This article presents an analysis of the strengths, weaknesses and threats of teledermatology.
Main benefits
Recognized main benefits of teledermatology are:
- Reduction of wait time to get a specialist diagnosis or a specialist risk assessment.
- No need for travels and for related costs.
- Reduction in the number of referrals.
- Ensuring access to specialist care in some disadvantaged areas (e.g. rural areas).
Specific issues
Clinical aspects
Quality of image and diagnosis accuracy
Diagnostic quality of images is doubtful in primary teledermatology when photos are used; on the contrary in secondary teledermatology, where photos and dermoscopic images can be combined, there is consistency and quality of the acquired images. In addition thanks to the mediation of a medical professional a comprehensive set of information (anamnesis, info on the lesion, etc.) can be provided to the dermatologist for a more accurate diagnosis. On the contrary in primary teledermatology a problem could be represented by the poor reliability of self-provided information.
A negative aspect is that teledermatology does not allow palpation that is very useful in case of dermatoses such as psoriasis, atopic dermatoses, actinic keratoses.
Accuracy of diagnoses done by using teledermatology is still a controversial issue:
- Some studies show a 90 to 98% concordance between teledermatology and face-to-face clinical diagnoses[1] but according to other studies, “despite telemedicine’s big success, the accuracy of in-person visits is still 11% greater than teleconsultations”[2].
- Diagnosis accuracy is highly depending on the skills of both the remote dermatologist and the referring physician; for this last one, important issues are the ability in the acquisition of the images, in the completeness and relevance of the set of info transmitted to the dermatologist and the capability of giving follow up to the dermatologist’s recommendations.
Integration into clinical practice
There is a lack of technological infrastructures in some countries; om the contrary teledermatology is already integrated in the national health system in several countries such as The Netherlands, Canada, United Kingdom, South Arabia, Norway. In other countries / regions (e.g. North America and Australia), it is supplied by large programs[3].
Barriers are represented by:
- Legal issues (e.g. data privacy, liability).
- A lack of coordination with primary care physicians and uncertainties about the follow up (patient’s compliance).
- Health insurance coverage and lack of transparent reimbursement policies.
- interfacing of teledermatology applications with the existing EMR.
Reimbursement
Represents another main obstacle for the implementation of telemedicine into the national health care system. As an example, in U.S.A. reimbursement policies vary significantly among different states and “could be critical in determining the growth and survival of teledermatology in the future”. Currently, all states and the District of Columbia have defined telemedicine law, regulations, and Medicaid policies (Centre for Connected Health Policy, 2016). However, telemedicine policy varies greatly from state to state on how telemedicine is defined, regulated and reimbursed. Many states continue to require that services are delivered in real time or by live video and therefore exclude coverage for store-and-forward services even though it has been proven to be more cost-effective and equally reliable.
In Europe the Netherlands has completely integrated teledermatology into its healthcare system but reimbursement for services is conditioned (Tensen et al., 2016); teledermatology is reimbursed under the condition that there was a first face-to-face visit between patient and care provider. It means that it is reimbursed only for GPs and remote dermatologist belonging to the same organization e.g. to the National Health Service (public dermatology practices). For private dermatologists only follow up teleconsultations are reimbursed.
Lack of standards
Environmental conditions could affect the quality, appearance, and consistency of images. There is a need for standards in the image acquisition (i.e. lighting, background, camera position, patient pose and standard view sets).
Satisfaction by patients
Various studies demonstrate a good level of satisfaction both by patients and by clinicians (an example is a study involving 334 patients in Northern Ireland).
Nevertheless, there are some concerns about the risk of promoting a technology-centred rather than a patient-centred healthcare model.
Some outcomes of other studies:
- 75% of patients indicated that they will recommend the service to other individuals.
- Even patients who preferred a face-to face consultation perceived teledermatology as an acceptable way for consultation.
- The preference between real time video conferencing and store & forward remote consulting is unclear[4].
- Teledermatology is appreciated mainly in rural areas rather than in urban areas (Coates et al., 2015).
- Reasons of patient dissatisfaction with teledermatology include feeling uncomfortable or even embarrassed; the absence of the interaction with the dermatologist such as in a face-to-face office visit; the lack of follow up from the referring physician.
The judgement of the physicians
For dermatologists the key elements that could facilitate the adoption of teledermatology are:
- An appropriate organizational infrastructure; b. Training of physicians; c. Full and continuous technical support. In addition, they think that there are critical issues still to be solved such as:
- The medical legal liability; b. a better diagnostic reliability allowed by teledermatology; c. the lack of patient follow up; d. the absence of palpation of the skin; e. the limited reimbursement.
For physicians the key requirements for the implementation of teledermatology are represented by
- Access to timely dermatology care; b. High quality of images taken; c. Secure transmission of images; d. Standardization of imaging and equipment; e. training for medical professionals.
Economics
Cost effectiveness
When assessing cost-effectiveness of teledermatology, it is important to consider societal costs in addition to direct medical costs; teledermatology not only decreases appointment waiting times and the amount of time needed for a consultation but decreases also travel costs and loss of productivity.
There is the need to increase the base of evidence; today the focus is on theoretical studies, and we lack actual the outcomes of large scale implementation.
It has been recognized that secondary teledermatology, “when accordingly used for selected patients by general practitioners in daily practice, improves efficiency and quality of care at lower cost”.
Particularly store-and-forward teledermatology is cost effective in terms of significantly decreasing the need for in-person visits (Landow et al., 2014). By including cost saving associated with loss of productivity a study estimated a ratio of 2:1 between standard care and store-and-forward teledermatology.
Here below we report some quantitative assessments of the benefits of teledermatology:
- 45% of face-to-face visits could be avoided with store & forward teledermatology.
- 18% reduction of direct medical costs.
- 45% reduction of travel costs of the patients.
A study done in Spain concluded that teledermatology could generate savings if the distance to a dermatologist in hospital is longer than 75 km or when consultations more than 37% could be prevented with the use of teledermatology.
From the other side it must be notice that the increased awareness of the citizens and the doubtful feedback due to limited accuracy of some available solutions could have as affect the unjustified growth of the demand of dermatologic services by worsening i.o. reducing the problem of long dermatology wait lists.
Ethical and legal issues
Some ethical and legal issues are still open. Among them:
- Cross border consultations: It remains unclear if a dermatologist can operate as a remote consultant for other countries or just in the country of practice (for example, some states in the USA impose restrictions in providing teledermatology to other states in which the physician is not working and licensed).
- Legal responsibility in case of misdiagnosis: Further confusion surrounds whether legal responsibility in the case of misdiagnosis or management lies with the referring doctor or the teleconsultant, and where the teleconsultants are charged (in their own country or that of the patient) in case they are found to be negligent.
- Malpractice insurance: It is not yet established whether malpractice insurance for a dermatologist includes work as a remote consultant.
- Protection of patient data: Concern exists for protecting servers that store patient data and images; in addition, there is a lack of international standards in areas such as encryption protocols. Other aspects to be considered are authentication, authorization, storage & network security, confidentiality, non-repudiation. Standards such as the ISO/TS 13131:2014 on Telehealth services or the ISO/IEC 27001:2013 on information technology security, can be very useful tools to address data security & privacy issues.
- Legal responsibility of ICT systems providers: there are a lot of unclear issues; it explains why manufacturers (see as an example SkinVision) market their products as “a non-diagnosis solution that complements a dermatologist”.
- Lack of technological standards: they are lacking in areas such as image resolution (spatial and color resolution), reproduction ratios, post-acquisition image processing, colour calibration, compression, image archiving and storage, and image security during transmission and storage.
[1] Arzberger E, Curiel-Lewandrowski C, Blum A, et al. Teledermoscopy in high-risk melanoma patients: a comparative study of face-to-face and teledermatology visits. Acta Derm Venereol. 2016;96:779–83. [PubMed] [Google Scholar]
[2] Gilmour E, Campbell SM, Loane MA, et al. Comparison of teleconsultations and face-to-face consultations: preliminary results of a United Kingdom multicentre teledermatology study. Br J Dermatol. 1998;139:81–7. [PubMed] [Google Scholar]
[3] Trettel A, Eissing L, Augustin M. Telemedicine in dermatology: findings and experiences worldwide – a systematic literature review. J Eur Acad Dermatol Venereol. 2018;32(2):215–224.
7 Tensen E., Van Der Heijden JPJaspers MW, et al. Two decades of teledermatology: current status and integration in national healthcare systems. Curr Dermatol Rep. 2016;5:96–104.
[4] R. Marchell, C. Locatis, G. Burgess, R. Maisiak, Wei-Li Liu, and M. Ackerman - Patient and Provider Satisfaction with Teledermatology - TELEMEDICINE and e-HEALTH , VOL. 23 NO. 8 AUGUST 2017;
Coates SJ, Kvedar J, Granstein RD. Teledermatology: From historical perspective to emerging techniques of the modern era: Part I: History, rationale, and current practice. J Am Acad Dermatol 2015;72(4):563–74.
Coates SJ, Kvedar J, Granstein RD. Teledermatology: From historical perspective to emerging techniques of the modern era: Part II: Emerging technologies in teledermatology, limitations and future directions. J Am Acad Dermatol 2015; 72(4):577–86.