Jennifer L. Weinberg

Mobile teledermatology in the developing world: Implications of a feasibility study on 30 Egyptian patients with common skin diseases

BACKGROUND The expansion of store-and-forward teledermatology into underserved regions of the world has long been hampered by the requirement for computers with Internet connectivity. To our knowledge, this study is one of the first to demonstrate the feasibility of teledermatology using newer-generation mobile telephones with specialized software and wireless connectivity to overcome this requirement in a developing country. OBJECTIVE We sought to demonstrate that mobile telephones may be used on the African continent to submit both patient history and clinical photographs wirelessly to remote expert dermatologists, and to assess whether these data are diagnostically reliable. METHODS Thirty patients with common skin diseases in Cairo, Egypt, were given a diagnosis by face-to-face consultation. They were then given a diagnosis independently by local senior dermatologists using teleconsultation with a software-enabled mobile telephone containing a 5-megapixel camera. Diagnostic concordance rates between face-to-face and teleconsultation were tabulated. RESULTS Diagnostic agreement between face-to-face consultation and the two local senior dermatologists performing independent evaluation by teleconsultation was achieved in 23 of 30 (77%) and in 22 of 30 (73%) cases, respectively, with a global mean of 75%. LIMITATIONS Limited sample size and interobserver variability are limitations. CONCLUSION Mobile teledermatology is a technically feasible and diagnostically reliable method of amplifying access to dermatologic expertise in poorer regions of the globe where access to computers with Internet connectivity is unreliable or insufficient.

HIV positive patients in Botswana state that mobile teledermatology is an acceptable method for receiving dermatology care

There is a severe shortage of dermatologists in sub-Saharan Africa, with many areas having no dermatologists at all.[1] Furthermore, there is an increased prevalence of skin disease in HIV patients, with many conditions being unique to this population or more severe than in immunocompetent patients.[2] The presence of many of these conditions may affect HIV management.[3,4] Store-and-forward teledermatology offers a method for increasing access to skin specialists. Although many areas have limited computer connectivity, mobile phone networks are more accessible.[5, 9] Mobile teledermatology uses mobile phones to perform store-and-forward teledermatology consultations. Studies evaluating patient acceptability of conventional store-and-forward teledermatology have been conducted in various study populations.[6,7,8] However, it is unknown whether patients, particularly those infected with HIV in resource-limited settings such as southern Africa, find the use of mobile phones acceptable for collecting their health information and would be willing to receive skin care through this method. It is possible that patients with a socially stigmatizing condition such as HIV have additional privacy concerns or that they may feel concerned about transmission of sensitive information by mass telecommunication technologies. While several studies have evaluated patient acceptance of store-and-forward teledermatology in industrialized countries, we were unable to find any studies on patient acceptance in resource poor settings among patients with HIV.[8,9,10,11] We have investigated whether the use of mobile teledermatology technology in a resource-limited setting in Botswana was culturally acceptable to HIV positive patients. Survey We conducted a cross-sectional survey of adult patients with HIV and mucocutaneous complaints in Botswana. Survey questions were developed by physicians in Botswana and the US, and were vetted by dermatologists with clinical experience in Botswana for face and content validity. The survey questions were tested with HIV positive outpatients at the dermatology clinic at the Princess Marina Hospital in Gaborone, Botswana. The study was approved by the appropriate ethics committees and the Botswana Ministry of Health. The study was conducted in consecutively recruited HIV positive patients in Botswana. The patients were at least 18 years old and presented with a skin or mucosal complaint that had not been previously evaluated by a dermatologist. The patients were recruited from the medical and oncology wards, the dermatology clinic, and the Infectious Disease Care Centre at the Princess Marina Hospital; from the Independence Surgery Center, a private primary care clinic in Gaborone; and from the outpatient clinics and medical wards at Athlone Hospital in Lobatse over a 5-week period from August 2009. Enrolled patients received both a face-to-face and mobile teledermatology evaluation and were afterwards asked to complete a questionnaire on their attitudes to mobile teledermatology at the end of the doctor-patient encounter. A Setswana-speaking nurse obtained consent, clarified any patient questions and administered the questionnaire in Setswana to patients unable to read English. Patients who were comfortable reading and writing in English completed the questionnaire on their own if they chose to do so. Enrolled patients received 30 pula (US

The WHO Clinical Staging System for HIV/AIDS.

4.5) compensation to cover the cost of their travel. We screened 89 patients, of whom 77 (87%) were recruited and 75 completed the survey (97% completion rate), see Table 1. Two patients agreed to participate but could not complete the survey due to nausea from chemotherapy. Most patients (71%) were 31–50 years old. Thirty four (44%) were males. Most patients were single (71%). A significant proportion of patients was unemployed (44%) or received their regular skin care outside Gaborone (39%). The majority of patients stated that time (76%), costs (57%) and distance (41%) were the major barriers in seeking medical care for their skin conditions (Table 2). Forty five percent of patients stated that it took 1–3 h to see a skin specialist, while 53% of patients stated that it took more than 3 h. If privacy was guaranteed, 99% of patients reported that they would be completely comfortable with a mobile teledermatology consultation, while only one patient stated that he or she would have to think about it, and none stated that they would be uncomfortable. When asked what their greatest concern was regarding mobile phone skin consultations, 82% of patients reported none, while 8% reported concerns over not having a face-to-face interaction with the physician and an equal number (n=6) reported concerns over an incomplete representation of their skin or poor photograph quality (Table 2). The majority of patients (91%) believed that they would receive the same treatment and quality of care via mobile teledermatology consultation as with a face-to-face interaction. Most patients were willing to wait 1–3 days (40%) or up to one week (27%) to receive a response from the mobile teledermatology consultation in exchange for the convenience of not having to travel to see a skin specialist. When asked which body sites patients were willing to accept having a mobile teledermatology consultation for, 58% of patients said that photography of the face was acceptable, 97% accepted photography of the chest, 92% accepted photography of the genitals, 96% accepted photographs of the legs and 95% accepted photography of the body as a whole. There was a significant difference between the acceptability of mobile consultation for lesions on the face versus all the other body sites (all P-values<0.01). There was no significant difference for any body site by age or sex (P=0.15–0.75). Most patients cited reduced cost of travel (85%) and reduced time away from home or work (65%) as the benefits that would make them prefer mobile teledermatology consultations over face-to-face consultations, while 13% of patients stated that they would not prefer mobile teledermatology consultations over face-to-face interaction with a dermatologist. Table 1 Characteristics of the study population Table 2 Barriers to dermatology care and attitudes towards mobile teledermatology Our results provide insight into the demographics of the adult HIV positive population seen by the dermatology service in Gaborone and surrounding areas. A greater proportion of our patients (56%) were female, which reflects the national gender disparity in the prevalence of HIV. The median age of our cohort was 39 years, which is consistent with the age of peak prevalence of HIV nationally. Unlike national estimates however, most of our patients were single (71%), whereas the national HIV prevalence is highest in those who are widowed (40%).[12] In the context of a severe shortage of dermatology providers in Botswana, our results emphasise the difficulties these patients often encounter in obtaining dermatology care, including distance, cost and time as barriers to care. Furthermore, patients viewed mobile teledermatology as an acceptable alternative to obtaining skin care from a face-to-face consultation with a dermatologist. Our study had several limitations. The survey questions were not extensively validated. The questions were vetted by several dermatologists and other physicians and epidemiologists who all agreed on the importance of the inclusion of each question, which provides our instrument with some measure of content validity. The questions covered the dimensions recommended by Demiris et al. in their systematic review of patient acceptability studies in teledermatology.[8] Another limitation was the generalizability of our findings, since the results were obtained in HIV-positive adult patients in Botswana. However, it is reassuring to note that our cohort of patients was fairly representative of the general HIV-positive population in Botswana in terms of age and gender distributions. Finally, our patients were given compensation to help defray transportation costs, which may have led to response bias. However, such compensation is common in many studies. Overall, mobile teledermatology consultations were well accepted by HIV-positive patients with mucocutaneous conditions in Botswana. Most patients said that mobile teledermatology consultations for all parts of their body would be acceptable. Patients were most sensitive about the transmission of facial lesions through mobile teledermatology. However, even patients who cited concerns about the transmission of identifiable facial photographs consented to mobile teledermatology evaluations of facial lesions, so long as care was taken to minimize the possibility of recognition. Previous studies have assessed patient satisfaction with traditional store-and-forward teleconsultation in remote settings. [13] To our knowledge, this is the first study to address patient acceptance of mobile teledermatology in a population with a potentially stigmatizing underlying illness such as HIV. Given the rapid growth of mobile phone networks in developing countries, mobile teledermatology may be increasingly used to provide skin care in underserved communities. Our study demonstrates that HIV-positive patients find this technology acceptable for specialist consultations when face-to-face consultations may be difficult to obtain.

Teledermatology in developing countries

Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

The Computer Will See You Now: Ethics of Teledermatology

Teledermatology can facilitate access to high-quality, cost-effective health care in developing countries, as well as play an essential role in clinician education, foster distribution of educational materials, and promote independence in clinical practice as well as improving patient care.

Dermatologists Within, Beyond and Struggling with Borders: The Global Dermatologist

Teledermatology is the use of telecommunication for dermatology diagnosis and care. This technology can provide diagnostic services to underserved and rural regions that lack access to higher-level specialty medical expertise. Accumulating data shows that teledermatology is diagnostically accurate, safe, cost-effective, and well received by patients. While the potential of teledermatology to increase access to care is exciting, it is critical to recognize that the nature of the doctor–patient relationship is drastically altered when the doctor is located remotely, never having face-to-face contact with the patient. This is a new type of therapeutic relationship, one in which the principles of respect for autonomy, beneficence, non-maleficence, and justice must be emphasized, and at the same time recontextualized. Case scenarios will be used to examine some of the ethical issues that may arise with the use of teledermatology. As a framework for our analysis, we will use the generally accepted ethical principles to which physicians are expected to adhere and will discuss how these principles apply specifically to challenging scenarios with which practitioners of teledermatology may be faced.

Global health ethics at home and abroad.

Improved international travel and communication has led to an increased awareness of and interest in global health issues. Many dermatologists and trainees now volunteer in less-developed nations. While their intentions are excellent, these volunteer activities may raise ethical challenges. Specifically, international volunteers may inadvertently tax limited local resources, confront cultural and language challenges, and face an unfamiliar emphasis on population health. In addition, volunteer physicians may find themselves dealing with lack of local diagnostic and therapeutic resources and limited follow-up. Several hypothetical case scenarios are presented that illustrate some of these challenges and their ethical ramifications. In addition, ethical issues relating to trainees volunteering in underdeveloped countries are addressed.

Identifying Differences in Communication Technology Preferences Across the Lifespan

Introduction to the March 2010 issue of Virtual Mentor on the topic of global health ethics in practice. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.

The African Teledermatology Project: Providing access to dermatologic care and education in sub-Saharan Africa

to build public awareness against such stigma, as well as to highlight that successful aging is achievable. In conclusion, from the program development perspective, we have the following recommendations to promote dementia awareness in ethnic minority: increase dementia information available in the Chinese language; raise public awareness through collaborating with media outlets, such as ethnic radio stations; present the medical background of dementia, and put a face on mental illness!