Teledermatology Referrals Research Articles

Improving patient satisfaction with communication in teledermatology referrals

Improving patient satisfaction with communication in teledermatology referrals

Effectiveness and diagnostic accuracy of teledermatology for the assessment of skin conditions.

Teledermatology provides a platform for swift specialist advice without the potential need for face-to-face review. Our objectives were to investigate the effectiveness, accuracy and diagnostic concordance of the platform with regard to the remote management of skin conditions. We undertook a single-centre, retrospective chart review over a 1-year period, comprising a total of 1703 teledermatology referrals. Two physicians independently assessed the diagnostic concordance between telederm diagnosis (TD), in-person diagnosis (ID) and histopathological diagnosis (HD). There were a total of 1703 TD referrals, of which 341 were rejected, leaving 1362 referrals for evaluation. Sixty-five per cent of these referrals were managed remotely and discharged with advice, although 4.6% of these were later re-referred for an in-person review. A total of 20% of referrals were rejected, of which the majority was due to a lack of appropriate imaging. The total concordance of TD compared to ID was 76.4%. When comparing the TD and ID/HD, we obtained a Kappa value of 0.636 indicating substantial agreement. In terms of accuracy, there were 49 biopsy-proven skin cancers picked up by the service in this cohort of data. Of these, 61.2% were given an accurate diagnosis on first impression via teledermatology, 14.3% were given a different diagnosis but correctly categorised as skin cancer and 24.5% could not be assessed; however, they were triaged and escalated based upon clinical suspicion. Our study demonstrates that teledermatology is an effective platform in terms of diagnosis and remote management, with adequate diagnostic accuracy and concordance to in-person diagnosis.

Teledermatology in an emergency department: benefits and gaps

BackgroundTeledermatology has provided new avenues through which dermatologists can provide healthcare. Teledermatology was introduced to the Emergency Department (ED) to enable immediate dermatological consult. We aimed to assess the impact of teledermatology on the management of dermatological conditions by emergency medicine physicians and subsequent health resource utilization.MethodsWe conducted a retrospective review of teledermatology referrals from the ED of our tertiary hospital in Singapore from June 2015 to December 2019. The dermatological conditions, the triaging and treatment recommendations were analyzed. Follow-up plans were recorded.ResultsBetween June 2015 and December 2019, 147 patients were referred from the ED via teledermatology; 11 (7.5%) were admitted, and 136 (92.5%) were recommended to be discharged with a dermatological diagnosis and management plan. If required, a follow-up appointment in the dermatology specialist clinic was arranged. Of the 136 patients who were discharged, 129 (94.9%) patients were provided with outpatient appointment in the dermatology clinic, out of which 110 patients returned for follow-up. 90 (81.8%) patients retained the initial teledermatology diagnoses and 20 (18.2%) patients had their teledermatology diagnoses revised after in-person review.ConclusionsTeledermatology allows for more efficient triaging of patients with dermatological conditions. Reliability between teledermatology and clinic-based examination is good. Patients may be managed mainly in the outpatient setting with appropriate specialty-directed treatment, return advice, and appropriately-triaged follow-up outpatient appointment.

BT22 The concordance between dermatology doctors in their approach to teledermatology referrals

Abstract Telemedicine is an innovative, rapidly evolving method of care delivery in the National Health Service. The main long-term benefit of teledermatology triage is to ensure that patients receive timely care in the most appropriate setting, and to increase capacity in secondary care for patients who need face-to-face referrals. However, the diagnosis made and the advice given may vary depending on the experience and knowledge of the person triaging. The aim of this study was to evaluate how the interpretation of the information/images by different clinicians can affect the outcome of a teledermatology referral. The data collected in this project are expected to provide knowledge about the concordance between dermatology doctors in their approach to teledermatology referrals and to evaluate the impact on quality of care. The teledermatology service referrals to our dermatology department are made through the national electronic Referral Service, with the option to attach images or to refer patients to an image-taking clinic based at the hospital. Dermatology consultants will then review referrals virtually, relaying advice back to the referrer. We provided a mixture of 10 teledermatology referrals who had attended the image-taking clinic to dermatology consultants and dermatology trainees. The dermatology doctors were asked to complete an outcome template for each referral based on the information/images provided. The study was completed by nine consultants and four trainees. Only three consultants (33%) and no trainees had previous experience of the teledermatology service. The respondents evaluated the clinical information provided in the referrals as good (41%), satisfactory (47%) and poor (12%). The clinicians evaluated the quality of images taken following the referral as good (68%), satisfactory (28%) and poor (4%). Overall, 90% of the consultants and 72% of the trainees agreed with the final diagnosis/outcome of the teledermatology referral. The benign skin lesions had the least consistency between the clinicians in terms of the diagnosis and type of the follow-up arranged. The follow-ups arranged after a referral included routine referral to clinic (consultants 30%, trainees 32%), urgent referral to clinic (consultants 25%, trainees 40%), referral to clinic if not improved (consultants 21%, trainees 17%) and discharge (consultants 23%, trainees 10%). In conclusion, there was satisfactory concordance between clinicians in responding to the majority of the teledermatology referrals. Trainees have shown to agree with the final diagnosis in the majority of cases; however, they still need more training in this area, particularly on how to gain confidence in arranging an appropriate follow-up plan after the advice given.

Impact of dermoscopy-aided pediatric teledermatology program on the accessibility and efficiency of dermatology care at community health centers

Background There are few studies focusing on pediatric teledermatology, and the impact of a large-scale pediatric teledermatology program on the accessibility and efficiency of dermatology care remains unclear. This study evaluated the impact of a state-wide implementation of a store-and-forward teledermatology program augmented by the incorporation of dermoscopy in pediatric patients visiting community health centers. Methods It was a descriptive, retrospective cohort study of 876 pediatric dermatology referrals. Results In the traditional referral system, only 60 patients (17.6%) were seen by dermatologists with average waiting times of 75 days due to limited access. In comparison, with an implementation of dermoscopy-aided teledermatology, all 536 teledermatology referrals received dermatological care within 24 h, of which only 64 (12%) patients requires face-to-face (F2F) consultation. Patients referred for F2F consultation via eConsults had a much lower no-show rate as compared to the traditional referral system (39% vs. 71%). Side by side comparison between general population and pediatric population has demonstrated shared features in efficiency and access improvement but revealed specific characteristics of pediatric teledermatology in terms of diagnosis and treatment. Conclusion Coordinated store-and-forward teledermatology platform with incorporation of dermoscopy between large community care network and dermatology provider can greatly improve access to pediatric dermatology care especially in underserved population. The efficiency of teledermatology in access improvement for pediatric population is comparable with adult population in eConsults. There are also unique features and challenges in pediatric teledermatology that require further research.

Inpatient Teledermatology Referrals During the COVID-19 Pandemic in a UK Trust: A Comparative Review and Doctor Survey

Background The COVID-19 pandemic has broadened the scope of teledermatology services in the United Kingdom from a primarily outpatient-based triage tool to the management of inpatient referrals. In order to reduce the risk of transmission in hospital, a number of changes were implemented within our department. As part of this, our on-call referrals were transferred to a telemedicine app, which incorporates the secure transfer of user-generated patient images onto a web-based image management system providing remote access for the dermatology team. Objective This study aimed to compare how the introduction of this referral method impacted the nature and number of referrals received, the efficiency of the on-call service, and user preferences. Methods A retrospective cohort study was conducted to compare the number of referrals, time taken to review, and referral diagnoses between previous referral methods to the dermatology department (bleep, fax, email) (July and September 2019) and the new teledermatology app (July and September 2020). We also performed a survey of junior doctors, seeking their feedback and preferences pertaining to the new referral system. Results The number of referrals increased by 80%, with a 6-fold increase in lesion referrals. There is a possibility that not all referrals from 2019 were accounted for as paper documents are easily lost or discarded, highlighting another advantage of teledermatology in providing a reliable record of referrals. Dermatology referrals may have increased as the telemedicine app is more accessible to staff across sites. The telemedicine app also led to a reduction in time to review by 0.53 days, resulting in a significantly higher number of patients being given dermatology input on the day of the referral (78% vs 58%). This will have led to earlier treatment, improved patient outcomes, and shorter inpatient stays, resulting in potential cost reductions for the hospital. The survey of junior doctors showed that 81% preferred teledermatology to the previous referral methods. Conclusions The introduction of teledermatology has provided an effective and acceptable method of managing on-call dermatology referrals. Easier access to dermatology advice via teledermatology may result in higher numbers of referrals, which may warrant strict referral criteria to prevent oversubscription of the on-call service. Teledermatology ensures an accurate log of referrals, including the nature of referrals, allowing for better auditing and service improvement. Teledermatology referrals allow for advice to be provided within shorter time frames compared to previous methods. This should improve patient outcomes and reduce hospital admission stays, potentially resulting in cost savings for the hospital. Conflict of Interest None declared.

Clinical outcomes and operational impact of a medical photography based teledermatology service with over 8,000 patients in the UK

A new, store-and-forward, fully digitised Teledermatology (TD) pathway was designed and implemented in an urban setting for non-two-week wait routine patients. In total 8,352 new patients had a TD consultation over 37 months. Of these, 4,748 (56.8%) were referred back to their GP, 1,634 (19.6%) were referred directly for a surgical procedure and 1,970 (23.6%) for a face-to-face review with a Dermatologist (F2F). The average waiting time for a TD appointment was 3 vs. 30 weeks for a routine F2F appointment. Between 2019 and 2018, TD referrals rose by 38%, routine dermatology referrals reduced by 16% and cancer referrals increased by 6%. Using medical photographers proved to be effective with only two cases (0.02%) of images being of insufficient quality to form a clinical opinion. Hitherto, savings for the local Commissioning Groups were estimated at £671,218. Last financial year savings (2019–2020) were £284,671. The average cost savings per TD patient appointment was £80.36. Savings in the Trust’s overhead costs were £53,587. TD consultants reviewed almost twice the number of patients vs. F2F for the same amount of consultant programmed activities. 95% of surveyed patients would be likely or extremely likely to recommend this service to friends and family.

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.

A UK-wide survey looking at teaching and trainee confidence in teledermatology: a vital gap in a COVID-19-induced era of rapid digital transformation?

SummaryTeledermatology has had an explosive impact on the provision of dermatology services in recent times, and even more so with the unprecedented situation created by the COVID‐19 pandemic. Although teledermatology is not presently a feature of the Joint Royal Colleges of Physicians Training Board (JRCPTB) curriculum for dermatology training, this is due to change imminently. Specialty trainees need training in this area to be able to confidently and competently meet the demands of the changing face of dermatology services. We surveyed dermatology registrars in training across the UK, prior to the outbreak of COVID‐19, to ascertain the teledermatology teaching available and trainee confidence in this area. Our survey found that only 15% of respondents felt slightly confident in their ability to deal with teledermatology referrals and almost all (96%) felt more teaching was needed.

Impact of standardized templates and skin cancer learning modules for teledermatology consultations.

Little research has been done in teledermatology to examine the effects of standardized templates and subject-specific learning modules. We performed a prospective study examining the effects of standardized templates and standardized cutaneous oncology learning modules on teledermatology referrals at Mayo Clinic. This data was then compared to previous teledermatology referrals before standardized templates were adopted. A total of 42 teledermatology consultations were performed during the 4-month study period. The use of standardized templates resulted in an absolute reduction in face-to-face referrals. Teledermatology consultation increased the absolute diagnostic and management concordance by 26.2% (P = 0.02) and 33.3% (P < 0.01), respectively, and decreased the absolute diagnostic and management discordance by 19.1% (P = 0.03) and 31.0% (P < 0.01), respectively. The largest knowledge gaps were identified in cutaneous oncology. Educational intervention improved theoretical referral rates and confidence in diagnosis and management overall. The implementation of standardized intake templates reduces the rate of face-to-face referrals. Teledermatology improves primary care-based dermatological care and reduces theoretical referral rates.

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

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. 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. 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. Referrals were managed using store-and-forward teledermatology or a conventional text-based referral process. 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. 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). 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. clinicaltrials.gov Identifier: NCT00488293.

Evaluation of Skin Cancer in Northern California Kaiser Permanente's Store-and-Forward Teledermatology Referral Program

To determine whether teledermatology referrals yield a shorter time to biopsy of the most common types of skin cancer versus conventional dermatology referrals. A retrospective chart review was performed of California's Central Valley Kaiser Permanente conventional dermatology or teledermatology referrals that yielded a positive skin cancer biopsy over a 7-month period. Four primary care clinics at Kaiser Permanente's Stockton Medical Center in California's Central Valley were included. Patients who were studied were treated for squamous cell carcinoma of skin, basal cell carcinoma of skin, and malignant melanoma. We compared the time interval between initial evaluation and biopsy of the most common types of skin cancer for teledermatology versus traditional referrals from primary care. Our study criteria were met by 293 patient cases (58% conventional referrals and 42% teledermatology referrals). The mean time to biopsy of skin cancer was 13.8 days for conventional referrals (median, 12.0 days) versus a mean of 9.7 days (median, 9.0 days) for teledermatology referrals (p<0.0001). The use of teledermatology in remote areas results in a shorter time to biopsy than traditional referral methods as a result of improved triaging measures.

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.

Teledermatology Operational Considerations, Challenges, and Benefits: The Referring Providers' Perspective

Teledermatology has been used to provide increased specialty access for medically underserved communities. In California, policies enable the California Medicaid (Medi-Cal) program to provide reimbursement for both store-and-forward (S&F) and live-interactive teledermatology consultations. To assess the effectiveness of teledermatology operations for this population, understanding the referring providers' perspective is crucial. The primary objective of this study was to explore the perspective of referring primary care providers (PCPs) on teledermatology by focusing on the operational considerations, challenges, and benefits to participating in teledermatology referral in the context of the Medi-Cal population. We conducted hour-long one-on-one interviews with 10 PCPs who refer patients to teledermatology regularly and who together serve an average aggregate referral base of 2,760 teledermatology cases yearly. Of the 2,760 aggregate annual teledermatology referrals, PCPs reported that they serve predominantly uninsured or underinsured populations and participate in S&F consultations. The majority of surveyed PCPs treat common skin conditions themselves. However, these PCPs refer more patients to teledermatology consultations than in-person dermatology encounters. Several factors influence PCPs' decision to refer to teledermatology, which include complexity of the skin problem, distance to accessible dermatologist, patient's insurance, and patient's preferences. PCPs identified improved workflow, enhanced communication with dermatologists, and faster turnaround for recommendations as three areas that referring physicians would like improved in their experience with teledermatology. Understanding the referring provider's perspective and subsequently adopting policy and practice solutions to address their challenges are vital to prompting further teledermatology participation for underserved communities.

Use of the mobile phone multimedia messaging service for teledermatology

We examined the feasibility of using mobile phone Multimedia Messaging Service (MMS) to send teledermatology referrals from a general practitioner to a dermatologist. Digital photographs of skin conditions in 40 consecutive patients were sent together with relevant clinical information to dermatologists at a university hospital. Two dermatologists separately assessed the MMS referrals. The suspected diagnosis, triage and management decisions were compared to those given after separate face-to-face (FTF) visits, and again after agreeing on a final clinical and/or histopathological diagnosis. Thirty-two patients (80%) were diagnosed with skin tumours and 8 patients (20%) with other skin conditions. Both dermatologists were able to make a correct diagnosis in 31 patients (78%) based solely on the MMS referral. They also provided adequate management recommendations for 98% of the patients. Adequate triage decisions after assessment of the MMS referrals were made for 34 (85%) and 38 (95%) patients by the two dermatologists. There was an inter-observer concordance of 68% for the teledermatology diagnosis, compared to 88% concordance after the separate FTF visits. The diagnostic accuracy and adequacy of the triage and management decisions achieved using MMS referrals were similar to those obtained with other store-and-forward teledermatology methods.

Evaluation and Comparison of Store-and-Forward Teledermatology Applications

Store-and-forward (S&F) teledermatology has been used to increase patient access to dermatologic care. A major challenge to implementing S&F teledermatology is selecting secure and cost-saving applications for data capture and transmission. Detailed analyses and comparison of the major S&F teledermatology applications do not exist in the current peer-reviewed literature. The objectives of this study were to identify, evaluate, and compare the major S&F teledermatology applications in the United States to help referral and consultant sites select applications responsive to their needs. We identified four major, commercially available S&F teledermatology applications after surveying the members of the American Telemedicine Association Teledermatology Special Interest Group and the Telemedicine Task Force of the American Academy of Dermatology. A multidisciplinary team of dermatologists, primary care physicians, and information technologists established a set of criteria used to evaluate the applications. We performed a comparative analysis of the four major S&F teledermatology applications based on the predetermined evaluation criteria. The four major, commercially available S&F teledermatology applications evaluated in this study were Alaska Federal Health Care Access Network, Medweb, TeleDerm Solutions, and Second Opinion. All four teledermatology applications were mature and capable of addressing the basic needs of S&F teledermatology referrals and consultations. Each application adopts different approaches to organize medical information and facilitate consultations. Areas in need of improvement common to these major applications include (1) increased compatibility and integration with established electronic medical record systems, (2) development of fully integrated billing capability, (3) simplifying user interface and allowing user-designed templates to communicate recommendations and patient education, and (4) reducing the cost of the applications. The four major S&F teledermatology applications in the United States are versatile applications capable of facilitating communication between referral and consultant sites. Continued efforts in making these applications more secure, robust, user-friendly, and affordable will contribute to wider implementation of S&F teledermatology.

Economic evaluation of a store-and-forward teledermatology system for skin cancer patients

We conducted an economic analysis of a store-and-forward teledermatology system for the routine triage of skin cancer patients. A cost-identification, cost-effectiveness and sensitivity analysis under a societal perspective was used to compare teledermatology with the conventional care alternative. In the period March 2004 to July 2005, a total of 2009 teledermatology referrals were managed from 12 Primary Care Centres (PCCs) of the public health system. The unit cost was of Euro 79.78 per patient in teledermatology, and Euro 129.37 per patient in conventional care (P < 0.005), with an incremental cost of Euro 49.59 per patient in favour of teledermatology. The cost ratio between teledermatology and conventional care was 1.6. There was a significant inverse relation between the unit cost in each participating PCC and the number of teleconsultations transmitted from them (P < 0.001). Teledermatology resulted in a more cost-effective, or dominant, methodology. In a public health system equipped with an intranet, the routine use of teledermatology in skin cancer clinics is a cost-effective method of managing referrals.

The impact of store-and-forward teledermatology on skin cancer diagnosis and treatment

Although the diagnostic accuracy of teledermatology has been extensively studied, the clinical outcomes associated with teledermatology are still unclear. We examined the time intervals in which skin cancer patients referred conventionally or by store-and-forward teledermatology were evaluated, diagnosed, and treated. A chart review was performed of all patients who had been treated for skin cancer in a Veterans Affairs medical center's dermatologic surgery clinics as a result of a conventional dermatology or teledermatology referral from 3 remote primary care clinics over a 4.5 year period. One hundred sixty-nine patient cases met the study criteria (45.6% conventional referrals, 54.4% teledermatology referrals). For conventional and teledermatology referrals, respectively, the overall mean time intervals for initial consult completion were 48 and 4 days (p < .0001), for biopsy were 57 and 38 days (p = .034), and for surgery were 125 and 104 days (p = .006). Teledermatology consults were also associated with fewer dermatology clinic visits before surgery (p = .02). This was a retrospective study conducted on a Veterans Affairs healthcare system and a specific skin cancer patient population, which may not be directly comparable to other organizations. Clinical outcomes in skin cancer management via teledermatology, as measured by times to diagnosis and to surgical treatment, can be comparable to, if not better than, management by conventional referrals for remotely located patients.

An evaluation of the role of a store-and-forward teledermatology system in skin cancer diagnosis and management

There is currently much interest in the potential role of telemedicine in improving the delivery of dermatological care in the UK. The two teledermatology systems available at present are divided into live video and store-and-forward technology. We investigated the value of a store-and-forward teledermatology system in the diagnosis and management of lesions suspicious of skin cancer. A total of 163 store-and-forward referrals of patients with one lesion each were assessed independently by a Consultant and a third-year trainee dermatologist. The accuracy of diagnosis and appropriateness of management from these assessments was compared to a subsequent face-to-face consultation with the Consultant. Analysis of the Consultants' diagnoses showed that 48% were identical for teledermatology and conventional face-to-face consultations. A further 17% of teledermatology diagnoses included the actual clinical diagnosis as a possibility but 20% were either incorrect or a diagnosis could not be made. In the remaining 15% of cases the digital image was of insufficient quality for assessment. Of the trainee's reports, 44% were identical to the clinical diagnoses and another 20% included the clinical diagnosis as a possibility. The management plan was appropriate in 55% of the total teledermatology referrals assessed by the Consultants and in 52% assessed by the trainee when compared with the conventional consultation. This study illustrates that the store-and forward type telemedicine system has limited diagnostic accuracy for skin lesions. However, our results suggest that store-and-forward teledermatology may be suitable and safe for screening out clearly benign lesions but the study casts doubt on its efficiency.

Asynchronous Teledermatology in an Urban Primary Care Practice

This study evaluated the accuracy, access time, cost, and acceptance by patients and physicians of asynchronous teledermatology referrals in an urban primary care practice. Primary care physicians in a multi-specialty group referred patients for a teledermatology consult. Same-day history and digital images taken by a nurse were electronically sent to a dermatologist who rendered a diagnosis to the physician. Fifty-two patients completed the study. History was adequate for diagnosis in 81% of cases; images were adequate in 75% of cases. Accuracy of the teledermatology diagnosis in cases with adequate images was 97%; accuracy for all cases was 92%. A dermatology visit was recommended in 26% of cases with adequate images, and 42% of all cases. Access time for a teledermatology opinion was 1.9 days versus 52 days for a regular dermatology appointment. Patient and referring physician were highly in favor of teledermatology. Cost evaluations for 20% of patients suggested the cost of a remote consult to be significantly less than the cost of performing an in-person referral. Asynchronous teledermatology may serve as a valuable tool for triage of dermatology referrals and possibly for delivering care to more patients than in urban areas. It can decrease waiting time for a dermatology diagnosis. In an urban multi-specialty clinic-based primary care practice, results suggest the cost of a teledermatology consult is less than that of an in-person service.