTICIPANTS: Patients being referred to a dermatology clinic were randomly assigned, stratified by site, to teledermatology or the conventional consultation process. Among the 392 patients who met the inclusion criteria and were randomized, 326 completed the allocated intervention and were included in the analysis. INTERVENTIONS: Store and forward teledermatology (digital images and a standardized history) or conventional text-based consultation processes were used to manage the dermatology consultations. Patients were followed up for 9 months. MAIN OUTCOME MEASURES: The primary end point was change in Skindex-16 scores, a skin-specific quality-of-life instrument, between baseline and 9 months. A secondary end point was change in Skindex-16 scores between baseline and 3 months. RESULTS: Patients in both randomization groups demonstrated a clinically significant improvement in Skindex-16 scores between baseline and 9 months with no significant difference by randomization group (P = .66, composite score). No significant difference in Skindex-16 scores by randomization group between baseline and 3 months was found (P = .39, composite score). CONCLUSIONS: Compared with the conventional consultation process, store and forward teledermatology did not result in a statistically significant difference in skin-related quality of life at 3 or 9 months after referral. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00488293.

Store-and-forward teledermatology results in similar clinical outcomes to conventional clinic-based care.

We compared the clinical outcomes after store-and-forward teledermatology with those following conventional clinic-based consultation. Subjects were randomized to either usual care (a conventional clinic-based dermatology appointment) or a store-and-forward teledermatology consultation. All subjects received baseline digital imaging and re-imaging was performed four months later. A total of 776 subjects were approached for inclusion, and a total of 508 image sets were reviewed, 236 in usual care and 272 in teledermatology. The image sets from both study arms were used to make clinical outcome assessments between baseline and four months. A dermatologist who was blinded to the randomization rated the clinical outcomes using a three-point clinical course rating scale (1 = improved, 2 = no change, 3 = worse). In the usual care group, 65% were rated as 'improved', 32% were rated as 'no change' and 3% were rated as 'worse'. For teledermatology, 64% were rated as 'improved', 33% as 'no change' and 4% as 'worse'. The results of the study indicate that store-and-forward teledermatology consultations produce similar clinical outcomes when compared with conventional clinic-based consultations.

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.