Continuing medical education
Teledermatology: From historical perspective to emerging techniques of the modern era: Part I: History, rationale, and current practice

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Telemedicine is the use of telecommunications technology to support health care at a distance. Technological advances have progressively increased the ability of clinicians to care for diverse patient populations in need of skin expertise. Dermatology relies on visual cues that are easily captured by imaging technologies, making it ideally suited for this care model. Moreover, there is a shortage of medical dermatologists in the United States, where skin disorders account for 1 in 8 primary care visits and specialists tend to congregate in urban areas. Even in regions where dermatologic expertise is readily accessible, teledermatology may serve as an alternative that streamlines health care delivery by triaging chief complaints and reducing unnecessary in-person visits. In addition, many patients in the developing world have no access to dermatologic expertise, rendering it possible for teledermatologists to make a significant contribution to patient health outcomes. Teledermatology also affords educational benefits to primary care providers and dermatologists, and enables patients to play a more active role in the health care process by promoting direct communication with dermatologists.

Introduction

Key points

  1. Telemedicine is medicine practiced at a distance

  2. Telemedicine's development paralleled urbanization and subspecialization

  3. Telecommunication advances enhanced the practicality of telemedicine

Telemedicine uses telecommunications technology to convey clinical information from patients to remotely situated providers. Its development occurred in parallel with urbanization and the development of technologies that quickly or instantly link individuals and allow for the rapid conveyance of information across great distances. Telemedicine represents an evolving attempt to meet the needs of diverse patient populations with a variety of dermatologic complaints, although it may afford the greatest benefits to patients that were previously underserved by skin care experts for geographic and/or economic reasons. Indeed, it may have the potential to bring about a “disruptive innovation” that, in part, transforms traditional dermatology practice. There may be a variety of situations where teledermatology (TD) may appropriately substitute for a traditional dermatology encounter with less cost and/or improved efficiency.

Telemedicine can be traced to the early 1900s, when ship captains used radio to receive medical advice.1, 2 In 1906, Einthoven used telephone lines to transmit electrocardiograms, allowing him to monitor patients from afar.3, 4 Telemedicine was later used to monitor astronauts' vital signs during the Space Age.5 In the late 1950s, National Aeronautics and Space Administration (NASA) technology supported telemedicine for patients living on the Arizonan Papago Indian Reservation and, later, in rural Alaska.6

Television provided the first mechanism for live transmission of visual data with high fidelity.3 The first analog units required expensive equipment and technicians, limiting their use to large-scale academic endeavors rather than day to day practice. In the 1950s, televisions linked national medical society meetings.7 In 1965, Dr Michael DeBakey showed an aortic valve replacement using NASA's Early Bird satellite to connect hospitals in Texas and Switzerland.7

The development of analog to digital compressors in the 1980s made digital video teleconferencing possible by converting images into electronic binary code.3 Television alone, however, did not provide sufficiently high-quality images compared to still photography. Widespread Internet use provided the missing link by making store-and-forward (S&F) telemedicine possible, allowing providers to instantly relay high-resolution still images and clinical histories to experts around the world.

Mobile technology is now increasing the utility of telemedicine. In many regions, wired connectivity has lagged behind the development of wireless networks. In 2012, the World Bank estimated that 75% of the world's population had access to a mobile phone, up from 60% just 3 years earlier.8 Devices are continuously becoming less expensive and more powerful, while transmission networks double their bandwidth every 1.5 years and are continually extended into new territories.8 The medical mobile application market is growing rapidly.8, 9 A recent study reported a total of 229 dermatology-related mobile applications, approximately half of which are intended for patient use.10 Smartphones represent the possibility of interconnectedness across social, technological, and medical dimensions.

Key points

  1. The burden of skin disease is vast in both developed and developing countries

  2. The demand for medical dermatologists exceeds the current supply

  3. Teledermatology may partially solve healthcare disparities

TD, defined as the practice of providing skin care at a distance using telecommunications technologies, has been used by the US Department of Defense for several decades,3 and began to be described in the medical literature in the early 1990s.11, 12, 13, 14 Its use was reported in the literature in 1993 based on experiences in Norway, where telemedicine gained substantial ground during this time in a variety of medical specialties with highly visual components, including radiology and pathology.11, 12, 13 In the United States, TD was described as early as 1995 as a mechanism for providing care to underserved populations in rural Oregon.14 Figure 1 shows the growing body of TD literature over the last 20 years.

TD has the potential to greatly impact dermatology. The prevalence of skin diseases collectively exceeds that of obesity, hypertension, and cancer.15 Skin disease accounts for 12.4% of primary care visits in the United States, and most patients with dermatologic complaints contact only their family physician.16 However, an Irish study of nearly 500 cases found that dermatologists are significantly more successful than family physicians (87% vs 22%) at diagnosing biopsy-proven skin cancers.17 Another study involving 656 consecutive general practitioner referrals to an Australian dermatology clinic, 151 of which had histologic confirmation, found that general practitioners agreed with biopsy-proven diagnoses in 24% of cases, whereas dermatologists agreed in 77% of cases.18 Additional investigations have found that dermatologists are superior to primary care providers at correctly diagnosing melanomas and managing pigmented lesions.19

While the number of dermatologists has grown more quickly than the US population—increasing from 1.9 to 3.2 per 100,000 persons between 1970 and 2010, respectively20, 21—evidence suggests a shortage of medical dermatologists.20, 22, 23, 24 The average wait time for an appointment was 33.9 days in 200925; a 2006 study revealed that even for urgent conditions (ie, changing nevi), patients experienced long wait times.23 Interestingly, waits are reportedly 50% shorter for cosmetic procedures.26 A recent study revealed that a pediatric dermatologist shortage disproportionately affects Medicaid-insured children.27 This suggests that payment structures and other socioeconomic factors may be contributing to disparities in skin care delivery.

One factor that may be contributing to long wait times and the apparent shortage of skin expertise is the geographic distribution of dermatologists (Fig 2). In the 3 US urban areas with the highest density of dermatologists (Boston, MA; Palo Alto, CA; and New York City, NY), there are 25 dermatologists per 100,000 people, compared to 0.17 per 100,000 in the 3 lowest-density cities.21 Moreover, hundreds of rural counties, particularly in the central and western regions of the United States, have no local dermatologists to serve their respective patient populations on an in-person basis. Economic factors may also pay a role; many dermatologists decline to accept some types of health insurance (eg, Medicaid), contributing to the difficulty some patients have in obtaining an appointment with a dermatologist. Although the relationship between geographic and economic disparities in dermatology service delivery is not clear, both factors may be at play in many regions, such that health care disparities are compounded for millions of patients.

Finally, there is a trend among dermatologists toward early retirement and shorter workweeks,20, 22 perhaps exacerbating the shortage of dermatology services. The economic recession at the end of the last decade had a smaller impact on demand for dermatologists' services than was seen in other medical fields, probably reflecting the discrepancy between the supply of and demand for dermatologic expertise, and suggesting important implications for improving or enhancing current mechanisms of accessing it.28 TD may mitigate inequities in health care delivery and recruit part-time or retired dermatologists.29

Key points

  1. The 3 technological modalities of teledermatology are store-and-forward, real-time, and hybrid

  2. Store-and-forward is the most widely used modality

  3. Practice models include consultative, triage, direct care, and follow-up

Three distinct TD modalities have been developed to bring care to remote populations.30 Modality selection may reflect referring providers' capabilities, teleconsultants' practice structures, and other aspects of local health care system infrastructures, including choices made by payers, hospitals, and individual physicians. Table I shows the advantages and disadvantages of each modality. In S&F TD, consultants access data asynchronously, interfering less with daily workflow. Real-time TD (RTTD) enables direct interaction via a live video connection, requiring coordination between providers but potentially saving time by immediately clarifying aspects of complaints. Hybrid models merge advantageous aspects of both S&F and RTTD.

Four TD practice models have been identified: consultative, triage, direct care, and follow-up.31 The most commonly used is the consultative model, in which teledermatologists make recommendations from afar using any of the aforementioned technological modalities and referring providers assume the responsibility for adopting recommendations. The triage model uses TD to prioritize patient care and determine the need for in-person visits. This may improve access by reducing unnecessary referrals or shortening wait lists, the implications of which may be particularly important in underserved and/or resource-poor settings, although TD may be generally useful and efficient for appropriate triage. The direct care model supports direct communication between dermatologists and patients with skin complaints. More specifically, patients using this model photograph their own skin lesions and send images directly to consultants. This approach is limited by willingness to prescribe medications to patients not seen in a clinic setting, but it affords the greatest flexibility to many patients. The follow-up model enables remote monitoring of chronic skin conditions, such as psoriasis or stasis ulcers, that would otherwise warrant frequent clinic visits to assess disease activity and optimize therapy. While the follow-up model (which is a form of direct care) may be used with either direct or indirect communication lines between patients and dermatologists, it is typically described in settings of established in-person care, for which subsequent remote follow-up sessions may save both time and money for patients with chronic conditions.31

Section snippets

Usefulness and reliability

Key points

  1. Diagnostic and management decisions made via teledermatology are reliable and accurate

  2. Clinical outcomes are reportedly similar to those of standard care

Multiple studies support the reliability (ie, agreement) and accuracy of TD.32, 33, 34, 35, 36, 37, 38, 39 Complete agreement means consultants arrive at the same single diagnosis, whereas partial agreement means they list several diagnoses, some of which match one another. A systematic review found that S&F TD typically yields high degrees of

Global uses of teledermatology

In 2010, 38% of countries had some form of TD program, and 30% had government agencies devoted to TD.87 High-income countries have more initiatives than low-income countries.87 TD has thrived in highly integrated systems, such as Kaiser Permanente in California and in countries with state-supported universal health care.88, 89

TD is an answer to long waiting lists in an era of heightened demand for specialists, and has gained value as a mechanism for triaging patients in both the outpatient and

Conclusion

As summarized above, technological advances have the potential to revolutionize patient care by delivering skin expertise to a broader array of patient populations than was previously possible and replacing some of the traditional in-person dermatology patient encounters with a more financially and time-efficient mechanism in a variety of economic and cultural settings. A substantial and growing body of literature supports the reliability of TD as a tool for providing care on a remote basis to

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      Citation Excerpt :

      Recently, and even more in the current pandemic context, teledermoscopy has also increased patient access to expert dermatologic care, thanks to the electronic transmission of dermoscopic images. Moreover, as technology continues to evolve, the use of smartphone cameras for skin lesion image acquisition has been investigated in numerous studies as a potential tool for general practitioners who can then consult expert dermatologists in dubious cases [6–8]. The accuracy of the clinical diagnosis of skin disease by a board-certified dermatologist is highly experience-related [9], and there are many factors that can influence the final quality of the image that is used for diagnosis.

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    Funding sources: None.

    Conflicts of interest: None declared.

    Date of release: April 2015

    Expiration date: April 2018

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