Teledermatology Today

• Abstract
• Introduction
• Interactive Clinical Teledermatology
• Store and Forward Teledermatology
• Successes of Teledermatology
• Reported Failures
• Satisfaction with Teledermatology
• Standards and Guidelines
• Outcomes and Economic Value
• Conclusion
• Acknowledgements
• References

Abstract
Teledermatology is one of the most popular applications for telemedicine and can be delivered via videoconference, web sites and email. It can involve synchronous and/or asynchronous interaction between dermatologists, primary care physicians and other health professionals, students and patients wherever they are located. Expert teledermoscopy allows early diagnosis of malignant melanoma. However successful teledermatology requires a simple interface, rapid communication systems and trained users.

Despite good intentions, ad hoc services in telemedicine fail because of lack of sustainable funding, poor quality equipment or lack of need. Technical and clinical protocols and standards for telemedicine are still evolving. However, teledermatology is expected to have an increasing role in patient care as secure broadband communication systems become widely distributed in health services.

Introduction
Telemedicine is the practice of medicine at a distance using technological aids such as computers and telecommunications systems. It is a component of e-health, ie, health care that uses information and communication technology (ICT). Ten years ago, there was little published about telemedicine in the peer-reviewed literature. The last decade has seen a rapid growth in numbers of articles on the subject and the emergence of two specialist, peer reviewed, scientific journals ("Journal of Telemedicine and Telecare" and "Telemedicine Journal"). A Medline search in February 2005 using the keyword "teledermatology" revealed 145 papers originating from many different parts of the world.

Dermatology has been part of telemedicine activities since the 1970s. "Teledermatology" refers to diagnosis and treatment services provided by moving patient information rather than the patient. It offers improved access to specialist care for rural, disabled or institutionalised patients with skin diseases. Potential uses include a supporting role for primary care, more accurate triage of dermatology referrals or "advice only" service reducing the need for dermatology patients to attend outpatient clinics. The specialty relies on history and examination to make a diagnosis, with investigations playing a minor part. Given comprehensive patient information and clear images, the dermatologist can often make a diagnosis at a distance and instruct the local doctor how to care for the patient. A variety of individuals can initiate teledermatology consultations in numerous settings.

"Teledermatopathology" is a telemedicine application relating to histological diagnosis of cutaneous specimens for training, supervision, second opinions, research or general interest. "Teledermoscopy" uses digital images of skin surface microscopy to enhance diagnosis of pigmented skin tumours.

Synchronous teledermatology services are interactive in real time using video conferencing and/or telephony. "Store-and-forward" systems enable data to be acquired at one site, stored on a computer, and then transmitted to another location where it may be stored again before review. They are becoming more popular as they are less expensive and more convenient. Consultations of this type are considered asynchronous since the images are obtained, sent and reviewed at different times. They usually depend on a secure website, electronic mail or picture messaging.

Interactive Teledermatology
Interactive or synchronous consultations are generally undertaken using 2-way videoconference equipment. "POTS" (Plain Old Telephone System),^{[ 1 ]} cellular phones^{[ 2 ]} and Internet telephony^{[ 3 ]} can be used but the main concern in dermatology is low-resolution images. The higher the bandwidth, the easier it is to evaluate a skin condition and converse. Higher communication link bandwidth allows higher resolution images to be transmitted at a faster rate. The higher the resolution of the images, the easier it is to evaluate a skin condition.

The American Academy of Dermatology’s Position Statement on Telemedicine recommends a connection speed of 384 kbps (using ISDN) and a minimum resolution of 800x600 pixels for diagnostic images, but lower speeds can be successful for selected patients providing there is access to freeze-frame or captured still images.^{[ 4-5 ]}

Using the Internet cuts telecommunication call costs. Desktop videoconferencing systems using Virtual Private Networks over the Internet are already in use. It is anticipated that much higher and inexpensive bandwidth will be available to the health sector within the next few years.

A typical teledermatology clinic involves the diagnosing dermatologist in a clinic room or videoconferencing facility at the base hospital with referral and clinic notes and the patient at a medical centre or small hospital accompanied by a health professional. The dermatologist will consult with the patient and attempt to examine their skin via the television monitor, possibly using close-up and/or dermoscopy cameras; good lighting and a plain background are critical and the patient must remain very still. The condition and recommended treatment are discussed and a prescription and patient information may be provided to the patient by fax or mail. A proportion of patients will be given telemedicine follow-up or follow-up appointments at the base hospital for investigations (patch tests, biopsies), procedures (excisions, electrosurgery, laser treatment) or definitive diagnosis.

Consultations take about the same time or longer than a standard outpatient consultation and are quite suitable for adult patients with common inflammatory dermatoses such as acne, dermatitis or psoriasis. Conversations with deaf individuals can be more difficult than usual because the deaf person cannot see enough detail in lip movements and must depend on an interpreter.

It can be difficult to confidently diagnose skin complaints when subtle visible signs normally obtained by palpation are missing. Examining young children might not be possible because of the need for them to keep still. It is not wise to diagnose very small lesions or pigmented lesions that might be melanoma without very high-resolution still images and dermoscopy.

Telecommunication and equipment failures can be frustrating and can result in cancelled clinics. A skilled technician is not always immediately at hand to identify and correct the problem. However, equipment is becoming more reliable and easy to use.

Videoconferencing may also be used by dermatologists to present cases to their colleagues or to teach students. PowerPoint presentations and still images can be shown on a second screen, forwarded prior to the meeting or synchronously (depending on available technology). This is a convenient way to deliver a talk to an international conference or to attend a Grand Round being held at a regional centre.

Store-and-Forward Teledermatology
"Store-and-forward teledermatology’ is becoming established as a routine service in many regions internationally. It accounts for 99% of all teledermatology consultations according to the American Telemedicine Providers.^{[ 6 ]} Consultations may be web-based or via email. Images may also be provided by Polaroid,^{[ 7 ]} print photograph or on portable media (floppy disk or CD-ROM). Audio telephone calls may enhance the service. Doctors and patients in some urban, as well as rural or institutional, settings are finding teledermatology convenient and time-effective.

A dermatologist is likely to ask to see a patient face-to-face if they have been provided with poor images and/or an inadequate written referral. Unfortunately, the primary care physician or GP often has little experience of dermatology. Despite seeing many patients with skin conditions (up to 30% of a GP’s workload), few of these are referred to a dermatologist. It is important that, as with all clinical consultations, the relevant history be provided in as much detail as possible, and that images be of as high a quality as possible.

Training and protocols improve the quality of telemedicine consultations and may facilitate the direct interaction of the patient with the expert.^{[ 19 ]} This is not always practical; another solution is for patients to attend specific nurse or "consult manager" clinics. Information is collected by experienced health professionals who take high quality and appropriate images and complete electronic templates designed to capture all required data about melanocytic naevi (mole mapping), skin lesions, fungal infections, acne or general skin complaints. High quality images of the affected region, close-ups of the lesion(s) and dermoscopic images can be stored and transmitted to an expert dermatologist for diagnosis. The dermatologist refers the patient back to their GP for management, which may include a face-to-face appointment with a specialist for investigation, procedure or definitive diagnosis. "Store-and-forward" consultations may be enhanced by a phone call or videoconference for clarification or to discuss management options. Reportedly, accuracy of diagnosis by this method can equal that of face-to-face consultations, with up to 95% diagnostic concordance in selected cases.^{[ 8 ]}

Email is now a widely available, cheap, simple and convenient tool although the lack of security of regular email makes it unsuitable for the transfer of identifiable personalised medical information. There are numerous unaudited and informal dermatology email consultations every day. However, there is great concern among dermatologists that their overloaded in-boxes include incessant demands from their own patients and desperate strangers. Providing advice to overseas patients and prescribing to patients that have not had a face-to-face consultation may contravene practice regulations, such as outlined in the Medical Council of New Zealand’s Statement on the use of the Internet.^{[ 9 ]} Large inappropriate files can block their electronic communication systems. The Internet is basically insecure and unsuitable for the transfer of personal medical information but virtual private networks, such as the New Zealand Health Intranet, may allow safe communication.

On the other hand, email is a popular way for dermatologists in sole practice to gain second opinions and share their interesting cases. It is important to recognise, however, that the number of email messages sent by list services such as rxderm-l, a subscription email discussion group for dermatologists, can be overwhelming.^{[ 10 ]} In addition, more formal case histories and images may be uploaded to one of several local or international case-discussion web sites, such as Virtual Grand Rounds in Dermatology, telederm.org or DermConsult. Moderated and un-moderated threaded discussions can aid patient management and continuing professional development.

Successes of Teledermatology
Several studies have proved the inadequacy of GPs^[11] and emergency physicians^{[ 12 ]} to accurately diagnose common dermatological diseases.^{[ 13 ]} This is of particular concern for melanoma as late diagnosis can be life threatening.^{[ 14-15 ]} A significant percentage of a GP’s workload is dermatological but their ability to manage these patients is very variable.

Diagnostic accuracy studies have, in general, found teledermatological diagnosis to be reliable, ranging from 40% to 100% concordance with face-to-face diagnosis.^{[16 ]} A variety of systems have been described. Diagnostic accuracy may be greater for video-conferencing than for store-and-forward systems. Accuracy is dependent on the quality of the referral data^{[ 17 ]} and the technological experience of the dermatologist.^{[18 ]} Successful store-and-forward systems usually rely on experienced "consult managers" to complete templates and take high quality and appropriate images.

Teledermatology referral may result in earlier definitive intervention and avoid the need for a visit to the dermatology clinic. Thus, patients save time and money by not having to travel to specialist consultations. There may be a reduction in the number of patients requiring urgent face-to-face appointments. However, teledermatology clinics may become so popular that they too generate long waiting lists.^{[ 19 ]}

Teledermoscopy, which uses digital images of skin surface microscopy to enhance diagnosis of pigmented skin tumours, may have advantages over a face-to-face skin examination, because a still image on a computer is more convenient to view than live dermoscopy and can easily be compared with previously stored images to detect subtle changes. The virtual Consensus Net Meeting on Dermoscopy took place in 2000. This international collaboration aimed to standardise dermoscopic terminology and validated telediagnosis of pigmented skin lesions.^{[ 20 ]}

MoleMap NZ^{[ a ]} has been using teledermoscopy to evaluate skin lesions in patients at risk of skin cancer for several years. The patient is expected to return annually for re-scanning to detect change, and the system depends on the experience of the melanographer to scan the appropriate lesions. The company reported an average of 1,000 consultations each month during 2004 and a relatively low false positive rate of detection of melanoma (data on file; figure 1 shows the MoleMap NZ reporting screen).

Figure 1: MoleMap NZ reporting screen

Telemedicine may lower the costs of providing a health service and help to raise the quality of care. In some areas, teledermatology consultation is now the usual way of providing care to patients with skin disease. The American Telemedicine Association lists thousands of consultations performed in 2003 by 62 active teledermatology programmes and reimbursed by Medicaid, the US military or insurance carriers.^{[ 21 ]} In the UK, TDS (Dermatology) Ltd has been contracted by the NHS to provide more than 35,000 teledermatological consultations in the last 5 years.^{[ 22 ]}

The Swinfen Charitable Trust^{[ b ]} based in the United Kingdom uses an automatic message-handling system to provide rapid second opinions to doctors in developing countries. Volunteer experts include dermatologists and other specialists from several countries.^{[ 23 ]}

Teledermatology benefits for a referring physician can include recommendations for new treatment, fast access to specialist knowledge and improved co-operation between health care providers. Online multimedia dermatology teaching programmes allow self-directed learning at home, such as those provided for students in Switzerland, by Medscape for dermatologists and DermNet NZ for primary health physicians.

For the dermatologist, the positive aspects of working with telemedicine include less travelling, which allows more time for other work, less need to travel in poor weather, an increased sense of professional security and the satisfaction of communicating with colleagues.^{[ 24 ]} Several societies have been established to facilitate successful worldwide collaboration for continuing medical education, patient care and research. These include the Internet Dermatology Society, the International Society of Teledermatology and the International Dermoscopy Society.

Reported Failures in Telemedicine
There have been many telemedicine services that are no longer exist, including in New Zealand,^{[ 25 ]} although they may have been initiated with enthusiasm. The primary reasons for these failures appear to be lack of sustainable funding, lack of physician adoption, concerns about medical indemnity and/or lack of need.

Videoconferencing is particularly expensive, because of the costs involved, rarity of equipment on the desktop and its underuse when it is available. Scheduling is inconvenient, requiring two or more health professionals’ timetables to coincide with the availability of the equipment, and the consultations do not save time compared with standard outpatient appointments. Working with telemedicine can be tiring for the specialist. Electronic transfer of image and relevant clinical data can be augmented by web-cam if a "live" consult is required but there is minimal benefit from this.

Less expensive, apparently convenient web or email-based systems have sometimes proved less popular than anticipated. For example, in one study of a store-and-forward teledermatology service for GPs in regional Queensland, Australia, where digital pictures and a brief case history were transmitted by email to a consultant dermatologist, low use was attributed in part to lack of remuneration for referrers. Additional images or biopsy results were requested in 16% of cases because image quality was inadequate.^{[ 26 ]} Despite the proliferation of affordable digital cameras, high quality image acquisition, storage and transfer frequently present barriers to success.

The lower diagnostic certainty level of teledermatologists may also lead to a greater number of diagnostic biopsies (as in the above study), although these can often be performed by GPs or ancillary staff. Such procedures are costly, particularly to the patient, and may result in significant avoidable morbidity.

Patients do not always value teledermatology consultations, especially when not directly involved in the process, and may be reluctant to pay for it despite demonstrated savings in time and money and the distress of on-going skin disease.^{[ 27 ]}

Although teledermatology is potentially a useful communication tool for selected patients in primary care, it is unlikely to solve waiting list problems or replace the need for local dermatology services, as described in the Netherlands.^{[ 28 ]} There are only 40 dermatologists in New Zealand, for example, and it is common for patients to wait for 3 to 6 months to be seen at private or public clinics. According to the New Zealand Ministry of Health, 15 percent of the total population of 4 million live more than 80 km from a dermatologist. Many published papers from Europe and America refer to waiting times of 12 months or longer for appointments and to unfilled dermatology positions. Teledermatology could potentially disadvantage the face-to-face outpatient service.

There may be unexpected barriers to teledermatology in developing countries, such as power cuts and termites, as experienced in Tanzania.^{[ 29 ]}

Satisfaction With Teledermatology
Studies of the levels of satisfaction with teledermatology may evaluate the opinion of dermatologists, referring physicians and/or patients. There are methodological deficiencies in the published research but some general observations are possible.^{[ 30 ]} Referring clinicians and consultants tend to be enthusiastic, depending on the model of care.^{[ 31 ]} Patients participating in a variety of telemedicine systems worldwide, using videoconferencing^{[ 32 ]} and store-and-forward consultations,^{[ 33 ]} are generally happy with the process.

Receiving a diagnosis, treatment and cure, receiving adequate information and explanations, being taken seriously, receiving individualised personal care, and having only a short waiting time for an appointment and treatment are all aspects of care and management most likely to result in patient satisfaction, regardless of modality.^{[ 34]} Common patient concerns are lack of direct contact with the specialist, length of waiting time, and issues with follow-up. There were also privacy concerns but these were less common.^{[ 35]}

Standards and Guidelines
There are many different models of teledermatology, and technology systems are constantly being upgraded, both of which make it difficult for organisations to produce clinical, operational or technical Standards and Guidelines of Care in this area. There are no specific teledermatology training courses to the author’s knowledge. Earlier recommendations for image resolution have become outdated because of improvements in communications and computer systems.

Licensing of the provider will depend on the specific jurisdiction in which the provider wishes to offer a telemedicine service. Telemedicine practitioners are subject to legislation, indemnity, credentialing and privileging at the distant site when they are providing direct care to the patient. However, for many cases where the store-and-forward approach is used, dermatologists are just providing advice, recommendation or an opinion. The responsibility of care remains with patients’ local physicians. As of 1 January 2004 in the US, the Joint Commission for Accreditation of Health Care Organisations (JCAHO) has not required consultants participating in store-and-forward teledermatology to be credentialed at the originating site.^{[ 21 ]}

The American Telemedicine Association provides links to various clinical guidelines and technical standards that have telemedicine application, including email, and these may also be relevant to dermatology.^{[ 36 ]} Various forms can be downloaded from the Teledermatology Special Interest Group, including a basic guide to dermatologic photography and templates for referrals.^{[ 37 ]} A review of telemedicine guidelines^{[ 38 ]} refers to the American Academy of Dermatology’s Position Statement, which was revised in 2004.^{[ 39 ]}

The Medical Council of New Zealand^{[ 9 ]} and the American^{[ 40 ]} Medical Informatics Association have published guidelines for doctors using the Internet. It is deemed inadvisable to diagnose and prescribe to patients locally or overseas in the absence of a face-to-face consultation and examination.

A visible light supplement to DICOM (Digital Imaging and Communications in Medicine) made the DICOM standard relevant in dermatology. DICOM is a communications protocol that specifies the information content of images (structure and encoding), a set of DICOM services for managing the information and a messaging protocol.^{[ 41 ]} However, unlike radiology, this standard is not in general use in dermatology. Digital clinical photographs are frequently taken in an informal setting and the DICOM requirements are complex.

Outcomes and Economic Value
Good quality outcome and economic studies of teledermatology are scarce.^{[ 42 ]} The challenges of assessing outcomes in teledermatology include patient loss to follow-up with the teledermatologist, lack of information in patient records and low rates of patient return to the referring clinician for follow-up. However, similar challenges may apply to standard outpatient consultations.

Use of health care resources means loss of opportunities and loss of (health) benefit elsewhere ("opportunity cost"). Economic evaluation aims to estimate resource use (ie, opportunity cost) and health consequences (benefits) of medical interventions in order to guide resource use in a way that yields the maximum health benefit from scarce resources. It has proved difficult to demonstrate that teledermatology results in economic savings.

Teleconsultation does not fit into current models of care. Economic evaluations require complex analysis of the direct and indirect costs to initiating and diagnosing health care providers and to patients and of the impact of earlier diagnosis and expert management. Referrals may reduce as initiating health providers learn to manage their own dermatology patients. Time and monetary savings to patients have been described in Ireland,^{[ 43 ]} New Zealand^{[ 44 ]} and the US,^{[ 45 ]} but providers rarely reduce their costs unless outreach clinics are replaced or staff travel reduced.

Conclusion
Teledermatology is firmly established as a means of enhancing dermatological health care and has benefits for dermatologists, other health professionals and patients. Low cost ICT can be used but successful consultations require high quality referral text and images. More research is required to determine the best ways to deliver health care economically and effectively. Despite the best of intentions, ad hoc services fail because of lack of sustainable funding, poor quality equipment or lack of need. Technical and clinical protocols and standards for telemedicine are still evolving. Nevertheless, we can expect teledermatology to have an increasing role in patient care as secure broadband communication systems become widely distributed in health services.

Acknowledgements
I would like to thank my enthusiastic teledermatology colleagues in Australia, Austria, Italy, Pakistan, Portugal, Switzerland and the US for their contributions in the preparation of this article.

Disclosure
1. I am employed by Health Waikato
2. I am contracted to MoleMap NZ
3. I am website manager for DermNet NZ

These organisations provide teledermatology services of various kinds.

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