Teledermatology: Benefits, Types and Implementation
This whitepaper outlines the key things to consider when implementing telemedicine between patients and dermatologists.
What is Teledermatology?
Teledermatology is the term commonly used for telehealth (telemedicine) carried out in dermatology. It covers the delivery of dermatology care through modern electronic or digital forms of communication1.
Most skin diseases are visible and can be photographed or filmed for a healthcare provider. That is why teledermatology is one of the most developed telehealth areas. Telehealth dermatology is particularly important for dermatologists, for remote diagnosis, assessment, and management recommendations.
Benefits of Teledermatology
In the era of smartphones and the ease with which you can photograph the skin, online dermatology is one of the areas in medicine that can potentially benefit from innovative telehealth implementations2.
In the right setting and context, diagnosis and disease management can be eased through teledermatology and a cost-efficient way to pre-screen patients. Dermatology telehealth can determine which patients need to be seen in-person and which can be prescribed new treatment without a physical visit.
Teledermatology benefits include:
- Increasing convenience for patients and dermatologists
- Providing access to care if a physical visit is not possible
- Reducing wait times
- Lowering healthcare costs3 4
A telehealth visit can be a way for a new patient to be able to see a dermatologist. That is especially the case in rural areas where a lack of providers and large distances between patients and clinics can cause challenges.
Management via teledermatology can be even more effective for patients who already have a confirmed diagnosis and prescribed treatment plan by their dermatologist.
Patients with chronic skin conditions such as eczema, acne, and psoriasis often require many follow-up visits for complex treatments and some of these follow-up visits could occur remotely5 as teleconsultations.
Dermatology telemedicine may also benefit patients at risk of developing skin cancer or patients with a previous skin cancer diagnosis. Some of those patients require annual mole exams.
Teledermatology could complement these consultations, leading to increased patient participation, satisfaction, and reduced cost6. It can be particularly helpful to the dermatologist if the patient has a well-documented photographic history of their skin. Close-up photos of atypical moles and large body areas can help evaluate for changes in skin lesions.
Types of Teledermatology
Teledermatology can be characterized based on:
- Who participates in the online dermatology consultation
- The mode of communication that is employed
- The clinical objective of the consultation
Types of Teledermatology
- Participants in Teledermatology (Primary, secondary, tertiary)
- Teledermatology modes of communication
2.1 Real-Time Synchronous Modes (Voice calls, Live Video Interaction)
2.2 Asynchronous Modes (Store-and-Forward teledermatology)
2.3 Real-time Video vs. Store-and-Forward
- Clinical Objectives in Teledermatology
3.2 Follow-up consultations
1. Participants in Teledermatology
Primary teledermatology covers direct communication between a patient and a healthcare provider such as a dermatologist.
Secondary teledermatology describes communication between healthcare providers. For instance, a general practitioner may request a specialist consultation from a dermatologist in secondary teledermatology.
Tertiary teledermatology refers to a telehealth collaboration between dermatologists, often to seek a second opinion or to obtain consensus7.
2. Teledermatology modes of communication
Different modes of teledermatology uses the following telecommunication technologies:
- Transfer of audio information
- Transfer of video information
- Transfer of patient data (such as information reported by patient or data from the patient’s electronic health record)
Communication between the participants can be delivered:
- Synchronous – a real-time conversation between patient and dermatologist (live-interactive teledermatology or videoconferencing)
- Asynchronous – communication at different points in time
2.1 Real-Time Synchronous Modes
The simplest and most widespread form of telehealth in dermatology today is a simple voice call via the telephone. This allows the practitioner and patient to quickly exchange information.
Given the lack of visual information (images/video), its use for diagnosis, assessment, and management is limited. It very rarely meets the criteria for reimbursed mobile teledermatology due to the lack of physical examination and verifiable disease.
Therefore, most teledermatology implementations employ visual data for accuracy and quality assurance.
Live Video Interaction
Live video interaction is a popular mode of communication in telemedicine and has been thoroughly researched for implementation in dermatology.
Live video communication offers the same voice interaction between the participants as on the telephone, but the live camera can be directed towards a rash or skin lesion for visual inspection in real-time. In most cases, it lacks the quality of high definition still images. In particular because a patient’s internet speed may not be able to support a full high-definition video consultation.
2.2 Asynchronous Modes
In ‘store-and-forward’ teledermatology images or video are transmitted to allow for a consultation to happen asynchronously. It allows the participants to communicate at a distance and at different points in time. Using this type of telehealth consultations, patients send high-quality images and other relevant information for remote evaluation.
The asynchronous nature of store-and-forward teledermatology makes it the most promising variant of telehealth dermatology.
Asynchronous teledermatology allows more efficient use of a providers’ scarce time. Providers do not have to wait for patients to present and “no shows” are avoided. Patient no-shows can be a big issue in healthcare systems with long wait times for access.
Within store-and-forward teledermatology, teledermoscopy utilizes a dermatoscope attachment to the camera to acquire optically 20x magnified images. This results in more information available to the professional trained in dermoscopy, such as a dermatologist.
2.3 Teledermatology: Real-time Video vs. Store-and-Forward
Video is already a commonly reimbursed form of telehealth in other medical fields. That’s why live video interaction between a medical practitioner and a patient is currently the most commonly reimbursed form of teledermatology.
Store-and-forward telehealth services may be a better solution in dermatology and are also reimbursed.
Some of the advantages of store-and-forward telederm communication over real-time are that it works on any internet connection speed and does not require appointment scheduling between the patient and provider. It provides more flexibility and convenience for both. Store-and-forward telederm implementations can, therefore, help reduce wait times8 9.
There is evidence that store-and-forward teledermatology in the right setting can be more affordable. That is especially when it’s used as a triage mechanism to reduce face-to-face appointments and in rural settings10.
A cost-effectiveness study demonstrated that store-and-forward dermatology telemedicine achieved high patient satisfaction. Afterwards, it showed no further post-consultation costs11.
3. Clinical Objectives in Teledermatology
The patient’s first consultation with a dermatologist is usually a face-to-face appointment.
Some patients prefer a face-to-face appointment for the first consultation. However, if there are long waitlists or travel distances, patients may be able to be seen remotely as a first consultation. This depends on the objective of the consultation and treatment needed.
Teledermatology consultations through efficient triage and care follow-up however make dermatologists’ schedules more efficient for the patient and the dermatology clinic.
Triage is a common telehealth strategy through which qualified healthcare providers assign urgency and potentially preliminary care to patients. Patients are then sorted based on their reported signs or symptoms. It is often done by telephone and the healthcare professional evaluates the concerns to recommend a management course for the patient12.
In many medical specialties, a patient can reasonably communicate their symptoms via the telephone. Telephone triage can be used to screen for patients in critical need of care. Dermatology is different because patients cannot sufficiently describe visual signs on their skin. Additionally, patient concerns rarely require urgent intervention or an emergency room visit13.
Images recorded by patients can increase efficiency in dermatology triage. Skin photos play a very important role in determining a preliminary diagnosis of common dermatological skin problems. This can result in remotely starting treatment. Telehealth triage can also confirm the need for physical face-to-face consultation for further evaluation and management.
3.2 Follow-up consultations
Telehealth allows for easier follow-up consultations for patients living far away from their dermatologists. A telehealth visit can maximize efficiency of the dermatologists’ time and resources while still providing necessary care through remote access.
Follow-up consultations can be delivered asynchronously, by using a ‘store-and-forward’ solution, or in real-time via video or on the phone. The patient ideally pre-records high resolution images so that the healthcare professional can view them during the live consultation.
Telehealth and Dermatology Guidelines
When implementing a teledermatology service, there are a number of elements that need to be considered.
Organizations, such as the American Medical Association, American Academy of Dermatology, and the British Association of Dermatologists, have published guidelines for telehealth and teledermatology. There are likely similar guidelines in most other countries.
Please, get informed about the teledermatology and other telehealth services guidelines recommended in your own country. Also, below you can read more about other important things to consider when implementing your teledermatology program.
Commencing a teledermatology program
1. Usability is key
When creators of digital experience talk about usability, they mean that the process for the end-user (patient/provider) should be clear, comprehended, and well structured. This is often an area that is overlooked because creators of telehealth systems are often medical, legal, and technical experts who tend to focus more on their areas of expertise and less on the user experience.
It is vitally important to get user experience right. Even a strategic telehealth dermatology program will fail if patients and providers do not find it convenient to operate in practice. Whether it is a teledermatology app-based solution for phone or desktop or a web-based solution, user experience is key.
2. Make a commitment to quality
It is also important to make sure that the quality of the technical implementation is sufficient. There are three areas that are very important to consider:
- The system should be well-tested. When using a glitchy and error-prone platform, users might quickly lose motivation if there are too many interruptions and annoyances in the experience.
- It is important that data is securely captured and not lost in the process. It is crucial since vital information is handled through telehealth and findings may not be reproducible.
- If the platform captures photos or videos, the clarity and quality of the digital images or video stream are important. In mobile-based dermatology (known as mobile teledermatology), video streams can be problematic due to poor data connections. Bad connection causes the video to be unclear and useless. Considering this, an image-based store-and-forward solution helps dermatologists get a better view of a rash or lesion on the skin.
The good news is that the camera quality of newer smartphones more than meets the requirements set out in recommended guidelines. It is important that images are taken in proper lighting conditions and at the right distance from the skin. A well-designed teledermatology application enables users to take proper photos with the help of computer vision and artificial intelligence.
3. Ensure patient data privacy
In any health solution patient data privacy is very important. Data or information privacy is the right for the individual to know:
- what type of information is being collected
- for what purpose the information is collected
- And freedom from undesired intrusion of your data
Data privacy is dealing with proper and transparent handling, processing, access, storage and usage of your private data.
Data shielding and security is how data privacy is enforced to secure your privacy and the prevention of unwilling intrusion. This includes:
- Storage encryption
- Transport encryption
- Network security
- Identity management and secure authentication
- Access control and audit logs
- Breach response
In the United States, health information is protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA is a federal law enforced by the US Department of Health and Human Services (HHS) that protects sensitive patient health information from being disclosed without the patient’s consent or knowledge.
In the European Union, patients’ data privacy is protected by the General Data Protection Regulation (GDPR). However, it’s important to pay attention to the additional requirements that may apply around sensitive health information. Those requirements may include strict adherence to patient consent and extra high focus on data shielding and security.
4. Gather the correct patient consent
Patient data consent is essential when securing data privacy and should be a transparent and informative solution. It should explain how and what your data is used for before processing the information in a teledermatology context.
A patient should give explicit consent for the intended use of personal images for his or her care. Only after that, images recorded by patients and other information can be used for a teledermatology consultation.
5. Coordination with existing care team
During teleconsultations, patients can connect to their own healthcare provider or a third party teledermatology provider. It is important that all information collected during the consultation can be saved to the patient’s record. It should also be available to the existing care team. Similarly, teledermatology requires adequate patient history for the consultation.
Considering these demands, a patient’s own healthcare provider may be a better choice for teledermatology consultations.
6. Now is a good time to start
Since the beginning of the COVID-19 crisis, many clinics have implemented teledermatology video consultations. Well-known services like FaceTime and Zoom enabled clinics to resume some consultations. It also made patients be able to remotely see their doctor again to receive care.
Solutions like FaceTime and Zoom may be reimbursed by some health insurers during this crisis. Critically, high-quality images taken by patients may be a much-needed add-on for such consultations. The ability to offer a user-friendly and affordable ‘store-and-forward’ teledermatology solution to patients could therefore be beneficial for many providers
The expectation is that teledermatology will remain highly relevant and a necessary element of any future dermatology service.
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