Teledermatology Programs Research Articles

Association of rurality and health professional shortages with the clinicopathologic characteristics of melanoma in North Carolina.

To assess rural-urban and health professional shortage area (HPSA)-related influences on the characteristics of melanoma in North Carolina. We conducted a single-center retrospective cohort study of patients living in North Carolina with an available pathology report for invasive cutaneous melanoma seen in the Duke University Health System from 01/01/2014 to 12/31/2020. Multivariable logistic regression models were employed to compare patient and tumor characteristics between rural versus urban county residence as well between melanoma thicknesses dichotomized into thin (≤1.0mm) and thicker (>1.0mm) tumors. The cohort included 807 patients, and rural patients accounted for 177 (21.9%) of invasive cutaneous melanomas. Rural patients had significantly higher odds of having thicker tumors than urban patients (odds ratio [OR] = 1.78, 95% confidence interval [CI]: 1.17-2.71; P =.008). Rural patients were significantly more likely to be female (OR = 1.59, 95% CI: 1.10-2.28; P =.013) and located in a population-based (OR = 2.66, 95% CI: 1.84-3.84; P<.001) or geographic-based (OR = 8.21, 95% CI: 3.33-20.22; P<.001) HPSA. Living in a medium- or high-shortage population-based HPSA was associated with higher odds of thicker tumors (OR = 2.65, 95% CI: 1.85-3.80; P<.001). Patients living in rural North Carolina counties were more likely than those in urban counties to be diagnosed with melanomas >1.0mm in thickness, a clinically significant difference with important prognostic implications. Interventions at the county- and state-level to address this disparity may include improving access to skin cancer screening and teledermatology programs, increasing partnerships with primary care providers, and targeting interventions to counties with health professional shortages.

Using the RE-AIM framework to assess national teledermatology expansion.

Teledermatology has been utilized in the United States Department of Veterans Affairs (VA) for decades but continues to have incomplete penetration. VA has funded an initiative to enhance access to dermatology services since 2017 to support asynchronous teledermatology for Veterans living in rural areas. As part of an ongoing evaluation of this program, we assessed the teledermatology activity between the fiscal years 2020 and 2022. We focused on the second cohort of the initiative, comprising six VA facilities and their 54 referral clinics. We studied teledermatology programs at cohort facilities using the reach, effectiveness, adoption, implementation, and maintenance framework. We used a mixed-methods design including annual online reports completed by participating facilities and VA administrative data. When possible, we compared the data from the 3 years of teledermatology funding with the baseline year prior to the start of funding. Reach: Compared with the baseline year, there was a 100% increase in encounters and a 62% increase in patients seen at the funded facilities. Over 500 clinicians and support staff members were trained. Effectiveness: In FY 2022, primary or specialty care clinics affiliated with the funded facilities had more dermatology programs than primary or specialty care clinics across the VA (83% vs. 71% of sites). Adoption: By the end of the funding period, teledermatology constituted 16% of dermatology encounters at the funded facilities compared with 12% nationally. This reflected an increase from 9.2% at the funded facilities and 10.3% nationally prior to the funding period. Implementation: The continued funding for staff and equipment facilitated the expansion to rural areas. Maintenance: By the end of the funding period, all facilities indicated that they had fully implemented their program for patients of targeted primary care providers. The Program Sustainability Index scores generally increased during the funding period. Targeted funding to support asynchronous teledermatology implementation for rural Veterans increased its reach, adoption, and implementation, ultimately improving access. Providing program guidance with staffing and training resources can increase the impact of these programs. Ongoing efforts to maintain and increase communication between primary care and dermatology will be needed to sustain success.

Teledermatology in remote Indigenous populations: Lessons learned and paths to explore, an experience from Canada (Québec) and Australia.

Recent introduction of a provincially funded and administered teledermatology platform in Quebec presents a major opportunity to improve healthcare delivery to rural Indigenous communities where healthcare is suboptimal. In this study, we assessed approaches, challenges, solutions, and outcomes in implementing teledermatology in rural Indigenous communities of Australia and Canada. A narrative review was performed using journal articles and grey literatures to assess challenges encountered in Canadian and Australian teledermatology programs in rural Indigenous communities. We then conducted a focused search to identify solutions and outcomes to these challenges. We identified four main areas of focus for implementing teledermatology: financial, cultural, legal, and provider competency. Main financial concerns included identifying the cost-to-benefit ratio of teledermatology and financial benefits of the store-and-forward system compared to videoconferencing. Delivery of teledermatology through culturally considerate services is crucial to mend the mistrust felt by Indigenous people toward mainstream health services. From a legal standpoint, patient confidentiality and physician liability must be considered. A uniform teledermatology platform and physician competency in both telemedicine and dermatology are needed to ensure standard of care. Teledermatology initiatives represent great opportunities to improve healthcare services to rural Indigenous populations.

Teledermatology in 2020: past, present and future perspectives.

Born in 1995, teledermatology (TD) turns 25 years old today. Since then, TD evolved according to patients and physicians needs. The present review aimed to summarize all the efforts and experiences carried out in the field of TD and its subspecialties, the evolution and the future perspectives. A literature search was conducted in PubMed and Google Scholar. The state of the art of the "tele-dermo research" included TD and clinical trials, TD/TDS web platforms, TDS and artificial intelligence studies. Finally, the future perspective of TD/TDS in the era of social distancing was discussed. Using TD in specific situations adds several benefits including time-effectiveness of intervention and reduction in the waiting time for the first visit, reduced travel-costs, reduced sanitary costs, equalization of access from patient to specialistic consult. The communication technologies devices currently available can adequately support the growing needs of tele-assistance. A main limit is the current lack of a common clear European regulation for practicing TD, encompassing privacy issues and data management. The pandemic lockdown of 2020 has highlighted the importance of performing TD for all those patient, elderly and/or fragile, where the alternative would be no care at all. Many efforts are needed to develop efficient workflows and TD programs to facilitate the interplay among the different TD actors, along with practice guidelines or position statements.

Attitudes and perceived barriers toward store-and-forward teledermatology among primary care providers of the rural Mississippi.

Telehealth expands the capacity to care for patients in rural and underserved settings. Store-and-forward teledermatology is a simple and effective approach which enables remote dermatological diagnosis and treatment. Implementing store-and-forward technology in rural Mississippi has the potential to expand access to dermatology services at locations, where an in-person dermatologist is not available including: emergency rooms, urgent care centers, and primary care practices. A survey study was conducted to assess perceived obstacles and attitudes about store-and-forward teledermatology among primary care providers in Mississippi's rural areas. Most providers are very interested in the telehealth program and the opportunities it provides them to best treat their patients. Key barriers to engagement in teledermatology were (1) primary non-adherence: this is rooted in misconception about teledermatology, the investment in time required to master the technology and establish digital links between primary care provider and consultant; and, (2) secondary non-adherence: this is related to the time required to submit a teledermatology consult which disrupts busy offices. Emphasizing the benefits of teledermatology to primary care physicians and simplification of the teledermatology consult submission process may increase the use of teledermatology in rural Mississippi and serve as a model for other academic teledermatology programs throughout the United States.

Sistematización del programa de Teledermatología de la Universidad de Caldas – departamento de Caldas, 2002- 2010

Introducción: el uso de la teledermatología como herramienta diagnóstica está introduciéndose en la práctica diaria del dermatólogo. Múltiples factores explican el gran potencial que la teledermatología tiene en un país como el nuestro. Al momento, existen pocos estudios publicados acerca del tema y ninguno de ellos describe la aplicación y el impacto que generan los programas de teledermatología en nuestro medio. Materiales y métodos: estudio observacional-retrospectivo, realizado en el programa de Teledermatología de la Universidad de Caldas entre 2002 y 2012. Se describieron las características sociodemográficas, la frecuencia de enfermedades, la concordancia entre los diagnósticos emitidos por el médico general y el dermatólogo, la capacidad resolutiva, los motivos de derivación a la consulta presencial y los problemas para emitir un diagnóstico. Resultados: se analizaron 4333 teleconsultas y 4713 diagnósticos. Los grupos de enfermedades más frecuentes en la teleconsulta fueron las enfermedades inflamatorias (49%), seguidos por las neoplasias benignas (19%). La concordancia diagnóstica fue del 52,4%. La capacidad resolutiva fue del 68,5%. El motivo de derivación más frecuente fue la confirmación diagnóstica. El 2,2% de los casos presentó dificultades en la teleconsulta. El principal motivo fueron los problemas con las imágenes fotográficas. Conclusión: las características sociodemográficas y las enfermedades consultadas presentan una distribución similar a la de otros estudios. La capacidad resolutiva es alta y evita más de la mitad de las derivaciones a la consulta presencial. En pocos casos se tuvieron inconvenientes para realizar la teleconsulta. El grado de concordancia con el diagnóstico del médico general es adecuado.

Impact of Teledermatology Program on Dermatology Resident Experience and Education.

Background: Despite many dermatology residency programs establishing teledermatology programs, few studies have analyzed its impact on resident education. Introduction: We evaluated the University of California, San Francisco School of Medicine teledermatology program at the Zuckerberg San Francisco General Hospital and Trauma Center (ZSFG). We sought to evaluate resident perspectives on teledermatology and quantify its effects on the number of cases evaluated. Materials and Methods: Each week, dermatology residents triage new teledermatology referrals under the supervision of a dermatology attending. We anonymously surveyed dermatology residents and recent graduates who participated in teledermatology and evaluated responses through inductive thematic analysis. We also used administrative records to compare the productivity ratio (cases evaluated per hour) in clinic versus in teledermatology from June to December 2017. Results: Fifteen out of 21 (71%) potential respondents completed the survey. Five primary content areas emerged through the analysis, with teledermatology providing high caseload, a low-stress learning environment, and opportunities to consider a broad differential diagnoses while developing visual diagnostic and triaging skills. Residents had a productivity ratio of 4.55 (680.7 patients/149.7 h) in dermatology clinic versus 11.49 (299.7 patients/26.1 h) in teledermatology sessions. Discussion: Our thematic analysis to identify the most valued components of teledermatology is novel and can aid the design of teledermatology programs in other settings. We also found that residents evaluated twice the number of patient cases per unit time, with the implication that teledermatology can catalyze the development of visual morphology abilities. Conclusions: Teledermatology is viewed positively by dermatology residents and enables efficient case review by residents.

RE‐AIM Framework‐Based Implementation Evaluation of Teledermatology Programs to Serve Rural Veterans

Research ObjectiveIn fiscal year (FY) 2017, the Veterans Affairs (VA) Rural Teledermatology Program was established to enhance access to dermatology services via store‐and‐forward teledermatology, which allows primary care providers to consult with dermatologists to diagnose and manage dermatologic conditions via digital transmission of clinical history and skin images. In addition to specific guidance on expanding teledermatology programs, grantees/teledermatology hub sites were funded to support primary care staff effort and training to manage teledermatology patients and dermatologist effort to review consults.Study DesignMixed‐methods evaluation of the VA Rural Teledermatology Program was based on Glasgow (reach‐effectiveness‐adoption‐implementation‐maintenance) implementation evaluation framework. Data were obtained on the utilization of teledermatology services from the VA Corporate Data Warehouse. 14 grantee facilities completed a site report covering the degree of teledermatology implementation, barriers to and facilitators of teledermatology implementation, and state of program sustainability/maintenance for FY‐2019.Population Studied14 primary hub grantees/facilities supporting 247 additional “spoke” care locations, with 235,544 unique dermatology encounters for Veterans in FY‐2019.Principal FindingsReach: Participating hub and spoke sites had 47 342 teledermatology encounters among 44 774 unique patients in FY‐2019, a 42.4% increase since FY‐2016 (year before program began) (P &lt; 001, chi‐square national level data).Effectiveness: For this program, a measure of effectiveness is the percentage of dermatology encounters occurring through teledermatology. In FY‐2019, 20.1% of dermatology visits at the funded sites were via teledermatology, an increase from 15.1% from FY‐2016. Paired t test showed no significant change (P &lt; .10). Nationally, 10.2% of FY‐2019 dermatology encounters were via teledermatology (8.5% if FY‐2016). Among the patients seen by teledermatology at grantee sites in FY‐2019, 1389 had an associated diagnosis of skin cancer, including 58 melanomas.Adoption: Adoption of teledermatology was assessed utilizing a modification of Stages of Implementation Completion. All 14 grantees report broad implementation of teledermatology within their medical center/health care system, compared to approximate half of grantees at the conclusion of the program’s first year.Implementation: There is generally strong support from key stakeholders. However, the greatest areas of most minor concern related to support form telehealth support staff, clinical application coordinators, and primary care providers. Based on analysis of open‐ended survey questions, sites engaged in a wide variety of strategies to enhance implementation of teledermatology, including outreach to primary care providers, events specifically related to teledermatology, and a variety of training activities. Nevertheless, there is a continuing need at some sites to address staffing issues and collaboration between primary care and dermatology.Maintenance: Based on the Mancini and Marek Program Sustainability Index, there is indication that sites generally report a high degree of potential sustainability for the teledermatology programs. Potential challenges may relate to ensuring stakeholder collaboration, funding, and being prepared to respond to changing program needs.ConclusionsAn overall high degree of implementation and sustainability of teledermatology is reflected in the noted successes of grantees and large number of patients served.Implications for Policy or PracticeAsynchronous tele‐health programs may increase access to specialty care, especially for rural patients. Providing program guidance and initial staffing and training resources can increase the impact of these programs. However, specific efforts aimed at enhancing primary care‐specialty collaboration are needed.Primary Funding SourceDepartment of Veterans Affairs.

Implementing Teledermatology for Rural Veterans: An Evaluation Using the RE-AIM Framework.

Introduction: Few systematic evaluations of implementing teledermatology programs in large health care systems exist. We conducted a longitudinal evaluation of a U.S. Department of Veterans Affairs (VA) initiative to expand asynchronous consultative teledermatology services for rural veterans. Methods: The reach, effectiveness, adoption, implementation, and maintenance framework guided the evaluation, which included analysis of quantitative VA administrative data as well as an online survey completed by participating facilities. The first 2 years of the program were compared with the year before the start of funding. Results: Sixteen hub facilities expanded teledermatology's reach over the 2-year period, increasing the number of referral spoke sites, unique patients served, and teledermatology encounters. Effectiveness was reflected as teledermatology constituted an increasing fraction of dermatology activity and served more remotely located patients. Adoption through defined stages of implementation progressed as facilities engaged in a variety of strategies to enhance teledermatology implementation, and facilitators and barriers were identified. Program maintenance was assessed by Program Sustainability Index scores, which reflected the importance of executive support, and ongoing concerns about staffing and longitudinal funding. Discussion: Enabling hubs to create solutions that best fit their needs and culture likely increased reach and effectiveness. Important facilitators included organizational leadership and encouraging communication between stakeholders before and during the intervention. Conclusions: A systematic analysis of teledermatology implementation to serve rural sites in VA documented a high degree of implementation and sustainability as well as areas for improvement.

Evaluation of Barriers to Telehealth Programs and Dermatological Care for American Indian Individuals in Rural Communities

Understanding geographic and financial barriers to health care is an important step toward creating more accessible health care systems. Yet, the barriers to dermatological care access for American Indian populations in rural areas have not been studied extensively. To evaluate the driving distances and insurance coverage for dermatological care and the current availability of teledermatological programs within the Indian Health Service (IHS) or tribal hospitals system. This mixed-methods study was conducted from May 7, 2018, to September 1, 2018, and did not take place in any IHS or tribal health care facility in the continental United States. The study design involved a geographic analysis and a cross-sectional telephone survey with brick-and-mortar dermatology clinics (n = 27) and teledermatological programs (n = 49). Brick-and-mortar clinics were selected for their proximity to a rural IHS or tribal hospital. Mean driving distance from rural IHS or tribal hospital to nearest dermatology clinic, number of dermatology clinics within a 35-mile or 90-mile radius of IHS or tribal hospitals, insurance and referral types accepted by dermatology clinics, and number of teledermatological programs collaborating with IHS or tribal hospitals or health centers. In total, 27 brick-and-mortar dermatology clinics and 49 teledermatological programs were identified and contacted for the survey. The median (interquartile range [IQR]) driving distance between rural IHS or tribal hospitals and the nearest dermatology clinic was 68 (30-104) miles. Of the 27 dermatology clinics in closest proximity to rural IHS or tribal hospitals (median [IQR] driving distance, 82.4 [31-114] miles), 25 (93%) responded to the survey, 6 (22%) did not accept patients with Medicaid, and 6 (22%) did not accept IHS referrals for patients without insurance. Of the 49 teledermatological programs, 45 (92%) responded and 14 (29%) were no longer active. Ten (20%) teledermatology programs were currently partnering (n = 6), previously partnered (n = 2), or were setting up services (n = 2) with an IHS or tribal site. Only 9% (n = 27) of the 303 rural IHS or facility in the continental United States reported receiving teledermatological services. Substantial geographic and insurance coverage barriers to dermatological care exist for American Indian individuals in rural communities; teledermatological innovations could represent an important step toward minimizing the disparities in dermatological care access and outcomes.

Artificial Intelligence in Teledermatology

This review summarizes current and prospective applications of artificial intelligence (AI) and smartphone technologies to automated diagnosis and teledermatology. Healthcare institutions are rapidly scaling up telehealth programs and embracing long-distance consultation. New developments in deep learning, a type of artificial intelligence, have reached dermatologist-level performance in diagnosing cases of melanoma from lesion images. The smartphone industry projects that next-generation devices and widespread adoption will put deep learning-capable hardware in the hands of consumers everywhere in the coming decade. The expansion in teledermatology programs over the past decade is driven by efforts to lower cost of care, expand access to underserved areas, and improve the monitoring of chronic conditions. Although long-distance diagnosis still underperforms relative to traditional, in-person diagnosis, deep learning technologies have demonstrated the potential to achieve results on par with face-to-face care. Current mobile app diagnosis systems rely on unproven technologies which do not achieve the same standard of accuracy. Over the next few years, research in teledermatology must refine deep learning methods to work with highly variable smartphone images in order to achieve functional long-distance diagnoses.

Use of Teledermatology to Improve Dermatological Access in Rural Areas.

Introduction: Dermatological access in rural regions has been impacted due to an acute, global dermatologist shortage coupled with a striking disparity in dermatologist density between urban and rural areas. As a result, the dermatological arena has been under notable pressure to amplify access. Teledermatology has entailed the use of technology to provide dermatological services to individuals located at a remote distance. The purpose of this literature review was to examine the effect of utilization of teledermatology to determine enhancement of dermatological access to residents of rural areas. Materials and Methods: This review followed a systematic approach and utilized five electronic databases to obtain peer-reviewed journal articles. A PRISMA approach was used and a total of 86 references were employed. Results: Teledermatology programs have been able to complement conventional dermatological care to enhance dermatological access to rural areas that have suffered from a shortage of dermatologists and could aid in supplementing traditional care as well. Within rural settings, the results of three studies in this review indicated the importance of improved quality for diagnostic precision, whereas one study reported that clinical images might not provide sufficient insight to deliver clear-cut diagnoses. In addition, enhancements in diagnostic precision could be obtained by upgrades in phone cameras to capture images. Finally, to most of the existing literature, in using teledermatology, physician satisfaction has been stronger than patient satisfaction. Conclusions: Teledermatology has had a beneficial impact in improving dermatological access to rural areas. The success of this technology is contingent upon the commitment and willingness of the dermatologist in utilizing it.

Teledermatology in the United States: An Update in a Dynamic Era.

Teledermatology is rapidly advancing in the United States. The last comprehensive survey of U.S. teledermatology programs was conducted in 2011. This article provides an update regarding the state of teledermatology programs in the United States. Active programs were identified and surveyed from November 2014 to January 2017. Findings regarding practice settings, consult volumes, payment methods, and delivery modalities were compared to those from the 2011 survey. Findings from the Veterans Affairs (VA) were reported as an aggregate. There were 40 active nongovernmental programs, amounting to a 48% increase and 30% discontinuation rate over five years. Academia remained the most common practice setting (50%). Median annual consultation volume was comparable with 263 consultations, but maximum annual consultation volume increased (range: 20-20,000). The most frequent payment method was self-pay (53%). Store-and-forward continued to be the most common delivery modality. In Fiscal Year 2016, the VA System consisted of 62 consultation sites and performed a total of 101,507 consultations. The limitations of this study were that consult volume and payment methods were not available from all programs. U.S. teledermatology programs have increased in number and annual consultation volume. Academia is the most prevalent practice setting, and self-pay is the dominant accepted payment method. Innovative platforms and the provision of direct-to-patient care are changing the practice of teledermatology.

Teledermatology as a tool to improve access to care for medically underserved populations: A retrospective descriptive study

Teledermatology as a tool to improve access to care for medically underserved populations: A retrospective descriptive study

Teledermatology Within the Veterans Health Administration, 2002-2014.

In order to increase veterans' access to dermatologic care, the Veterans Health Administration (VHA) has developed one of the largest teledermatology programs in the United States. This article describes the recent expansion of the VHA's teledermatology program after local and national initiatives and resource allocation. This report describes routinely collected VHA data. For the first half of fiscal year 2014, the VHA recorded 31,926 teledermatology encounters, which represents 14% of all recorded teledermatology visits. Although every region in the VHA used teledermatology in the past year, four regions created 51% of the encounters. The use of store-and-forward telehealth (SFT), in which physicians view patient images after the patients were photographed, is increasing, whereas live video use is decreasing. Starting in 2012, encounters for patients in urban areas exceeded those in rural areas. The majority of patients were male veterans 60-79 years of age. Seventy-one percent of SFT consultations for the first half of 2014 were completed within 1 week. Although errors in and the evolution of coding encounters may distort results, the data show rapid growth of a telemedicine system that increases access to dermatology services for veterans. Most likely this growth reflects institutional commitment to telehealth via policy and resources.

Reimbursement for teledermatology in the United States: a review

Many individuals do not have adequate access to dermatologic care. Teledermatology stands as a potential method of increasing access to dermatologic care. However, one of the biggest obstacles to the expansion of teledermatology is reimbursement. Policies for reimbursement vary based on the insurer, the state, and even the city. In general, there is a lack of federal funding for teledermatology, but various contained systems—such as the Department of Veterans Affairs, Department of Defense, Department of Corrections, and academic medical centers – have used teledermatology sustainably. Whereas live-interactive teledermatology can often qualify for federal reimbursement, store-and-forward teledermatology (with some exceptions) typically cannot. Over the past decade, the number of active teledermatology programs has significantly decreased, and reimbursement difficulty is most likely a contributing factor. More uniform policies by organizations like Medicaid and private payers would enable a greater expansion of teledermatology services.

Teledermatology as pedagogy: Diagnostic and management concordance between resident and attending dermatologists

We performed a prospective study between January and November 2013 with inclusion of 84 consults encompassing 90 dermatologic conditions. This study received approval from the Philadelphia Field Initiating Group of Human Immunodeficiency Virus Trials, Philadelphia Department of Public Health, and University of Pennsylvania institutional review boards. Verbal informed consent and Health Insurance Portability and Accountability Act authorization were obtained from patients; written informed consent was obtained from providers. Consults were submitted to the University of Pennsylvania by 25 primary care providers at the Jonathan Lax Center, the Dr. Bernett L. Johnson, Jr. Sayre Health Center, and eight Philadelphia Department of Public Health centers using the AccessDerm (Vignet Corporation, Fairfax, VA) mobile platform.4 Diagnoses and management plans, initially drafted by dermatology residents, were reviewed, edited, and submitted by attending dermatologists. Nine residents and nine attending dermatologists responded to consults. For each dermatologic condition, two investigators (CAN, JT) independently determined the concordance of differential diagnoses and management plans between resident and attending dermatologists. Cohen’s κ assessing inter-rater reliability (95% confidence interval) for diagnostic and management concordance between the two investigators were 0.94 (0.91–0.98) and 0.87 (0.78–0.90), respectively. Statistical analyses were performed in Stata 12.1 (StatCorp LP, College Station, TX). Each resident responded to a median (interquartile range) of 9 (4–15) consults. The number of responses stratified by dermatology training year was: 10 (12%) first, 29 (34%) second, and 45 (54%) third year residents. Based on the leading diagnosis of the attending dermatologist or definitive diagnosis when available, dermatologic conditions were classified into the following categories: 24 (27%) eczematous conditions, 13 (14%) infectious diseases, 7 (8%) benign tumors or proliferations, 6 (7%) papulosquamous conditions, 5 (6%) pigmented disorders, 4 (4%) acneiform or follicular occlusion disorders, 4 (4%) premalignant or malignant lesions, 23 (26%) other, and 4 (4%) indeterminate. Diagnoses and management plans between resident and attending dermatologists were fully concordant for 53% and 65% of dermatologic conditions, respectively (Figure 1). Table I categorizes the changes made by attending dermatologists for those conditions with at least partial management discordance (adapted from Lamel et al5). Most changes were consistent with recommendation for education or observation (53%) and medication initiation or discontinuation (50%). Recommendation for in-person evaluation was concordant in 93% of consults. Figure 1 Diagnostic and management concordance between resident and attending dermatologists. Table I Categories of change in management With the development of sustainable teledermatology programs, it is important for dermatologists to become familiar with the strengths and limitations of this practice model. Our data revealed at least partial diagnostic and management discordance between resident and attending dermatologists for 47% and 35% of dermatologic conditions, respectively. Although limited by small sample size, this study suggests that teledermatology provides residents an opportunity for practice-based learning. Further research is required to evaluate educational outcome measures.

Primary care providers' perceptions of mobile store-and-forward teledermatology

Although teledermatology offers promise as a tool to increase access to care, adoption has been limited. Understanding the perspectives and experiences of key stakeholders, such as primary care providers (PCPs) and patients, is important to identify opportunities to reduce barriers to adoption and to improve teledermatology programs. Although many studies have examined patients' experiences and satisfaction with teledermatology, few have examined referring PCPs' perspectives. To identify PCPs' perceptions on the strengths and limitations of teledermatology in order to identify opportunities to improve teledermatology programs. We distributed an anonymous, web-based survey to 30 PCPs involved in a two-year study evaluating a mobile app-based teledermatology platform. 100% (18/18) agreed or strongly agreed that teledermatology increases access to dermatologic care, improves patient care, and is acceptable to patients. 100% (18/18) agreed or strongly agreed that teledermatology provides educational benefit to the PCP. Only 6% (1/18) agreed that teledermatology increases medical liability and 11% (2/18) agreed that it increases risk of a breach in privacy or confidentiality. Our findings highlight that PCPs are highly satisfied with mobile app-based, store-and-forward teledermatology and that they believe teledermatology offers synergistic educational benefit. We hope these results will help guide the development of teledermatology programs to increase access to timely, cost-effective care.

State of teledermatology programs in the United States

Teledermatology programs in the United States have evolved over the past several decades. No systematic survey of teledermatology programs in the United States is available in peer-reviewed literature. To provide up-to-date information regarding the state of teledermatology programs in the United States. Active U.S. teledermatology programs were surveyed in 2011 with regards to practice models, clinical volume, and payment methods. These findings were compared with those from 2003. By January 2012, 37 teledermatology programs were active in the United States. Store-and-forward teledermatology was the most frequent delivery modality offered by 30 (81%) of the programs. The majority of the programs were based at academic institutions (49%), followed by Veterans Administration hospitals (27%), private practice (16%), and health maintenance organizations (HMOs) (8%). The majority of programs (67%) provided services to their home state only, whereas the rest also served additional U.S. states or abroad. The median number of consultations per program was 309 (range, 5-6500) in 2011. The most frequent payer sources were private payers, followed by self-pay, Medicaid, Medicare, and HMOs. Since 2003, with the confirmed discontinuation of 24 previously active programs, the total number of active teledermatology programs in 2011 was 60% of that in 2003. However, the annual consult volume per program nearly doubled for the sustainable programs in 2011. Itemized billing information was not uniformly available from all programs. The turnover in teledermatology programs is relatively constant, with an increase in consult volume for sustainable programs. Store-and-forward is the dominant modality of delivery, while hybrid technology model is emerging.