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Practice Guidelines for Teledermatology

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Abstract

Previous American Telemedicine Association (ATA) Teledermatology Practice Guidelines were issued in 2007. This updated version reflects new knowledge in the field, new technologies, and the need to incorporate teledermatology practice in a variety of settings, including hospitals, urgent care centers, Federally Qualified Health Centers, school-based clinics, public health facilities, and patient homes.
Practice Guidelines
for Teledermatology December 2007
Quality Healthcare ThroughTelecommunicationsTechnology
V1.2007 1
AMERICAN TELEMEDICINE ASSOCIATION’S
PRACTICE GUIDELINE FOR TELEDERMATOLOGY
Elizabeth Krupinski, PhD
1
, Anne Burdick, MD, MPH
2
, Hon Pak, MD
3
, John Bocachica, MD
4
,
Lucius Earles, MD
5
, Karen Edison, MD
6
, Marc Goldyne, MD
7
, Tom Hirota, DO
8
, Joseph
Kvedar, MD
9
, Karen McKoy, MD, MPH
10
, Dennis Oh, MD
11
, Dan Siegel, MD
12
, Nina
Antoniotti, PhD
13
, Ivan Camacho, MD
14
, Lisa Carnahan
15
, Paul Boynton, PhD
15
, Richard
Bakalar, MD
16
, Richard Evans, MS
17
, Al Kinel, PhD
18
, Peter Kuzmak, MSBME
19
, Brian C.
Madden, PhD
20
, Sandra Peters, PhD
21
, Lynne Rosenthal
15
, Scott Simmons, MS
2
, Jordana
Bernard
22
, Jonathan Linkous
22
1
Arizona Telemedicine Program University of Arizona, Tucson, AZ
2
Associate Dean of Telemedicine and Clinical Outreach Miller School Medicine University of
Miami, Miami, FL
3Chief, Advanced Information Technology Group Telemedicine and Advanced Technology
Research Center, Ft. Detrick, MD
4
Departments of Dermatology and Teledermatology Alaska Federal Health Care Access
Network, Anchorage, AK
5
Section of Dermatology Department of Medicine Mt. Sinai Hospital Chicago, IL
6
Department of Dermatology University of Missouri Health Care, Columbia, MO
7
Department of Dermatology University of California San Francisco, San Francisco, CA
8
Dermatology Services Madigan Army Medical Center & Department of Dermatology F.
Edward Hebert School of Medicine Uniformed Services University of Health Sciences,
Bethesda, MD
9
Center for Connected Health Partners HealthCare System, Inc. Department of Dermatology
Harvard Medical School, Boston, MA
10
Lahey Clinic Department of Dermatology Burlington, MA & Department of Dermatology
Harvard Medical School, Boston, MA
11
Department of Dermatology University of California San Francisco & Dermatology Service
San Francisco VA Medical Center, San Francisco, CA
12
Department of Dermatology SUNY Downstate, Brooklyn, NY
13
Marshfield Clinic TeleHealth Network Marshfield, WI
14
Department of Dermatology and Cutaneous Surgery University of Miami, Miami, FL
15
Information Technology Laboratory National Institute of Standards and Technology,
Gaithersburg, MD
16
IBM Global Healthcare IBM Corporation
17
Utah Telehealth Network, Salt Lake City, UT
18
Director of Alliances Kodak Corporation, Rochester, NY
19
Department of Veterans Affairs VistA Imaging Project Silver Spring, MD
20
Program Director VISN 2 Telemedicine Department of Veterans Affairs & Department of
Dermatology University of Rochester, Rochester, NY
21
American Academy of Dermatology, Washington, DC
22
American Telemedicine Association
V1.2007 2
Table of Contents
1. Preamble……………………………………………………………………………….3
2. Introduction…………………………………………………………………………….3
3. I. Guidelines for the Practice of Teledermatology ………..…………………………….4
a. Technical Specifications………………………………………………………..4
i. Image Acquisition……………………………………………………...4
ii. Image Storage, Retrieval & Transmission……………………………..5
iii. Image Display………………………………………………………….5
b. Clinical Specifications…………………………………………………………6
i. Practice Specifications…………………………………………………6
4. II. Recommendations for Best Practices……………………………………………….8
a. Technical Specifications………………………………………………………9
i. Image Acquisition……………………………………………………...8
ii. Image Storage, Retrieval & Transmission……………………………..9
iii. Image Display………………………………………………………….10
b. Clinical Specifications…………………………………………………………11
5. III. Optional Steps Towards Optimizing Teledermatology Practices………………….11
a. Technical Specifications………………………………………………………..11
i. Image Acquisition……………………………………………………...11
ii. Image Storage, Retrieval & Transmission……………………………..13
iii. Image Display………………………………………………………….13
6. Glossary………………………………………………………………………………..15
7. Appendix A……………………………………………………………………………16
8. Appendix B…………………………………………………………………………….18
9. References……………………………………………………………………………..21
The American Telemedicine Association (ATA), with more than 2,500 members, is the
principal organization of telemedicine practitioners in the United States. The ATA is a
nonprofit society that seeks to bring together diverse groups from traditional medicine,
nursing, allied health professionals, academic medical centers, technology and
telecommunications companies, e-health, medical societies, government and others to
overcome barriers to the advancement of telemedicine through the professional, ethical and
equitable improvement in health care delivery. The ATA has strong ties and strategic
relationships with host organizations with other international telemedicine societies.
The ATA
will occasionally define new practice guidelines and technical standards for telehealth
practice to help advance the science of telehealth and to improve the quality of service to
patients. Existing practice guidelines and technical standards will be reviewed for revision or
renewal periodically.
The practice guidelines and technical standards generated by ATA have undergone a
thorough consensus and rigorous review, with final approval by the ATA Board of Directors.
The practice guidelines and technical standards recognize that safe and effective telehealth
practices require specific training, skills, and techniques, as described in each document.
Reproduction or modification of the published practice guideline and technical standard by
entities that do not provide these services is not authorized.
V1.2007 3
Preamble
These guidelines are designed to serve as both a consensus operational best practice reference
based on clinical empirical experience and an educational tool to aid practitioners in providing
appropriate telehealth care for patients. The practice of medicine is an integration of both the
science and art of preventing, diagnosing, and treating diseases. It should be recognized that
compliance with these guidelines will not guarantee accurate diagnoses or successful outcomes.
The purpose of these guidelines is to assist practitioners in pursuing a sound course of action to
provide effective and safe medical care that is founded on current information, available
resources, and patient needs. The guidelines are not meant to be unbending requirements of
practice and they are not designed to, nor should they be used, to establish a legal standard of
care. The American Telemedicine Association advises against the use of these guidelines in
litigation in which the clinical decisions of a practitioner are called into question.
The primary care practitioner is responsible for the decision about the appropriateness of a
specific procedure or course of action, considering all presenting circumstances. An approach
that differs from the ATA guidelines does not necessarily imply that the approach varied from
the standard of care. If circumstances warrant, a practitioner may responsibly pursue a course of
action different from these guidelines when, in the reasonable judgment of the practitioner, such
action is indicated by the condition of the patient, restrictions or limits on available resources, or
advances in information or technology subsequent to publication of the guidelines. Nonetheless,
a practitioner who uses an approach that is significantly different from these guidelines is
strongly advised to document in the patient record information adequate to explain the approach
pursued.
Introduction
Teledermatology is one of the most active applications of telemedicine rendered in the United
States. Dermatology is particularly suited to the use of advanced communication technologies
and the Internet for delivery of care. [1-38] By using advanced communication technologies,
dermatologists may be able to widen their reach to patients in a cost-effective manner,
ameliorating the maldistribution of specialty care. The following Guidelines were designed to aid
in the development and practice of coherent, effective, safe and sustainable teledermatology
practices. Establishing Guidelines for teledermatology may improve clinical outcomes and
promote informed and reasonable patient expectations.
The Practice Guideline for Teledermatology covers two major areas, reflecting the basic
component processes associated with most teledermatology consultations: technical and clinical
Administrative aspects of clinical teleconsultations in general are covered in the American
Telemedicine Association’s TeleHealth Administrative document. [39] In teledermatology,
store-and-forward (S&F) communication typically refers to the sending or forwarding of digital
images and associated patient data to the specialist for storage and consultation. For real-time
video teleconferencing (VTC), providers and patients interact via live videoconferencing. The
recommendations apply to S&F, VTC and hybrid (utilizing both S&F and VTC) modes for
teledermatology.
The document contains Guidelines for the practice of teledermatology that are required whenever
feasible and practical as determined by the referring clinician practicing under local conditions.
These Guidelines are presented first in the document and are identifiable in the text when “shall
V1.2007 4
is used (indicated by bold italics). In the following section, the document also contains
Recommendations for Best Practices that are indicated in the text by “should” to indicate an
optimal recommended action, one that is particularly suitable, without mentioning or excluding
others. The third section contains optional or permissible action indicated by “may/attempt to” to
indicate additional points that may be considered to further optimize the teledermatology consult
process.
A glossary of important terms, references to literature, and informative web sites are included at
the end of the document for further consideration. An Appendix is included with information
about the Digital Imaging & Communications in Medicine (DICOM) standard that is likely to
impact the practice of teledermatology in the very near future.
I. GUIDELINES FOR THE PRACTICE OF TELEDERMATOLOGY
a. Technical Specifications
i. Organizations shall ensure the technical readiness of the telehealth
equipment and the clinical environment. [40]
ii. Organizations providing telehealth services shall have processes in place
to ensure the safety and effectiveness of equipment through on-going
support and maintenance. [40-41]
iii. Organizations providing telehealth services shall have policies and
procedures in place to ensure the physical security of telehealth equipment
and the electronic security of data. [42]
1. Image Acquisition
a. Spatial Resolution: Spatial resolution is the ability of an
imaging system (e.g., digital camera) to permit two
adjacent structures to be perceived as being separate, or as
the distinctness or sharpness of an edge. [43-45] Spatial
resolution is the property of the actual image once
displayed (either on a digital monitor or printed out) and is
typically defined as number of pixels per inch (ppi).
i. For a digital device, a minimum of 75 ppi (pixels
per inch) shall be used. [44-46]
ii. For VTC, spatial resolution shall be a minimum of
full Common Intermediate Format (CIF) [352 x 240
NTSC; 352 x 288 PAL] with a preferred minimum
of 2 CIF [704 x 240 NTSC; 704 x 288 PAL].
b. Metadata Labeling/Tagging: All images associated with an
exam shall be appropriately labeled and tagged with patient
identifiers and when not encrypted, shall be linked
accurately to a patient and exam record that includes at a
minimum patient name, exam date, referring healthcare
provider and facility at which the exam took place. If VTC
video is stored it shall be labeled and marked with the
appropriate acquisition date and time to insure easy
retrieval.
2. Image Storage, Retrieval & Transmission
V1.2007 5
a. Security: United States Health Insurance Portability &
Accountability Act (HIPAA) [42] and state privacy
requirements shall be followed at all times to protect
patient privacy. Network and software security protocols to
protect privacy and confidentiality shall be provided as
well as appropriate user accessibility and authentication
protocols. Measures to safeguard data against intentional
and unintentional corruption shall be in place during both
storage and transmission.
i. Encryption: HIPAA requires that encryption (128
bit) of Electronic Protected Health Information
shall be addressed. [47] Consistent with HIPAA
and good practice, video sessions shall be secured
to the greatest practical extent.
b. Personal Computer/Network Storage/Picture Archiving &
Communications System (PACS): Storage shall comply
with all facility, state and federal regulations that pertain to
medical record retention. Images stored at both the
transmitting and receiving sites shall meet the jurisdictional
requirements of those sites.
c. Retrieval and transmission: Retrieval and transmission of
images (and audio for VTC) shall be done over a secure
network and a secure protocol should provide reliable
exchange of medical information. Transmission of
information over public or non-secured networks shall be
encrypted.
3. Image Display
a. Resolution: The resolution of the display monitor should
match as closely as possible the resolution of the acquired
image being displayed, or the originally acquired image
resolution should be accessible using zoom and pan
functions. A monitor with a minimum of 0.19-dot pitch
shall be used.
b. Luminance: Luminance specifies the perceived brightness
of a display. It is typically measured in Candelas per
Square Meter (cd/m
2
). The maximum to minimum
luminance ratio shall be at least 250 and manufacturers
provide this value typically as the brightness of the
monitor. The minimum luminance of the display should not
be smaller than the ambient (i.e., room) luminance. A
minimum of 0.5 cd/m
2
is recommended. Precise luminance
measurements can be made using a photometer or many
off-the-shelf calibration programs come with the required
photometer (often called a puck). [48-49]
c. Contrast: The contrast ratio (CR) is the ratio of the
luminance between the brightest white and the darkest
V1.2007 6
black that a display can produce. The higher the CR, the
sharper the image is perceived to be. CRs of 1:500 or
higher shall be used. The CR is greatly affected by ambient
light conditions, being reduced significantly with higher
room illumination levels. Monitors with wide viewing
angles are preferred since those with narrower viewing
angles tend to result in significant decreases in contrast
when viewed off angle.
b. Clinical Specifications
i. The telemedicine operation and its health professionals shall insure that
the standard of care delivered via telemedicine is at least equivalent to any
other type of care that can be delivered to the patient/client, considering
the specific context, location and timing, and relative availability of
traditional care.
ii. Health professionals shall be responsible for maintaining professional
discipline clinical practice guidelines to guide the delivery of care in the
telemedicine setting, recognizing that certain modifications may need to
be made to accommodate specific circumstances.
iii. Any modifications to specialty specific clinical practice standards for the
telemedicine setting shall ensure that clinical requirements specific to the
discipline are maintained.
iv. Health professionals providing telemedicine services shall have the
necessary education, training/orientation, and ongoing continuing
education/professional development to insure they possess the necessary
competencies for the safe provision of quality health services.
v. When guidelines, position statements or standards exist from a
professional organization or society such as the American Academy of
Dermatology (AAD) [50-51] they shall be reviewed and incorporated into
practice whenever safe and feasible. The specifications listed below are
not meant to supercede those of existing guidelines, position statements or
standards exist from a professional organization or society.
1. Practice Specifications
a. VTC: All persons in the exam room at both sites shall be
identified to all participants prior to the consultation.
b. Exam inclusion criteria/scope: All aspects of
dermatological care are suitable for teledermatology care:
skin, hair, nails and mucosas, including genitalia, unless
specified in the exclusion criteria. Teledermatology
encompasses pediatric and adult patients, all ethnicities,
and both genders. The inclusion of cases for a
teledermatology consult is ultimately at the discretion of
the referring and consulting clinicians.
c. Special Considerations: The exclusion of certain types of
cases from a teledermatology consult is ultimately the
discretion of the referring and consulting clinician. There
V1.2007 7
are certain types of exams/cases that may require special
consideration.
i. Full body exam: A full body skin exam using VTC
and S&F is possible, but it may not show all skin
surfaces sufficiently. Enhanced lighting may be
helpful.
ii. Hair-bearing skin: It is important to approach scalp
lesions (and those in other areas with lots of hair)
carefully. Special lighting may enhance viewing
conditions.
iii. Pigmented lesions: Pigmented lesions may present a
diagnostic challenge and may require a higher index
of suspicion when interpreting. Peripheral devices
such as dermatoscopes may be incorporated into
teledermatology consultations.
iv. Mucosal lesions: Mucosal lesions and orifices,
including genitalia, should be carefully assessed.
v. Skin color: Lighting and background conditions
may influence the recorded appearance of different
colors compared to how they appear in person.
d. Consult request data: As with any consultation,
information needs to be shared about the patient between
the referring and consulting clinicians.
i. Patient demographics: Age, gender, race shall be
included.
ii. Clinical history/results: This consult request shall
include the chief complaint, allergies and
medications. Information that may be useful
includes symptoms, duration, previous treatment for
the presenting condition and its response,
medications, personal and family history of any skin
cancers, and prior and existing medical/skin
conditions.
iii. Reports: As with any consultation, there shall be a
traceable record of the teleconsultation at both the
referring and consulting sites, containing at a
minimum the information in i-ii above and the
consult report. The consultant’s opinion and any
services that were ordered or performed shall also
be documented in the patient’s medical record and
communicated by written report to the requesting
physician or other appropriate source (e.g.,
physician assistant, nurse practitioner, doctor of
chiropractic, physical therapist, occupational
therapist, speech-language therapist, psychologist,
social worker, lawyer, insurance company).
V1.2007 8
Recommended language for the consultant includes
“Based on the images and history provided, my
impression is as follows.”
1. VTC: The reports can be done verbally, but a
written record of the interaction shall be
kept at least at one side (referring and/or
consulting). Reports may be faxed, mailed
or electronically sent after the interaction
has ended and should be done using secure
methods.
2. S&F: Electronic, faxed, mailed or e-mailed
notes shall be part of the patient’s medical
record and sent to the referring provider. If
the consulting clinician annotates the images
in any way, these annotated images may be
sent back to the referring clinician and
included in the record as well.
3. Consultant Report: This report shall include
at a minimum the diagnosis and/or
differential diagnoses, a summary of the
findings, and recommended management.
II. RECOMMENDATIONS FOR BEST PRACTICES
a. Technical Specifications
i. Organizations should have appropriate redundant systems and appropriate
recovery procedures in place that ensure availability of the network for
critical connectivity.
ii. Organizations should insure compliance with all relevant safety laws,
regulations, and codes for technology and technical safety. [40-41]
iii. Organizations should have infection control policies and procedures in
place for the use of telehealth equipment and patient peripherals.
1. Image Acquisition: Image quality is an essential component in
assuring the optimal communication of patient image data to the
dermatologist for teleconsultations. The following parameters of
image acquisition and display can be accounted for and optimized
as indicated to help insure the best possible diagnostic
interpretation environment. [43-44]
a. Device (e.g. digital camera): Digital cameras should be
used for image capture. They have better color acquisition,
white point adjustment and focus than cell phones, PDAs
(Personal Digital Assistant) or other dual-task devices with
cameras.
i. VTC: A dedicated patient exam camera should be
used for close-up views, while the general VTC
camera can be used for overviews. It is important to
keep the patient exam camera as steady as possible
V1.2007 9
during imaging/viewing to avoid motion artifacts. If
necessary a camera stand can be used to minimize
motion. Freeze frame can be used to capture still
images during a video sequence.
b. Macro: The macro mode should be used when appropriate
to acquire close-up images. The macro mode uses a special
lens designed specifically for close-up photography that
adjusts the focus to properly capture near objects. If the
macro mode is used then digital or physical zoom should
not be used at the same time.
c. Color Bit-depth: The acquisition device should allow for at
least 24 bits of color.
d. Compression: If the acquisition device automatically
applies compression (e.g., JPEG) the type and amount of
compression should be known. [44,46]
e. Room Lighting: The room in which the photography is
done should be well lit (150 ft candles at the patient
recommended), preferably using light sources as close to
white light as possible (i.e., fluorescent day-light or full
spectrum bulbs rather than incandescent).
f. White balance: Some digital cameras come with a white
balance function that can be adjusted, while others come
with auto-mode white balance. [44,52-54] White balance
should be set to obtain accurate colors in the image.
i. White balance for VTC: Each camera used for VTC
should be white balanced separately, i.e., both the
“main” (pan-tilt-zoom) camera and the “peripheral”
video microscopes/examination cameras. It should
be done for every session.
g. Backdrop: A non-reflective surface should be used as a
backdrop behind the region of interest whenever possible.
The background should be clean and plain in color (no
patterns or lines; neutral gray or dark blue blue is
preferred for VTC) and neither too shiny or too dark.
Ideally the backdrop should be outside the focal plane so as
not to distract during image viewing.
h. Viewpoint: In general, all images should be taken
perpendicular to the plane of the lesion. Include oblique
views if the lesion is subtle and difficult to evaluate in
height.
i. Clothing, jewelry & makeup: Clothing, jewelry & makeup
should be removed to obtain adequate viewing if
necessary.
2. Image Storage, Retrieval & Transmission
a. Storage medium in device (memory stick, secure digital,
compact flash, etc): All acquisition devices should have a
V1.2007 10
method for storing the acquired image data at its original
acquired resolution (whether or not compression is
automatically applied). The device should have a method
for warning the user if image data are going to be deleted
so the image data can be transferred to a secure archive.
Both fixed and transportable media are acceptable for
backup and archive purposes. Proper security measures
should be taken with portable devices since they may
contain identifiable patient data.
3. Image Display: There are many types of digital (i.e., computer)
displays available. Most displays contain a list of the most relevant
display property specifications. These specifications should be
considered when purchasing a display device.
a. QA/QC: Initial quality assessment (QA) should take place
when the monitor is purchased. Although manufacturers
calibrate monitors before shipping, changes can take place
because of movement etc. during shipping. Drifts in the
calibrated settings can occur as well simply as a function of
time. Quality Control (QC) should take place on a periodic
basis looking minimally at luminance levels (maximum and
minimum), gamma and white point. Older displays may
require more frequent QC.
b. Warm-up time: Displays should warm-up about 30 minutes
before being used to interpret images.
c. Tools: Image processing and manipulation tools should be
available when viewing images. Brightness, contrast, zoom,
pan and rotate (to access the originally acquired spatial
resolution) are a minimum set of tools available for the
specialist. To increase viewing speeds, presets may be
considered. Rotating and flipping are also useful since
many images do not appear in the proper orientation. Tools
for calculating linear distances and/or areas are useful.
i. VTC: Either the referring or consulting site should
have the ability to control the zoom and pan (up,
down, right, left) of the general room camera. When
capturing images for diagnosis, the camera should
be as still as possible to avoid motion artifacts. If
necessary a camera stand or tripod may be used.
d. Ambient room light levels: Some ambient room light is
required for optimal viewing. Approximately 25-40 lux
should be used. [55] Higher levels contribute to glare while
lower levels affect the visual system’s dark adaptation.
e. Ergonomic considerations: The comfort of the
dermatologist interpreting the images should be considered
to prevent fatigue, computer vision syndrome problems and
V1.2007 11
repetitive stress injuries common with increased computer
interactions. [56]
b. Clinical Specifications
i. Imaging protocols: Basic imaging protocols should be used whenever
possible. [57-59]
1. Identify anatomical units based on location(s) of skin involvement:
If more than one area is involved, all regions involved should be
included.
a. Anatomic Standard Views: A standard set of images for
each anatomic location should be used.
i. Head/Neck
ii. Trunk
iii. Arms
iv. Legs
v. Buttocks/Groins
vi. Hands
vii. Feet
2. Close-up: Detailed views designed to show the surface texture,
topography, color and architecture of the lesion should be used.
Clearly identify, focus and center the lesion in the close-up view.
ii. Complementary views: Complementary views should be included. For
example, if the hands are involved it is useful to include the feet and
perhaps evaluate and document the elbows and knees as well. [57 provides
a complete table of complementary image sets]
iii. Lesion identification: Lesions should be localized especially if there is
more than one lesion in a field of view or if it is difficult to see. The
placement of the identification marker should be close enough to the
lesion to clearly mark it without covering any portion of it.
1. On the skin: Lesions can be identified using sticky labels, surgical
tape, washable markers and other easily placed and removed tools.
2. In the image: Before sending the image, many programs will allow
the user to add a digital circle, box or arrow to the image as well as
digitally added numbers.
iv. Measurement: A ruler should be included in each image (general and
close-up) in close proximity to the lesion so that size/extent can be
determined from the image. [43]
v. Chaperone or guardians: A chaperone or legal guardian should be used as
required.
vi. QA/QC: Images should be reviewed during the acquisition process to
insure acceptable quality.
vi. Peripheral devices: Peripheral devices such as dermatoscopes may be
incorporated into teledermatology consultations.
V1.2007 12
III. OPTIONAL STEPS TOWARDS OPTIMIZING TELEDERMATOLOGY
PRACTICES
a. Technical Specifications
i. Image Acquisition
1. Color: Digital cameras capture only shades of gray. Filters that are
sensitive to certain wavelengths (blue, green & red) filter certain
wavelengths to the sensor pixels creating, by various wavelength
combinations, color. The sensors and filters of each manufacturer’s
camera typically differ so color rendition is typically different for
each camera model. Cameras may be characterized before
capturing images for diagnostic purposes. [44,60] Video cameras
come in two general types.1-chip cameras use a single chip to
process all the colors, while the 3-chip cameras uses one chip each
for red, blue and green. The 3-chip cameras are generally more
expensive but the color rendition is typically better.
a. Implementation strategy: One method to accomplish this is
to attach a color calibration label (e.g., GreTag Macbeth
Color Chart) to at least one image (preferably all) in a
patient/case image set. [52,60-61] The same color label is
then shown on the display being used to interpret the
images and the user gauges visually how well the display
device renders the color label (i.e., how well they match). If
the colors do not match, the monitor should be adjusted
using the display settings function in the computer control
or using color calibration software tools. [48-49,52,60-65]
In some cases a perfect match may not be possible.
2. Compression: Most digital cameras come with automatic settings
for high, medium and low compression of images, typically using
the JPEG compression scheme. Higher compression means that the
final image size is smaller and thus will transmit more quickly, but
at the expense of a potential loss in image quality. Lower
compression levels give larger file sizes, but the images tend to be
of a higher quality. In general, medium and low compression are
recommended (nothing greater than 20:1). Some cameras use the
high, medium and low to indicate the quality of the image rather
than the compression levels. The manufacturers specify what these
settings mean and generally provide the compression levels
associated with each setting.
3. Flash: The digital camera may have flash capability. If it does, it is
recommended that the flash output be adjusted to avoid washout of
close-up images. [43,52] Do not use the flash if washout occurs.
4. White balance: White balance may be adjusted and can contribute
to the overall color accuracy of the image so that the captured
image faithfully reproduces the live scene.
a. Implementation strategy: If the camera being used to
acquire cutaneous digital images is not being operated in an
V1.2007 13
automatic mode and does have a white balance function it
can be calibrated if the camera offers such capability. To
calibrate the white balance of a camera, aim the camera at a
white field using the ambient room light levels to be used
when capturing images. Fill the view with the white scene
and press the white balance tool on the camera (separate
button or in the menu). Some cameras have several pre-set
white balance adjustments (e.g., fluorescent lights,
outdoors) that can be used and matched for a given lighting
condition.
5. Auto-focus: Some cameras come with an auto-focus option that
generally does a good job of properly focusing the subject properly
at the appropriate depth. Limitations occur when ambient lighting
or contrast conditions are low and if there are not enough linear
edges in the field, leading to blurry images. The auto-focus option
can generally be turned off if necessary to obtain sharp pictures
using manual focus. [43] If the camera allows for it, use of spot
focus or center-weighted focus can be used tro assist in proper
focusing.
6. Audio synchronization: If using real-time VTC, audio
synchronization, good vocal tone and punctuation are important to
avoid overlapping conversations during live sessions due to normal
delays in transmission times. Speakers and microphone should be
placed nearby for adequate capture and transmission of sound
without being in the way. Echo canceling should be used.
ii. Image Storage, Retrieval & Transmission
1. Security with watermarking: Watermarking techniques are an
option to insure that if images are modified or manipulated without
permission, the changes are detectable. Editing of watermarked
images is typically allowed to only specific individuals with
permission.
2. Security with VTC: Security (to comply with HIPAA) may be
accomplished via one or more of the following methods.
a. Video encryption: Using the inherent real-time video
encryption in contemporary CODECs.
b. Virtual private networks (VPNs): Hardware and/or software
based systems that “tunnel” secure network sockets over
public networks can be used.
c. Isolated (private) networks: This may involve either private
VTC circuits or separate packet-based networks that do not
physically or logically interconnect with public networks.
d. Firewalls: It should be noted that firewalls only offer
protection behind the firewall. VTC sessions with sites
beyond the firewall’s protection are not necessarily
protected.
iii. Image Display
V1.2007 14
1. Color: A simple method for color calibration is to obtain a copy of
the Gretag Macbeth ColorChecker Chart (a printed chart of 24
colored squares [66]) and visually adjust the display to match as
closely as possible the chart colors. [48-49,52,60-66] For more
precise calibration when feasible, it is recommended that a color
temperature setting of 6500 deg K (D65, or sRGB are also
notations used) be used for most picture viewing (most new
monitors come at this setting). The gamma level should be set at
2.2 to allow maximum display of color range (most new monitors
come at this setting). Set the bit depth to a minimum of 24 using
the Display function in the Settings option of the monitor. Color
settings can be adjusted via the monitor itself or through software.
The DICOM (Digital Imaging & Communications in Medicine)
Grayscale Standard Display Function (GSDF) can also be used to
calibrate a display. [67-69]
a. Off-the-shelf devices such as the Spyder from ColorVision
can be used easily to calibrate color displays. These devices
come with a “puck” that records the luminance levels of a
display in association with software that uses these
measurement to calibrate the display to a selected setting.
2. Ambient room light levels: Ambient light can be measured using a
photometer or some digital cameras that have flash meters can
measure the ambient illumination level. If neither method is
feasible, display a typical clinical image on the monitor being used
and adjust the room lights until they appear to be about the same
level as the display. If the lights are not adjustable, it is better to
turn the ambient lights off rather than have them on. Diffuse
backlighting (behind the display) is preferred to direct overhead
lighting to avoid glare and reflections. Fluorescent (day-light or
full spectrum bulbs) are preferred to incandescent lights.
3. Ergonomic considerations: The following factors may be
considered.
a. Computer workstations require adequate airflow, optimal
room temperature and humidity controls.
b. If more than one workstation is in an area, consider
shielding them from each other to reduce noise (especially
if electronic dictation methods are being used).
c. Proper chairs with sufficient lumbar support can help avoid
well-known back, shoulder and neck injuries.
d. The workstation table and keyboard height can be adjusted
and the location of the keyboard and mouse should be
optimized for comfort and efficiency.
e. Easy access to dictation and other necessary tools (e.g.,
reference tools, access to the Internet) while at the
workstation improves workflow.
V1.2007 15
GLOSSARY
1. bit depth: The number of pieces of digital data (bits) used to store information about
each pixel. With 8 bits there are 256 colors available and with 24 bits there are
16,777,216 colors available.
2. CODEC: A device or program capable of performing encoding and decoding on
digital data streams or signals.
3. compression: A method to reduce the volume of data using encoding to reduce
image processing, transmission times, bandwidth requirements, and storage
space requirements. Some compression techniques result in the loss of some
information, which may or may not be clinically important.
4. dot pitch: Specification for computer displays that describes the distance between
LCD cells of the same color within the display screen (or phosphor dots in a
CRT). It is measured in mm and the smaller the number the sharper the image
(more dots per given area).
5. metadata: Information that describes a central set of data. In teledermatology, the
captured image is the data and metadata associated with that image can consist
of items such as patient name, date, time and so on.
6. ppi: pixels per inch or pixel density referring to the resolution of a computer display
or printed document.
7. Resolution: Spatial resolution is the ability of an imaging system (e.g., digital
camera) to permit two adjacent structures to be perceived as being separate.
8. white balance: The process of removing unwanted color casts in images so that
white objects appear white. White balancing takes into account the color
temperature (i.e., the spectrum of light radiated) of the light source in the
scene and adjusts white levels in reference to the scene color temperature.
V1.2007 16
Appendix A
Existing Digital Imaging Standards
This is not meant to be a comprehensive list of all existing standards, but rather provides a
description of the standards most relevant to the practice of teledermatology.
a. ISO/TC42/WG18 12233: This standard was developed (by the International Standards
Organization ISO [70]) for photography/electronic still picture imaging. Section 12233 includes
a resolution test chart and three measurement methods, including a computerized method of
measuring the spatial frequency response.
b. ITU-T: The International Telecommunications Union has established a series of standards
(H.300) for VTC. It includes such sections as the H.320 series for circuit-switched, n x 64 (i.e.,
ITU-T); the H.323series: packet-switched/network, Internet Protocol; and the H.324: Plain Old
Telephone Service (POTS).
c. Session Initiation Protocol (SIP): The Internet Engineering Task Force RFC 3261 also
applies to VTC. SIP is a text-based protocol for initiating interactive communication sessions
between users, including voice, video, chat, and virtual reality.
d. DICOM: The Digital Imaging & Communications in Medicine standard has a number of
sections dealing with medical image handling, transmission, archiving, and display. Originally
developed for Picture Archiving and Communications Systems (PACS) in radiology, many
components of this standard are being adapted for use in other medical imaging applications.
[67] DICOM currently has a visible light supplement that makes the DICOM standard relevant to
teledermatology. Appendix A provides additional details on the rationale for migrating
teledermatology to DICOM. Currently DICOM standards have two components:
ii. Information object definition: Assigns attributes to the information
contained to be identified such as file name, patient name, medical
record number, demographics, date, time etc.
iii. Services: Sends, stores and retrieves the object.
e. JPEG/TIF/WAV: Some of the most common compression methods used for still images
include the following. The method used depends on the achievable compression ratio and the
number and types of artifacts created during compression. Lossless compression allows for the
reconstruction of the exact original data prior to compression without any loss of information.
Lossy compression refers to methods that lose data once the image has been compressed and
uncompressed. The level of compression and method used affect the amount of data loss and
whether or not it is visually perceptible. The type and level of compression may vary depending
on the type of exam. Different compression algorithms will achieve different compression ratios
with varying degrees of artifacts. The choice of compression method and level should be
reviewed periodically for each image and exam type, to insure that artifacts are not perceptible. It
should be noted that lossy compression can affect the colors in an image.
1) JPEG (2000): JPEG 2000 uses wavelet technology that allows an image to be retained
without any distortion or loss. [71] File extensions for JPEG 2000 are either .jp2 or .j2c
(traditional JPEG is either .jpg or .jpeg).
V1.2007 17
2) TIF: Tagged Image File Format used for formatting and compressing images. It can be
lossy or lossless. The file extension TIF is .tiff or .tif.
3) WAV: A method of compression using wavelets transforms (mathematical functions
that divide data based on frequency components). There are a variety of file extensions
depending on the wavelet method used. It can be lossy or lossless.
f. HL7: Health Level Seven is one of several American National Standards Institute (ANSI)
Standards Developing Organizations (SDOs) operating in the healthcare arena. Health Level
Seven’s domain is clinical and administrative data. [72]
g. IHE: Integrating the Healthcare Enterprise is an initiative to improve how computer systems
in healthcare share information. It promotes coordinated use of established standards such as
DICOM and HL7 to address specific clinical needs to support optimal patient care. [73]
h. US HIPAA: The United Sates Health Insurance Portability & Accountability Act of 1996
(Public Law 104-191)calls for improved efficiency in healthcare delivery by standardizing
electronic data interchange, and the protection of confidentiality and security of health data
through setting and enforcing standards. [42,47] It has rules for:
1) Standardization of electronic patient health, administrative and financial data
2) Unique health identifiers for individuals, employers, health plans and health care
providers
1) Security standards protecting the confidentiality and integrity of “individually identifiable
health information,” past, present or future.
i. JCAHO: The Joint Commission evaluates and accredits nearly 15,000 health care
organizations and programs in the United States. An independent, not-for-profit organization,
The Joint Commission is a standards-setting and accrediting body in health care. Since 1951, The
Joint Commission has maintained state-of-the-art standards that focus on improving the quality
and safety of care provided by health care organizations. The Joint Commission’s comprehensive
accreditation process evaluates an organization’s compliance with these standards and other
accreditation requirements. Joint Commission accreditation is recognized nationwide as a
symbol of quality that reflects an organization’s commitment to meeting certain performance
standards. To earn and maintain The Joint Commission’s Gold Seal of Approval™, an
organization must undergo an on-site survey by a Joint Commission survey team at least every
three years. (Laboratories must be surveyed every two years.) [40]
V1.2007 18
Appendix B
DICOM for Teledermatology
Migrating Teledermatology to DICOM: There are two reasons for using DICOM for the creation
of an image object. First, it is desirable to create standard formatted dermatology image objects
that contain a predefined set of metadata elements like the patient name and identifier. Second, it
is advantageous to be consistent with the rest of the digital medical imaging community in order
to take advantage of existing interoperability opportunities (e.g., Integrating the Healthcare
Enterprise).
A DICOM image object is composed of a set of metadata elements followed by the image, and is
processed (that is, created, transmitted, stored, reviewed, archived, etc.) as a single entity. The
metadata consist of a specific set of data elements that are defined in the DICOM Standard for a
clinical discipline and an acquisition technology. DICOM was originally developed for
radiology and has been very successful there. It is now being used in other clinical specialties
like cardiology, dentistry, ophthalmology, endoscopy, and pathology.
Teledermatology provides an opportunity for DICOM to be used in the “low tech, low cost”
clinical settings, where there may be no healthcare system infrastructure at all. Teledermatology
is generally practiced by acquiring images with a digital camera, downloading them to a personal
computer (PC) or telemedicine workstation, attaching them to an email message, and sending
them to the dermatology consultant. DICOM can be used to standardize the image acquisition
process, the store and forward process, and the reading review process, and to do so at a low
cost.
Acquisition Software
A DICOM image acquisition software package needs to be loaded onto the PC that is going to be
used to obtain patient and study identification information, receive the images from the digital
camera, create DICOM objects from the metadata and the raw images, and send them to the
consulting service.
The DICOM metadata contained in every image object includes patient and study identification
information as well as clinical data. This is usually obtained by the DICOM software at the
beginning of the image acquisition session, although some image specific information (for
example, body site or laterality), acquisition parameters (for example, type of camera and
setting), and comments (for example, “Patient not cooperative”) may be input during the imaging
process.
Table 1 shows the set of data elements representative of the types of data that can be acquired
prior to the imaging process.
Data Element Tag (group, element)
Institution Name (0008,0080)
Institution Address (0008,0081)
Referring Physician’s Name (0008,0090)
Referring Physician’s Address (0008,0092)
Referring Physician’s Telephone Numbers (0008,0094)
Patient Name (0010,0010)
V1.2007 19
Data Element Tag (group, element)
Patient ID (0010,0020)
Issuer of Patient ID (0010,0021)
Patient’s Birth Date (0010,0030)
Patient’s Sex (0010,0040)
Other Patient IDs (0010,1000)
Patient’s Weight (0010,1030)
Patient’s Address (0010,1040)
Patient’s Telephone Numbers (0010,2154)
Additional Patient History (0010,21B0)
Reason for Study (64 characters only) (0032,1030)
Requested Procedure Description (0032,1060)
Study Comments (0032,4000)
Table 1: The set of data elements representative of the types of data that can be acquired prior to
the imaging process.
Values for some of these data elements, like the institution and referring physician information,
can be set via site-configurable options. Other data elements, like the patient and study
information, need to be acquired on a study-by-study basis. There are two ways to do this. If the
clinic has an order entry application as part of an Electronic Health Record (HER), it may be
possible to electronically transfer this information to the image acquisition system using the
DICOM Modality Worklist service. In the absence of such facilities, the data needs to be entered
manually.
Once this information is obtained by the DICOM software image acquisition can be performed.
As each image is acquired, additional information about the body site may need to be entered.
After the images are acquired, they are joined with their corresponding metadata and are formed
into DICOM objects. These DICOM objects are then sent to the consulting service.
Transferring the DICOM Objects
There are three different ways to send DICOM objects, depending upon the technical capabilities
of the consulting service.
If Internet connectivity does not exit, the DICOM objects can be written onto CD or DVD and
sent to the consultant via physical mail. The IHE Portable Data for Imaging (PDI) integration
profile specifies the implementation details for this. [73,74] The DICOM objects are written to
media along with an additional file named DICOMDIR containing the manifest and indexing
information. The IHE PDI requires that a diagnostic quality DICOM viewer be provided on the
media to display the DICOM images. It also recommends that the DICOM images be provided
on the media in web-enabled viewing format (typically JPEG).
If adequate Internet connectivity exists the DICOM objects can be sent via email. In this case,
the sender places the DICOM objects in a folder along with the DICOMDIR file, similarly to
what is done in the IHE PDI. The whole folder is then ZIPed, encrypted, attached to an email
message as DICOM.ZIP, and sent to the consulting service.
If the consulting service is DICOM enabled and there is a reliable permanent network connection
to it, the images can be transferred using the DICOM Storage Service Class communications
V1.2007 20
message exchange protocol. This is the method that would most likely be used in a secure
technically well-developed enterprise.
Reading Site
If the consulting service did not support DICOM at all, it should be able to handle the IHE PDI
portable media.
In order to handle the DICOM.ZIP email attachment, the consulting service would minimally
need to have a DICOM viewing application that would display the contents of the DICOM.ZIP
attachment. These are available from many sources free of charge. [75]
It the consulting service had a DICOM EHR/PACS and wanted to import the study from the
portable media or the email, then the IHE Import Reconciliation Workflow integration profile
can be used. [38] This allows the study to be directly imported into a DICOM EHR/PACS.
Implementation
If there is an order entry application available on an EHR system, then the image acquisition
workstation can use the DICOM Modality Worklist service to download the ordering
information. If the order entry application does not exist, then the same information needs to be
entered manually on the image acquisition workstation.
The images are acquired from the camera using whatever means are necessary to transfer them
(USB, removable memory device, TWAIN, etc.). The metadata for the study is incorporated in
the headers when these images are converted to DICOM. The images would use the DICOM
Visible Light Image SOP Class until a DICOM Dermatology SOP Class is defined. It is
assumed that the images would be lossy JPEG compressed approximately 25:1. (This is only a
convenience for the telecommunications.) The transfer syntax would be either for JPEG Process
1, JPEG Process 14, or JPEG 2000 lossy. The annotations would be conveyed using the
Grayscale or Color Softcopy Presentation State SOP Classes.
The DICOM objects would be placed into a folder and treated as a virtual DICOM file set
following the IHE Radiology Portable Data for Imaging (PDI) integration profile. The file set
would zipped and encrypted following the DICOM Standard (PS 3.11-2007 Annex L
(Normative) – ZIP File over Email Interchange Profiles). The display of the images by the
consultant is also defined by the IHE Radiology Portable Data for Imaging integration profile.
Should the consultant wish to import the study into their PACS, the IHE Radiology Import
Reconciliation Workflow integration profile would be used.
A minor issue that needs to be resolved is that while the IHE PDI specification handles only
uncompressed images, the dermatology consult images are lossy compressed.
The results would be formatted as an HL7 CDA XML-encoded document, with a style sheet
(XSLT). This would enable them to be easily display by the referring provider and would allow
the further utilization of the discrete data.
V1.2007 21
REFRENCES
1. Jones DH, Crichton C, Macdonald A, et al. Teldermatology in the Highlands of
Scotland. J Tyelemed Telecare 1996;2:7-9.
2. Kvedar JC, Edwards RA, Menn ER, et al. The substitution of digital images for
dermatologic physical examination. Arch Dermatol 1997;133:161-167.
3. Zelickson BD, Homan L. Teledermatology in the nursing home. Arch Dermatol
1997;133:171-174.
4. Lyon CC, Harrison PV. A portable digital imaging system in dermatology: diagnostic
and educational applications. J Telemed Telecare 1997;3:81-83.
5. Philips CM, Burke WA, Shechter A, et al. Reliability of dermatology
teleconsultations with the use of teleconference technology. J Am Acad
Dermatol 1997;37:398-402.
6. Philips CM, Burke WA, Allen MH, et al. Reliability of telemedicine in evaluating
skin tumors. Telemed J 1998;4:5-7.
7. Lesher JL, Davis LS, Gourdin FW, et al. Telemedicine evaluation of cutaneous
diseases: a blinded comparative study. J Am Acad Dermatol 1998;38:27-31.
8. 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;139:81-87.
9. Lowitt MH, Kessler II, Kauffman CL, et al. Teledermatology and in-person
examinations: a comparison of patient and physician perceptions and
diagnostic agreement. Arch Dermatol 1998;134:471-476.
10. Loane MA, Corbett R, Bloomer SE, et al. Diagnostic accuracy and clinical
management by realtime teledermatology. Results from the Northern Ireland
arms of the UK Multicentre Teledermatology Trialo. J Telemed Telecare
1998;4:95-100.
11. Reid DS, Weaver LE, Sargeant JM, et al. Telemedicine in Nova Scotia: report of a
pilot study. Telemed J 1998;4:249-258.
12. Loane MA, Bloomer SE, Corbett R, et al. Patient satisfaction with realtime
teledermatologty in Northern Ireland. J Telemed Telecare 1998;4:36-40.
13. Whited JD, Mills BJ, Dgugge RJ, et al. A pilot trial of digital imaging in skin cancer.
J Telemed Telecare 1998;4:108-112.
14. White H, Gould D, Mills W, et al. The Cornwall dermatology electronic referral and
image-transfer project. J Telemed Telecare 1999;5:85-86.
15. Whited JD, Hall RP, Simel DL, et al. Reliability and accuracy of dermatologists’
clinic-based and digital image consultations. J Am Acad Dermatol
1999;41:693-702.
16. Pak HS, Welch M, Poropatich R. Web-based teledermatology consult system:
preliminary results from the first 100 cases. Stud Health Technol Inform
1999;64:179-184.
17. Kvedar JC, Menn ER, Baradagunta S, et al. Teledermatology in a capitated delivery
system using distributed information architecture: design and development.
Telemed J 1999;5:357-366.
18. Krupinski EA, LeSuer B, Ellsworth L, et al. Diagnostic accuracy and image quality
using a digital camera for teledermatology. Telemed J 1999;5:257-263.
V1.2007 22
19. High WA, Houston MS, Calobrisi SD, et al. Assessment of the accuracy of low-cost
store-and-fgorward teledermatology consultation. J Am Acad Dermatol
2000;42:776-783.
20. Loane MA, Bloomer SE, Corbett R, et al. A comparison of real-time and store-and-
forward teledermatology: a cost-benefit study. Br JU Dermatol
2000;143:1241-1247.
21. Bergmo TS. A cost-minimization analysis of a realtime teledermatology service in
northern Norway. J Telemed Telecare 2000;6:273-277.
22. Wootton R, Bloomer SE, Corbett R, et al. Multicentre randomized control comparing
real time teledermatology with conventional outpatient dermatological care:
societal cost-benefit analysis. Br Med J 2000;320:1252-1256.
23. Chan HHL, Woo J, Chan WM, et al. Teledermatology in Hong Kong: a cost-effective
method to provide service to the elderly patients living in institutions. Int J
Dermatol 2000;39:774-778.
24. Lamminen H, Tuomi ML, Lamminen J, et al. A feasibility study of realtime
teledermatology in Finland. J Telemed Telecare 2000;6:102-107.
25. Nordal EJ, Moseng D, Kvammen B, et al. A comparative study of teleconsultations
versus face-to-face consultations. J Telemed Telecare 2001;7:257-265.
26. Taylor P, Goldsmith P, Murray K, et al. Evaluating a telemedicine system to assist in
the management of teledermatology referrals. Br J Dermatol 2001;144:328-
333.
27. va den Akker ThW, reker CHM, Knol A, et al. Teledermatology as a tool for
communication between general practitioners and dermatologists. J Telemed
Telecvare 2001:7:193-198.
28. Loane MA, Oekley A, Rademaker M, et al. A cost-minimization analysis of the
societal costs of realtime teledermatology compared with conventional care:
results from a randomized controlled trial in New Zealand. J Telemed
Telecare 2001;7:233-238.
29. Williams TL, May CR, Esmail A, et al. Patient satisfaction with teledermatology is
related to perceived quality of life. Br JU Dermatol 2001;145:911-917.
30. Lim AC, Egerton IB, See A, et al. Accuracy and reliability of store-and-forward
teledermatology: preliminary results from the ST. George Teledermatology
Project. Australas J Dermatol 2001;42:247-251.
31. Lamminen H, Lamminen J, Ruohonen K, et al. A cost study of teleconsultation for
primary care ophthalmology and dermatology. J Telemed Telecare
2001;7:167-173.
32. Loane MA, Bl,oomer SE, Corbett R, et al. A randomized comtrolled trial assessing
the health economics of realtime teledermatology compared with conventional
care: an urban versus rural perspective. J Telemed Telecare 2001;7:108-118.
33. Whited JD, Hall RP, Foy ME, et al. Teledermatology’s impact on time to intervention
among referrals to a dermatology consult service. Telemed J 2002;8:313-321.
34. Weinstock MA, Nguyen FQ, Risica PM. Patient and provider satisfaction with
teledermatology. J Am Acad Dermatolo 2002;47:68-72.
35. Krupinski EA, Barker G, Rodriguez G, et al. Telemedicine versus in-person
dermatology referrals: an analysis of case complexity. Telemed J 2002;8:143-
147.
V1.2007 23
36. DuMoulin MFMT, Bullens-Goessems YIJM, Henquet CJM, et al. The reliability of
diagnosis using store-and-forward teledermatology. J Telemed Telecare
2003;9:249-252.
37. Whited JD, Datta S, Hall RP, et al. An economic analysis of a store and forward
teledermatology consult system. Telemed J 2003;9:351-360.
38. Pak HS, Harden D, Cruess D, et al. Teldermatology: an intraobserver diagnostic
correlation study, part I. Cutis 2003;71:399-403.
39. Pak HS, et al. American Telemedicine Association TeleHealth Standards. 2007.
40. Joint Commission and Joint Commission International. http://www.jcrinc.com/ Last
accessed May 7, 2007.
41. Occupational Safety & Health Administration (OSHA). http://www.osha.gov/. Last
accessed May 7, 2007.
42. Health Insurance Portability and Accountability Act (HIPAA).
http://www.cms.hhs.gov/HIPAAGenInfo/ . Last accessed February 26, 2007.
43. Bhatia A, Kostuchenko P, Greenwood P. Digital cameras: still photography and video
imaging in teledermatology. In: Wootton R, Oakley A, eds. Teledermatology.
London: Royal Society of Medicine Press, 2002, pp. 41-55.
44. Madden BC, Miller CC. Teledermatology camera procedures and settings (v1.06):
Canon digital Rebel XT (350D). Brian.Madden@va.gov
45. About resolution: Understanding digital image resolution.
http://www.alpenglowimaging.com/resolution.htm. Last accessed April 6,
2007.
46. Whitehouse RW. Digital imaging. In: Wootton R, Oakley A, eds. Teledermatology.
London: Royal Society of Medicine Press, 2002, pp. 11-26.
47. Health Insurance Portability and Accountability Act (HIPPA) Security Standard.
http://www.cms.hhs.gov/SecurityStandard/ . Last accessed February 28, 2007.
48. ColorVision Spyder Calibration. http://www.colorvision.com/product-mc.php. Last
accessed February 23, 2007.
49. Color Schemer. http://www.colorschemer.com/online.html. Last accessed February
23, 2007.
50. American Academy of Dermatology and AAD Association Position Statement on
Telemedicine. http://www.aad.org/professionals/policies/policies_PDF.htm.
Last accessed February 27, 2007.
51. British Association of Dermatologists British Teledermatology Society.
http://www.teledermatology.co.uk/setting_up/index.asp. Last accessed
February 27, 2007.
52. Viopio V, Lamminen H. Lighting and colour in digital photography. In: Wootton R,
Oakley A, eds. Teledermatology. London: Royal Society of Medicine Press,
2002, pp. 27-40.
53. White Balance Tutorial. http://www.cambridgeincolour.com/tutorials/white-
balance.htm. Last accessed February 26, 2007.
54. Digital cameras – a beginner’s guide. http://photo.net/equipment/digital/basics/. Last
accessed February 26, 2007.
55. McEntee MF, Ryan J, Evanoff MG, Keeling A, Chakraborty D, Manning D, Brennan
PC. Ambient lighting: setting international standards for the viewing of soft
copy chest images. Proc SPIE Med Imag 2007;6515:65150M-1.
V1.2007 24
56. Occupational Safety & Health Administration (OSHA) workstation solutions.
http://www.osha.gov/SLTC/etools/computerworkstations/index.html
57. Pak HS. Implementing a teledermatology programme. J Telemed & Telecare
2005;11:285-293.
58. Phillips CM. Interactive teledermatology. EMedicine last updated January 27, 2007.
http://www.emedicine.com/derm/topic567.htm . Last accessed February 27,
2007.
59. Vidmar DA. The Idiot’s Guide to Teledermatology Imaging.
www.healthcare.hqusareur.army.mil/Telemedicine2004.02.04/Pubs/Telederm.
pdf
.
Last accessed February 27, 2007.
60. Vander Haeghen Y, Naeyaert JMAD, Lemahieu I. An imaging system with calibrated
color image acquisition for use in dermatology. IEEE Trans Med Imag
2000;19:722-730.
61. Vander Haeghen Y, Naeyaert JM. Consistent cutaneous imaging with commercial
digital cameras. Arch Derm 2006;142:42-46.
62. Whitworth JM, Wood B, Morse K, Rogers H, Haney M. The Florida child protection
team telemedicine program. In: Wootton R, Oakley A, eds. Teledermatology.
London: Royal Society of Medicine Press, 2002, pp. 135-149.
63. McNeill KM, Major J, Roehrig H, Krupinski E. Practical methods of color quality
assurance for telemedicine systems. Med Imag Tech 2002;20:111-116.
64. Maglogiannis I, Kosmopoulos DI. A system for the acquisition of reproducible digital
skin lesion images. Tech & Health care 2003;11:425-441.
65. Fitzpatrick TB, Johnson R, Wolff K, Suurmond R. Color Atlas & Synopsis of
Clinical Dermatology. New York, NY: McGraw-Hill Publishers, 2001.
66. GreTag Macbeth Color Chart.
http://www.gretagmacbeth.com/regionchooser?trgturl=http%3A//www.gretag
macbeth.com/index.htm. Last accessed May 7, 2007.
67. Digital Imaging & Communications in Medicine (DICOM). http://medical.nema.org/.
Last accessed February 26, 2007.
68. American Association of Physicists in Medicine (AAPM) Task Group 18 (TG18)
Assessment of Display Performance for Medical Imaging Systems.
http://deckard.duhs.duke.edu/~samei/tg18.htm. Last accessed February 26,
2007.
69. Chartier TK. DICOM (Digital Imaging and Communications in Medicine) in
dermatology. In: Wootton R, Oakley A, eds. Teledermatology. London: Royal
Society of Medicine Press, 2002, pp. 205-219.
70. ISO TC42/WG18. http://www.pima.net/standards/tc42.htm. Last accessed February
26, 2007.
71. JPEG 2000. http://www.jpeg.org/jpeg2000/. Last accessed February 26, 2007.
72. Health Level 7 (HL7). http://www.hl7.org/. Last accessed February 26, 2007.
73. Integrating the Healthcare Enterprise (IHE).
http://www.himss.org/ASP/topics_ihe.asp. Last accessed February 26, 2007.
74. IHE Radiology Technical Framework, Integration Profiles.
http://www.ihe.net/Technical_Framework/index.cfm#radiology;
http://www.ihe.net/Technical_Framework/upload/ihe_tf_rev7.pdf
V1.2007 25
http://www.ihe.net/Technical_Framework/upload/IHE_RAD-
TF_Suppl_IRWF_TI_2006-04-13.pdf
75. Free Medical Imaging Software:
http://medical.nema.org/ DICOMWebsite
http://www.idoimaging.com/index.shtml DICOMWorks for the PC
http://dicom.online.fr/ Osirix for the Macintosh
http://homepage.mac.com/rossetantoine/osirix/ Osirix for the Macintosh
http://amide.sourceforge.net/ Amide for Unix
Disclaimers: Dr. Oh’s participation and contributions were performed in his own professional
capacity, and do not necessarily officially represent the views of or an endorsement of this
document by the Department of Veterans Affairs
... Refer to ATA Practice Guidelines for Teledermatology clinical practice guidelines, informed consent, physical environment, patient evaluation and examination, follow-up care and coordination, and documentation 36 . ...
... The color of images taken over time shall be comparable to diagnose and monitor skin lesions correctly 32 . Based on recent ATA guidelines, an image color resolution of 24 bits is recommended for teledermatology applications 36 . Per manufacturer instruction, equipment shall be calibrated to prevent variability in color calibration and white balance between time points 32 . ...
... All edges of the lesion shall be visualized 32 . Images should be taken with a device less than 2 inches from the skin in non-contact mode or touching the skin after application of alcohol wipe to both skin and device in contact mode to improve luminance 36 . Dermoscopic images should be captured using the same orientation as the corresponding close-up 39 . ...
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Teledermoscopy, or the utilization of dermatoscopic images in telemedicine, can help diagnose dermatologic disease remotely, triage lesions of concern (i.e., determine whether in-person consultation with a dermatologist is necessary, biopsy, or reassure the patient), and monitor dermatologic lesions over time. Handheld dermatoscopes, a magnifying apparatus, have become a commonly utilized tool for providers in many healthcare settings and professions and allows users to view microstructures of the epidermis and dermis. This Dermoscopy Practice Guideline reflects current knowledge in the field of telemedicine to demonstrate the correct capture, usage, and incorporation of dermoscopic images into everyday practice.
... The patient should also be informed that there may be a possibility of the physician requesting the patient to attend an in-person visit where the physician considers such a visit to be more appropriate. The patient should be informed that they may withdraw consent from telehealth services at any point (before, during, or after the teleconsultation) [13,21]. While the standards and requirements of informed patient consent may vary depending on the jurisdiction, it is recommended to keep electronic records of informed consent. ...
Article
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To develop Best Practice Guidelines (BPG) for the use of Telehealth in Rheumatology in the Arab region, to identify the main barriers and facilitators of telehealth, and to provide rheumatologists with a practical toolkit for the implementation of telehealth. Guidelines were drafted by a core steering committee from the Arab League of Associations for Rheumatology (ArLAR) after performing a literature search. A multidisciplinary task force (TF), including 18 rheumatologists, 2 patients, and 2 regulators from 15 Arab countries, assessed the BPG using 3 rounds of anonymous online voting by modified Delphi process. The statements were included in the final BPG without further voting if ≥ 80% of TF members indicated high agreement. The voting on barriers and facilitators was performed through one voting round. The toolkit was developed based on available literature and discussions during the Delphi rounds. Four General Principles and twelve Statements were formulated. A teleconsultation was specifically defined for the purpose of these guidelines. The concept of choice in telehealth was highlighted, emphasizing patient confidentiality, medical information security, rheumatologist's clinical judgment, and local jurisdictional regulations. The top barrier for telehealth was the concern about the quality of care. The toolkit emphasized technical aspects of teleconsultation and proposed a triage system. The ArLAR BPG provide rheumatologists with a series of strategies about the most reliable, productive, and rational approaches to apply telehealth.
... Mobile telephone systems and professional corporate networks allow better intercommunication among professionals and patients. [1][2][3] Home monitoring is one of the most promising TICs for medicine. Its use has already demonstrated positive results in chronic diseases such as hypertension 4 and diabetes mellitus. ...
Article
Brief Summary The addition of home monitoring to an integrated care model in patients with advanced chronic heart/lung diseases decreases mortality, hospital and emergency admissions, improves functional status, HRQoL, and is cost-effective. Background Telemonitoring is a promising implement for medicine, but its efficacy is unknown in patients with advanced heart and lung failure (AHLF). Objective To determine the efficacy of a telemonitoring system added to coordinated clinical care in patients with AHLF. Design Randomized phase 3 multicenter clinical trial with parallel groups in adult patients. Participants Five spanish centers including patients with AHLF at discharge or in out-patient clinics. Intervention Patients were randomly assigned to receive a remote bio-parameters telemonitoring system (TELECARE) or best usual care (UCARE). TELECARE patients were provided with devices that collected symptoms and bio-parameters, and transferred them synchronously to a call-center, with a real-time health-care response. Main Measures Primary end point was the need of admissions/emergency room visits at 45, 90, 180 days. Secondary end points included health care requirements, mortality, functional assessment, health related quality of life (HRQoL), perceived satisfaction, and cost-efficacy. Results 510 patients were included (54.5% women, median age 76.5 years; 63.1% suffered heart failure, 13.9% lung failure, and 22.9% both conditions). Clinical and functional features were comparable in both arms. TELECARE globally needed less admissions with respect UCARE after 45 days of inclusion (35.4% vs. 46.9%, p < 0.05). This tendency was maintained in the subgroups of patients with multimorbidity (34.2% vs. 46.9%, p < 0.05), intermediate risk of mortality (36.5% vs. 51.1%, p < 0.05), and those included after hospital discharge (34.9% vs. 50.5%, p < 0.01). HRQoL significantly improved (TELECARE/UCARE EuroQol baseline of 56.2 ± 18.2/55.1 ± 19.7, p = 0.054, and 64 ± 19.9/56.3 ± 21.6; p < 0.01 at the end), and perceived satisfaction was also higher (6.77 ± 0.52 vs. 6.62 ± 0.81, p < 0.001; highest possible score = 7). A trend to mortality decrease was also observed (12.9% vs. 19.3%, p = 0.13). TELECARE was cost-efficacious (TELECARE/UCARE QALY 3.94 Euros/0.81Euros). Conclusions The addition of a telemonitoring system to an integrated care model in patients with AHLF decreases hospital and emergency admissions, improves functional status as well as HRQoL, and is cost-efficacious.
... A recent review of the available paediatric dermatology literature by Cartron et al 6 suggested that in general, paediatric dermatologists appear optimistic about the utility of telemedicine for their practices 7,8 and that teledermatology has applications in both outpatient and inpatient paediatric medicine to increase efficiency and reduce costs 6 . Recommended considerations prior to a paediatric teledermatology encounter 6,9 included determining the appropriateness of a virtual consultation on a case-by-case basis and the subsequent need to be seen FTF; establishment of a doctor-patient relationship (either in person or via video conferencing) and obtaining informed consent from patients and/or parents, as appropriate. ...
Article
Background The landscape of dermatology services, already rapidly evolving into an increasingly digital one, has been irretrievably altered by the Sars-Cov-2 pandemic. Data are needed to assess how best to deliver virtual dermatology services in specific patient subgroups in an era of ongoing social distancing and beyond. Initial studies of teledermatology in paediatric populations suggest that many of the problems experienced in adult telemedicine are more apparent when treating children and come with additional challenges. Objective To evaluate the efficacy of a virtual paediatric dermatology telephone clinic in comparison to traditional face-to-face (FTF) clinics, both from the clinician and patient/ parental perspective. Methods We carried out a prospective service evaluation examining a single centre cohort of paediatric dermatology patients managed via a telephone clinic supported by images during the Covid-19 pandemic, from June to September 2020. Outcomes data were collected from clinicians and a qualitative patient/parental telephone survey was undertaken separately. A 5-point Likert scale was used to assess both satisfaction and levels of agreement regarding whether telephone clinic was more convenient than face-to-face (FTF). Results Of 116 patients included, 24% were new and 76% were follow-ups, with a mixture of inflammatory dermatoses (75%) and lesions (25%). Most consultations (91%) were successfully completed over the telephone from the clinician perspective. Qualitative patient and parental feedback paradoxically illustrated that although nearly all (98%) respondents had no outstanding concerns, 52% felt highly unsatisfied and only 22% agreed that telephone clinics were more convenient. Most (65%) preferred FTF follow-up in the future. Chi² tests showed that preference among established follow-ups regarding future consultation type was independent of specific reasons for follow up. Conclusions Our study demonstrates a clear disconnect between the practical successes of a virtual service from the clinician’s perspective compared to a patient/parental one. Parental anxiety appears to be less effectively allayed virtually than FTF. Is there a role for virtual paediatric telephone clinics in the post-pandemic future? This may be best left to patients/parents on an individual basis to decide.
Article
The rapid adoption of digital skin imaging applications has increased the utilization of smartphone‐acquired images in dermatology. While this has enormous potential for scaling the assessment of concerning skin lesions, the insufficient quality of many consumer/patient‐taken images can undermine clinical accuracy and potentially harm patients due to lack of diagnostic interpretability. We aim to characterize the current state of digital skin imaging applications and comprehensively assess how image acquisition features address image quality. Publicly discoverable mobile, web, and desktop‐based skin imaging applications, identified through keyword searches in mobile app stores, Google Search queries, previous teledermatology studies, and expert recommendations were independently assessed by three reviewers. Applications were categorized by primary audience (consumer‐facing, nonhospital‐based practice, or enterprise/health system), function (education, store‐and‐forward teledermatology, live‐interactive teledermatology, electronic medical record adjunct/clinical imaging storage, or clinical triage), in‐app connection to a healthcare provider (yes or no), and user type (patient, provider, or both). Just over half (57%) of 191 included skin imaging applications had at least one of 14 image acquisition technique features. Those that were consumer‐facing, intended for educational use, and designed for both patient and physician users had significantly greater feature richness (p < 0.05). The most common feature was the inclusion of text‐based imaging tips, followed by the requirement to submit multiple images and body area matching. Very few skin imaging applications included more than one image acquisition technique feature. Feature richness varied significantly by audience, function, and user categories. Users of digital dermatology tools should consider which applications have standardized features that improve image quality.
Article
Teledermatology is an important subspecialty of telemedicine that continues to evolve with advances in telecommunication and mobile phone technology. A 19-week primary care quality improvement project collected baseline data and tested three change ideas, using the Model for Improvement method, with primary and secondary aims: to increase the weekly percentage of remote dermatological consultations with supporting images that were successfully concluded remotely to greater than 80% and to reduce the weekly percentage of dermatological face-to-face consultations to less than 50%. We hypothesised that by improving the quality of patient images and the confidence of reception staff in triaging skin complaints, there would be a decrease in the weekly number of face-to-face dermatological appointments, thereby decreasing the risk of COVID-19 transmission within the practice and community. Two change ideas focused on supporting patients to improve image quality by introducing '4 Key Instructions' and a patient information leaflet (PIL). The third focused on increasing reception staff confidence in triaging skin complaints by introducing a triage pathway guidance tool. A total of 253 dermatological consultations were analysed: 170 of these were telephone consultations with 308 supporting images. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to an increase in completed remote consultation. Our primary outcome measure was achieved. Our secondary outcome measure suggested that in the absence of high-quality images, it might not be possible to reduce dermatological face-to-face consultations much below 50% in primary care. Process measures showed clear improvements in the quality of images provided by patients which likely contributed to the increase in remote consultation. The implications of these findings for the theory of change are discussed.
Article
Background: Telemedicine has emerged as a feasible adjunct to in-person care in multiple clinical contexts, and its role has expanded in the context of the COVID-19 pandemic. However, there exists a general paucity of information surrounding best practice recommendations for conducting specialty or disease-specific virtual care. The purpose of this study was to systematically review existing best practice guidelines for conducting telemedicine encounters. Methods: A systematic review of MEDLINE, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) of existing guidelines for the provision of virtual care was performed. Data were synthesized using the Synthesis Without Meta-Analysis (SWiM) guideline, and the Appraisal of Guidelines for Research & Evaluation Instrument (AGREE II) tool was used to evaluate the quality of evidence. Results: A total of 60 guidelines for virtual care encounters were included; 52% of these were published in the context of the COVID-19 pandemic. The majority (95%) of provider guidelines specified a type of virtual encounter to which their guidelines applied. Of included guidelines, 65% provided guidance regarding confidentiality/security, 58% discussed technology/setup, and 56% commented on patient consent. Thirty-one guidelines also provided guidance to patients or caregivers. Overall guideline quality was poor. Discussion: General best practices for successful telemedicine encounters include ensuring confidentiality and consent, preparation before a visit, and clear patient communication. Future studies should aim to objectively assess the efficacy of existing clinician practices and guidelines on patient attitudes and outcomes to further optimize the provision of virtual care for specific patient populations.
Article
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Purpose of Review Inpatient teledermatology is a rapidly growing field with significant potential to add value and streamline patient care. This review summarizes the current literature on inpatient teledermatology, primarily focusing on its diagnostic and clinical management utility as compared to live dermatologic evaluation. Recent Findings The COVID-19 pandemic has accelerated the adoption of inpatient teledermatology, which has been shown to be comparable to live hospitalist evaluation for triage, diagnosis, and management of hospitalized patients for a wide variety of conditions. Despite its comparative cost-effectiveness and recent changes in reimbursement practices, inpatient teledermatology still lacks sufficient reimbursement incentive for widespread implementation. Summary Inpatient teledermatology is an effective, efficient, accurate, and cost-effective means of managing the hospital burden of skin disease, especially in areas where access to dermatologic care is limited. It is essential that dermatologists and referring providers comprehend the use and potential pitfalls of inpatient teledermatology to effectively incorporate it into hospital practice.
Article
Background Medication safety is a World Health Organization health priority, with recognition that greater focus is needed to address this long-standing healthcare challenge. As medication management experts, hospital pharmacists support the safe and quality use of medications and are ideally positioned to optimise medication safety throughout a patient’s hospital journey. However, hospital pharmacist services are commonly limited to business hours. Aim To synthesise evidence for best practice hospital pharmacist services, with a focus on transitions of care, in support of an extended hours seven-day service model. Method A literature search was conducted using PubMed, Embase and Google Scholar to identify studies that evaluated the provision of a seven-day hospital pharmacist service. Primary studies containing keywords ‘7-day service’ OR ‘after hours service’ OR ’24-h service’ AND ‘hospital pharmacist’ OR ‘clinical pharmacist’ AND ‘inpatient’ OR ‘hospital’, and related synonyms in the title and/or abstract, published to December 2019, were identified. Additionally, highly cited studies related to hospital pharmacist services were also reviewed to evaluate benefits during hospitalisation. A narrative synthesis was conducted. Results Only two studies have evaluated the benefits of seven-day services. A large number of studies, reporting hospital pharmacist services during inpatient admission support the need for pharmacist services beyond the 8–5 model. These studies demonstrate the vital role of pharmacists in medication management across the continuum of care. Conclusion Hospital pharmacists are essential in ensuring optimal patient outcomes; however, few studies have appraised extended pharmacy services. To deliver equitable patient-centred care, a robust evaluation of seven-day services is needed.
Chapter
Radiologic diagnosis relies on human beings seeing, perceiving, and processing images. Some of these steps are well understood, while others are being actively studied. A thorough understanding of how display monitors work and how human perception works is critical to optimizing the interactions between humans and computers. Mammography is a specialized topic within radiology, with unique IT requirements.
Article
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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 $66 145 (minimum, $58 697; maximum, $71 635), or $338 (SD, $291) per participant (196 participants); the total cost for teledermatology referrals was $59 917 (mimimum, $51 794; maximum, $70 398), or $308 (SD, $298) per participant (195 participants). The $30 difference in per-participant cost was not statistically significant (95% CI, −$79 to $20). From the societal perspective, the total cost for conventional referrals was $106 194 (minimum, $98 746; maximum, $111 684), or $542 (SD, $403) per participant (196 participants); the total cost for teledermatology referrals was $89 523 (minimum, $81 400; maximum, $100 400) or $460 (SD, $428) per participant. This $82 difference in per-participant cost was statistically significant (95% CI, −$12 to −$152). From baseline to the 9-month follow-up, the time trade-off utility value improved by 0.02 in the conventional referral group and 0.03 in the teledermatology group. This difference was not statistically significant (P = .50).Conclusions and Relevance Compared with conventional referrals, store-and-forward teledermatology referrals were performed at a comparable cost (VA perspective) or at a lower cost (societal perspective) with no evidence of a difference in utility as measured by the time trade-off method.Trial Registration clinicaltrials.gov Identifier: NCT00488293
Article
Integrating the Healthcare Enterprise (IHE) is a joint initiative of the American College of Cardiology (ACC), Radiological Society of North America (RSNA), and Healthcare Information and Management Systems Society (HIMSS) to improve the way computer systems in healthcare share information. This paper describes how IHE has been applied to Cardiology including Integration Profiles developed by the IHE Cardiology Technical committee, to address cardiac catheterisation and echocardiography workflows and the retrieval and display of electrocardiograms (ECGs).
Article
This Viewpoint describes a teledermatology network implemented to connect 56 primary care centers with the skin cancer and melanoma clinic of a university-based hospital in Seville, Spain, to address the problems associated with patient wait times.Albert Einstein defined insanity as “doing the same thing over and over again and expecting different results.” In 2004, the conventional structure and work flows of dermatology departments of public university hospitals in our region and at the Spanish national health system were unable to fulfill the ethical obligation of providing proper care at the correct time for patients with skin cancer. Patients with malignant melanoma (MM) or basal cell carcinoma (BCC) shared the same waiting times as patients having common acquired melanocytic nevi or viral warts. In this regard, waiting lists were a quantitative problem (how many patients were waiting?) that obscured a qualitative concern (which types of lesions were awaiting examination?). Increasing staff resources rarely provided a definitive solution unless the work flows were meaningfully redesigned. By increasing the number of dermatologists, malignant tumors and common acquired melanocytic nevi, viral warts, and seborrheic keratoses would have been diagnosed and treated sooner, but this did not guarantee the prioritization and immediate attention that skin cancer merits.
Article
Background: Teledermatology is a mainstream modality for delivering care in the Veterans Health Administration, especially in rural areas where access to traditional dermatology care is constrained. Previous investigations of the effect of teledermatology on improving patient access have focused largely on the metrics of visits avoided. However, the effect of teledermatology on improving patient access to face-to-face dermatology has not been well documented. The purpose of this study was to assess the impact of the implementation of store-and-forward teledermatology on access to face-to-face dermatology at the Mann-Grandstaff Spokane Veterans Administration (VA) Medical Center in Spokane, WA. Materials and methods: Completed requests for dermatology and teledermatology consultation originating from the Spokane main facility from January 1, 2012 through June 30, 2013 were obtained from the Corporate Data Warehouse by SQL query. The numbers of consult requests and wait times for care for overall dermatology, face-to-face dermatology, and teledermatology were compared across the baseline, transition, and intervention periods. Results: Within 6 months of implementation, the total number of requests for dermatology services increased by 40%. Access to face-to-face dermatology care improved, with a decrease in the duration of the interval between consultation request and consultation completion from a mean of 64.2 days to 20.3 days; overall access to dermatology (teledermatology and face-to-face dermatology) care improved with a decrease in the duration of the same from a mean of 61.2 days to 10.3 days. Conclusions: Implementation of a teledermatology program at the Mann-Grandstaff Spokane VA Medical Center improved access to face-to-face dermatology care.
Article
Many hospitals have limited inpatient dermatology consultation access. Most dermatologists are outpatient-based and may find the distance and time to complete inpatient consultations prohibitive. Teledermatology may improve access to inpatient dermatology care by reducing barriers of distance and time. We conducted a prospective two-phase pilot study at two academic hospitals comparing time needed to complete inpatient consultations after resident dermatologists initially evaluated patients, called average handling time (AHT), and time needed to respond to the primary team, called time to response (TTR), with and without teledermatology with surveys to capture changes in dermatologist opinion on teledermatology. Teledermatology was only used in the study phase, and patients were seen in-person in both study phases. Teledermatology alone sufficiently answered consultations in 10 of 25 study consultations. The mean AHT in the study phase (sAHT) was 26.9 min compared to the baseline phase (bAHT) of 43.5 min, a 16.6 min reduction (p = 0.004). The 10 study cases where teledermatology alone was sufficient had mean study TTR (sTTR) of 273.3 min compared to a baseline TTR (bTTR) of 405.7 min, a 132.4 min reduction (p = 0.032). Teledermatology reduces the time required for an attending dermatologist to respond and the time required for a primary team to receive a response for an inpatient dermatology consultation in a subset of cases. These findings suggest teledermatology can be used as a tool to improve access to inpatient dermatology care.
Article
In the cost-constrained NHS and in the quest for rapid diagnosis, teledermatology is a tool that can be used within general practice to aid in the diagnosis of benign-looking skin lesions and reduce referrals to secondary care. The setting for the study was a single general practice of 6500 patients in suburban Greater London. The aim of the study was to determine: (1) whether teledermatology in a single general practice is cost-effective, (2) whether the correct types of cases are being referred, and (3) if patients are satisfied with the service. Teledermatology was provided by a private provider. A trained member of staff took photographs in the practice. A consultant dermatologist carried out reporting. This is a retrospective analysis of case records over three years. The cases were adult patients (aged 18+) using teledermatology for the diagnosis and management of skin lesions thought to be benign by the general practitioner. Cost-effectiveness was calculated by considering savings made through reduced referral to secondary care, taking into account the cost of the service. To evaluate whether the correct cases were referred we reviewed whether the assessing dermatologist identified any previously undiagnosed skin cancer. Patient satisfaction assessment was performed using a standard questionnaire. Two hundred and forty-eight patients had teledermatology. These were patients who would have been referred to secondary care for a routine appointment. Of these, 102 were subsequently referred to secondary care and 146 were managed within the practice. Teledermatology saved £12 460 over the 3-year period. Patients were followed for up to 51 months and no lesions were found to be malignant. Ninety-seven percent of patients rated themselves as satisfied/very satisfied and 93% found the procedure comfortable/very comfortable. The median wait for the photos to be taken was 7 days, and 1-2 weeks for results. Teledermatology has been shown to be cost-effective, with referrals identified correctly when employed in this general practice setting. Satisfaction with the service was high.
Article
In order to increase veterans' access to dermatologic care, the Veterans Health Administration (VHA) has developed one of the largest teledermatology programs in the United States. This article describes the recent expansion of the VHA's teledermatology program after local and national initiatives and resource allocation. This report describes routinely collected VHA data. For the first half of fiscal year 2014, the VHA recorded 31,926 teledermatology encounters, which represents 14% of all recorded teledermatology visits. Although every region in the VHA used teledermatology in the past year, four regions created 51% of the encounters. The use of store-and-forward telehealth (SFT), in which physicians view patient images after the patients were photographed, is increasing, whereas live video use is decreasing. Starting in 2012, encounters for patients in urban areas exceeded those in rural areas. The majority of patients were male veterans 60-79 years of age. Seventy-one percent of SFT consultations for the first half of 2014 were completed within 1 week. Although errors in and the evolution of coding encounters may distort results, the data show rapid growth of a telemedicine system that increases access to dermatology services for veterans. Most likely this growth reflects institutional commitment to telehealth via policy and resources.
Article
The current era of ubiquitous digital cameras, digital cameras integrated into smartphones, and virtually limitless data storage affords exciting new opportunities for medicine in general and specifically dermatology. Digital photography has the potential to dramatically enable and facilitate improvements in dermatology teaching, clinical documentation, and diagnosis. One of the barriers to the diffusion of digital imaging into dermatology practice is the lack of standards for digital photography. As noted in the article by Quigley et al,¹ there are currently no standards for dermatologic photography designated by Digital Imaging and Communications in Medicine. While some organizations, such as the American Teledermatology Association,² have offered general guidelines, to our knowledge, no consistent actionable standards exist in medical publications. The absence of standards severely impedes the integration of dermatologic images across systems that support documentation, diagnosis, and clinical practice.
Article
Photographs are invaluable dermatologic diagnostic, management, research, teaching, and documentation tools. Digital Imaging and Communications in Medicine (DICOM) standards exist for many types of digital medical images, but there are no DICOM standards for camera-acquired dermatologic images to date. To identify and describe existing or proposed technology and technique standards for camera-acquired dermatologic images in the scientific literature. Systematic searches of the PubMed, EMBASE, and Cochrane databases were performed in January 2013 using photography and digital imaging, standardization, and medical specialty and medical illustration search terms and augmented by a gray literature search of 14 websites using Google. Two reviewers independently screened titles of 7371 unique publications, followed by 3 sequential full-text reviews, leading to the selection of 49 publications with the most recent (1985-2013) or detailed description of technology or technique standards related to the acquisition or use of images of skin disease (or related conditions). No universally accepted existing technology or technique standards for camera-based digital images in dermatology were identified. Recommendations are summarized for technology imaging standards, including spatial resolution, color resolution, reproduction (magnification) ratios, postacquisition image processing, color calibration, compression, output, archiving and storage, and security during storage and transmission. Recommendations are also summarized for technique imaging standards, including environmental conditions (lighting, background, and camera position), patient pose and standard view sets, and patient consent, privacy, and confidentiality. Proposed standards for specific-use cases in total body photography, teledermatology, and dermoscopy are described. The literature is replete with descriptions of obtaining photographs of skin disease, but universal imaging standards have not been developed, validated, and adopted to date. Dermatologic imaging is evolving without defined standards for camera-acquired images, leading to variable image quality and limited exchangeability. The development and adoption of universal technology and technique standards may first emerge in scenarios when image use is most associated with a defined clinical benefit.