Karen E. Edison

American Telemedicine Association's practice guidelines for teledermatology

The ATA assembled a group of experts to develop practice guidelines for teledermatology. This document represents the body of work that this distinguished group assembled. It was approved by the ATA Board of Directors and is presented here in its entirety.

Diagnosis, Diagnostic Confidence, and Management Concordance in Live-Interactive and Store-and-Forward Teledermatology Compared to In-Person Examination

Teledermatology studies have examined diagnostic concordance between live-interactive (LI) and in-person examinations (IP); and between store-and-forward (SF) and IP examinations. However, no studies have looked simultaneously across all three care delivery modalities, and few have measured management concordance and diagnostic confidence of the dermatologist. The purpose of this study was to compare LI and SF modalities with IP with respect to diagnostic and management concordance and to compare physician diagnostic confidence across the three modalities. Four dermatologists, in random rotation among all three care modalities, examined 110 new patients. Confidence was rated on a Likert scale from 1 to 5 (5 = total confidence; 1 = no confidence). Identical diagnoses were given to the patient by examiners from all three examination modalities in 70/110 patients (64%). More identical diagnoses were given for IP and LI examinations than for IP and SF examinations (80% vs. 73%); however, the difference was not statistically significant (p = 0.13). The highest self-reported confidence rating was given for 87% of IP examinations, 59% for LI, and 54% for SF. Diagnostic confidence ratings for SF and LI were not significantly different from each other (p = 0.50); however, diagnostic confidence ratings for LI and SF were both statistically lower than IP (p < 0.0001). Dermatologists were more confident with IP examination than either form of teledermatology. The percent of diagnostic and management agreement among IP, LI, and SF modalities was high.

Hospice staff attitudes towards telehospice

Telemedicine, defined as the use of advanced telecommunication technologies to bridge geographic distance and improve delivery of care, is perceived by many as a way to eliminate barriers to quality care at the end of life. The use of telemedicine in hospice, known as telehospice, is a novel approach to such care, and few pilot studies have investigated its feasibility. The purpose of this study was to assess hospice providers’ perceptions of telehospice. A focus group session was conducted with 10 staff members from five hospice agencies in Missouri. Participants included administrators, nurses, and social workers. Overall, providers had a positive perception of telehospice and found that the use of videophone technology enhanced care by enabling providers, patients, and family members a means to communicate. However, they emphasized that it was an additional tool and not a substitute for actual visits. Issues of privacy and usability were also raised.

Effect of Store and Forward Teledermatology on Quality of Life: A Randomized Controlled Trial

IMPORTANCE Although research on quality of life and dermatologic conditions is well represented in the literature, information on teledermatologys effect on quality of life is virtually absent. OBJECTIVE To determine the effect of store and forward teledermatology on quality of life. DESIGN Two-site, parallel-group, superiority randomized controlled trial. SETTING Dermatology clinics and affiliated sites of primary care at 2 US Department of Veterans Affairs medical facilities. PARTICIPANTS Patients being referred to a dermatology clinic were randomly assigned, stratified by site, to teledermatology or the conventional consultation process. Among the 392 patients who met the inclusion criteria and were randomized, 326 completed the allocated intervention and were included in the analysis. INTERVENTIONS Store and forward teledermatology (digital images and a standardized history) or conventional text-based consultation processes were used to manage the dermatology consultations. Patients were followed up for 9 months. MAIN OUTCOME MEASURES The primary end point was change in Skindex-16 scores, a skin-specific quality-of-life instrument, between baseline and 9 months. A secondary end point was change in Skindex-16 scores between baseline and 3 months. RESULTS Patients in both randomization groups demonstrated a clinically significant improvement in Skindex-16 scores between baseline and 9 months with no significant difference by randomization group (P = .66, composite score). No significant difference in Skindex-16 scores by randomization group between baseline and 3 months was found (P = .39, composite score). CONCLUSIONS Compared with the conventional consultation process, store and forward teledermatology did not result in a statistically significant difference in skin-related quality of life at 3 or 9 months after referral. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00488293.

Pediatric Teledermatology—A Survey of Current Use

Abstract:  Demand for pediatric dermatologic care far exceeds the supply of pediatric dermatologists. Teledermatology has been proposed as a solution to improve access to care, however, data regarding teledermatology use for pediatric patients are lacking. Surveys assessing use and experience with teledermatology were administered to pediatric dermatologists attending the 2006 Society for Pediatric Dermatology Annual Meeting and to programs offering teledermatology identified in the American Telemedicine Association’s 2003 Teledermatology Survey. Over half of the 76 pediatric dermatologists responding to the survey had previous experience with teledermatology and nearly half currently use some form of teledermatology. For most, this represents nonreimbursed, store‐and‐forward consultations. Respondents noted that teledermatology allows more accurate triage of dermatology patients, decreases travel and outpatient clinic visits, and provides an avenue for ongoing support and education for primary care physicians. While difficulties exist, overcoming obstacles to the use of pediatric teledermatology and reimbursement for such services could improve access to expert pediatric dermatologic care.

Choice, Transparency, Coordination, and Quality Among Direct-to-Consumer Telemedicine Websites and Apps Treating Skin Disease

IMPORTANCE Evidence supports use of teleconsultation for improving patient access to dermatology. However, little is known about the quality of rapidly expanding direct-to-consumer (DTC) telemedicine websites and smartphone apps diagnosing and treating skin disease. OBJECTIVE To assess the performance of DTC teledermatology services. DESIGN AND PARTICIPANTS Simulated patients submitted a series of structured dermatologic cases with photographs, including neoplastic, inflammatory, and infectious conditions, using regional and national DTC telemedicine websites and smartphone apps offering services to California residents. MAIN OUTCOMES AND MEASURES Choice of clinician, transparency of credentials, clinician location, demographic and medical data requested, diagnoses given, treatments recommended or prescribed, adverse effects discussed, care coordination. RESULTS We received responses for 62 clinical encounters from 16 DTC telemedicine websites from February 4 to March 11, 2016. None asked for identification or raised concerns about pseudonym use or falsified photographs. During most encounters (42 [68%]), patients were assigned a clinician without any choice. Only 16 (26%) disclosed information about clinician licensure, and some used internationally based physicians without California licenses. Few collected the name of an existing primary care physician (14 [23%]) or offered to send records (6 [10%]). A diagnosis or likely diagnosis was proffered in 48 encounters (77%). Prescription medications were ordered in 31 of 48 diagnosed cases (65%), and relevant adverse effects or pregnancy risks were disclosed in a minority (10 of 31 [32%] and 6 of 14 [43%], respectively). Websites made several correct diagnoses in clinical scenarios where photographs alone were adequate, but when basic additional history elements (eg, fever, hypertrichosis, oligomenorrhea) were important, they regularly failed to ask simple relevant questions and diagnostic performance was poor. Major diagnoses were repeatedly missed, including secondary syphilis, eczema herpeticum, gram-negative folliculitis, and polycystic ovarian syndrome. Regardless of the diagnoses given, treatments prescribed were sometimes at odds with existing guidelines. CONCLUSIONS AND RELEVANCE Telemedicine has potential to expand access to high-value health care. Our findings, however, raise concerns about the quality of skin disease diagnosis and treatment provided by many DTC telemedicine websites. Ongoing expansion of health plan coverage of these services may be premature. Until improvements are made, patients risk using health care services that lack transparency, choice, thoroughness, diagnostic and therapeutic quality, and care coordination. We offer several suggestions to improve the quality of DTC telemedicine websites and apps and avoid further growth of fragmented, low-quality care.

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

Importance 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. Objective 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. Design, Setting, and Participants 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. Interventions Referrals were managed using store-and-forward teledermatology or a conventional text-based referral process. Main Outcomes and Measures 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. Results From the VA perspective, the total cost for conventional referrals was

Telehealth Tools for Public Health, Emergency, or Disaster Preparedness and Response: A Summary Report

66 145 (minimum,

Users and Nonusers of University-Based Dermatology Services Following a Teledermatology Encounter: A Retrospective Descriptive Analysis

58 697; maximum,

Incorporating Telehealth into Primary Care Resident Outpatient Training

71 635), or