Article

Evaluation Criteria for Mobile Teledermatology Applications and Comparison of Major Mobile Teledermatology Applications

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Abstract

Background: Mobile teledermatology applications have enabled increased patient access to dermatologic care. For groups interested in starting a mobile teledermatology program, selection of the appropriate application can be challenging. Having pretested evaluation criteria allows for efficient, systematic assessment of mobile teledermatology applications and identification of features important for comparison. The primary aim of this study is to determine a framework for evaluation of mobile teledermatology applications and to compare two major mobile teledermatology applications available in the United States using the proposed criteria. Materials and methods: We incorporated previous teledermatology application evaluation criteria and developed new evaluation criteria to reflect matters specific to the mobile platform. Through a systematic search, we identified two publicly available mobile teledermatology applications in the United States and applied the evaluation criteria. Results: The 13-point evaluation criteria encompass three major domains: (1) technical specifications, (2) user experience and workflow, and (3) integration and scalability. The evaluation criteria provided an effective way of assessing the two mobile teledermatology applications. Both AccessDerm version 1.0 (Vignet Corp., McLean, VA) and ClickMedix version 1.3 (ClickMedix LLC, Rockville, MD) were capable of managing consultations. These applications adopted different approaches to balancing image quality versus data transmission, managing follow-up patients, and enabling dialogue between providers. Conclusions: Mobile teledermatology provides convenient and scalable means of providing specialty care. The creation of mobile application evaluation criteria offers a useful guide for assessing future mobile applications.

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We performed a systematic review of the literature addressing teledermatology: (1) diagnostic accuracy/concordance; (2) management accuracy/concordance; (3) clinical outcomes; and (4) costs. Peer-reviewed controlled trials published in English between 1990 and 2009 were identified through MEDLINE and PubMed searches. Of 78 included studies, approximately two-thirds comparing teledermatology and clinic dermatology found better diagnostic accuracy with clinic dermatology. Diagnostic concordance of store and forward with clinic dermatology was good; concordance rates for live interactive and clinic dermatology were higher, but based on fewer patients. Overall rates of management accuracy were equivalent, but teledermatology and teledermatoscopy were inferior to clinic dermatology for malignant lesions. Management concordance was fair to excellent. There was insufficient evidence to evaluate clinical course outcomes. Patient satisfaction and preferences were comparable. Teledermatology reduced time to treatment and clinic visits and was cost-effective if certain assumptions were met. Heterogeneity in studies (design, skin conditions, outcomes) limited the ability to pool data. The benefits of teledermatology need to be evaluated in the context of potential limitations.
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We wished to assess both diagnostic accuracy and concordance among dermatologists when evaluating digital images of skin disease presented using a low-cost asynchronous (store-and-forward) format. Each of eight board-certified dermatologists reviewed 50 clinical cases presented in digital format on a 15-inch computer monitor. For each case, the teleconsultants made a primary diagnosis and differential diagnosis and indicated whether or not a biopsy should be performed both before and after reviewing a brief history of each case. Diagnostic accuracy was calculated for each teleconsultant on the basis of biopsy, culture, or wet mount results. Concordance was determined by comparing primary and differential diagnoses made by the teleconsultants on all 50 cases with those made by the dermatologists who originally examined the patients in person. For eight skin cancers, the diagnostic accuracy for the inperson dermatologist was 88% versus 90% (range, 75-100%) for the teleconsultants. For the 25 cases (including the 8 skin cancers) confirmed by either biopsy (20), culture (1), or wet mount (4), the in-person accuracy was 84% compared to 73% (range, 65-88%) for the teleconsultants. The concordance between the in-person and teleconsultant diagnoses were in agreement 77% of the time (90% if differential diagnoses were included). After evaluating the accompanying history, teleconsultants changed their primary diagnosis in 11% of the cases (range, 2-22%). Biopsy rates were not significantly different between teleconsultants (45%) and in-person dermatologists (40%). An asynchronous software application can provide levels of diagnostic accuracy and concordance equivalent to those reported using live teleconsultation.
Article
Dermatology is perhaps the most visual specialty in medicine, making it ideally suited for modern telemedicine techniques, as has been shown in a number of recent studies investigating feasibility and reliability of teledermatology. It has generally demonstrated high levels of concordance in diagnosis and management plans compared with face-to-face consultations. Teledermatology also has been used for various purposes, including triage, diagnostic and management services, and second-opinion services for primary care practitioners. It has been set up in a number of ways: (1) direct referral for primary care using images and clinical history sent to secondary care dermatology services for second opinion and for triage referrals and (2) facilitating community-based clinics led by nurses or general practitioners. Moreover, in the last years new fields in teledermatology have grown up. Teledermoscopy is a promising area for melanoma screening as well as for the diagnosis and management of equivocal pigmented skin lesions. The feasibility of mobile teledermatology and mobile teledermoscopy recently has been proven, and these new facilities have the potential to become an easy applicable tool for everyone and may open the door for a new flexible triage system for detection of skin cancer in general and melanoma in particular. The implementation of virtual slide systems for teledermatopathology has allowed avoiding the limitations imposed by conventional microphotography. Finally, web consultations in dermatology are a rather new tool that became available in the last years and teledermatologic services through the Internet offer many possibilities, including continuing medical education, on-line atlases and databases, and specific web application suited for teledermatology (ie, www.telederm.org).
Article
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.
Article
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.