Proceedings of the 2nd WSEAS International Conference on BIOMEDICAL ELECTRONICS and BIOMEDICAL INFORMATICS

Teledermatology: Digital revolution in the management of skin disease

S. Oikonomou

Dermatology Department Ysbyty Gwynedd, North Wales NHS Trust Bangor, LL57 2PW, North Wales United Kingdom [email protected]

Abstract: - Telemedicine offers benefits to many patients, such as a shorter wait time or treatment without travelling to a remote clinic. Teledermatology, application of telemedicine, is one of the most often applied telemedicine applications worldwide. It has been practised both in real-time through the use of videoconferencing (synchronus), and as store-and-forward systems (asynchronus). Teledermatology has generally demonstrated high levels of concordance in diagnosis and management plans compared with face-to-face consultations. With the rapid evolution of communications technology leading to decreasing equipment costs, teledermatology holds great potential for revolutionizing the delivery of dermatologic services, especially among rural and remote communities. Potential uses include a supporting role for primary care physicians, more accurate triage of dermatology patients, or an ‘advice only’ service. High patient satisfaction with teledermatology appears to be a recurring theme throughout a number of studies [1-3]. Clinicians have also generally reported positive experiences with teledermatology. Moreover teledermatology has proved to be a convenient mode of education, academic and research activities and a tool of interaction between Dermatologists at a national and international level. Security concerns have been expressed with regards to maintaining privacy and confidentiality of patient data transmitted via the World Wide Web, encryption however of all sensitive medical information minimises risk. Future studies that focus on cost-effectiveness and patient outcomes will help further define the potential of teledermatology as a means of dermatologic healthcare delivery.

Key-Words: Telemedicine; teledermatology; store-and-forward systems; cost-effectiveness.

1 Introduction 2 Teledermatology technology Telemedicine is an emerging field within medicine The research and delivery of a teledermatology with potential to revolutionize the delivery of health service has usually been by means of care. It is defined as the use of telecommunication teleconferencing equipment or store-and-forward, technologies to transfer medical information. We computer-based, systems. Each modality has its can undoubtedly expect the continued improvements advantages and disadvantages and existing of technologies to facilitate a more accurate, timely information indicates that both store and forward and affordable telemedical service across all fields, and real time interactive technology result in reliable which translate perfectly to teledermatology due to diagnostic outcomes when compared with clinic- its visual nature. Dermatologists were early adopters based evaluations [6-7]. Whether using interactive of telemedicine because their consultations are or store-and-forward teledermatology, it is essential primarily about taking a careful history and visual to ensure privacy, security of data and technology inspection. With the current under-provision of that is accurate, reliable and simple to use. In dermatology service in the UK and the waiting list general, the patient’s express informed consent is targets set by government, teledermatology systems necessary. Teledermatology protocols should be have been proposed as a possible solution. Some carefully prepared and followed to protect the teledermatology trials have not shown patient. teleconsultations to be faster or more economical than conventional consultations, although evidence 2.1 Videoconferencing suggests that low-cost store-and-forward systems of Modern videoconferencing equipment allows real- teledermatology may reduce waiting times for some time consulting between two or more parties. This patients [4-5].

ISSN: 1790-5125 117 ISBN: 978-960-474-110-6 Proceedings of the 2nd WSEAS International Conference on BIOMEDICAL ELECTRONICS and BIOMEDICAL INFORMATICS equipment enables the dermatologist to see the 3 Diagnostic accuracy patient through the video link, while the patient has As with the implementation of any new intervention contact with the dermatologist through a small or technique, demonstrating the equivalence of digital camera mounted on the videoconferencing teledermatology with the current best available unit. This allows direct interaction between the practice (face-to-face clinical review) is essential. dermatologist, the patient and the person conducting Recent studies have directly addressed the issue of the video imaging. During a video session, the clinical outcomes achieved via teledermatology. The patient needs someone to explain the process data suggest that teledermatologists reviewing store beforehand and to facilitate the consultation. The and forward consults achieve accuracy comparable personnel involved should be adequately trained, but to that of clinic based dermatologists [9], however they do not have to be medical practitioners. such studies cannot determine whether patients Nursing staff and other non-medically qualified experience equivalent or improved outcomes in health care professionals are routinely involved in terms of morbidity, mortality, or quality of life. remote consultations across the UK. Real time video More studies evaluating similar clinical outcomes consultations have some significant clinical and must be performed before this information is educational benefits, but are inconvenient and time accepted by physicians and patients. consuming for the clinicians.

2.2 Store-and-forward systems 4 Cost-effectiveness The advantage of these systems is that they avoid Teledermatology is more likely to be widely adopted the logistical difficulties of setting up if it is reliable, efficient and can demonstrate videoconferencing consultations, and allow the economic viability. Recent studies [10-12] dermatologist to evaluate large numbers of captured comparing the cost-effectiveness of real-time images quickly. PCs with modern processor speeds teledermatology with conventional hospital and 256MB of RAM are adequate for most routine outpatient appointments showed advantages for the image handling and short term storage. Larger (17- patients in terms of time off work, loss of income to 21 inch) monitors with better quality screens yield the patient or productivity by the employer as well the best images and allow for multiple images and as time and expense of travelling to hospital. Real- text to be reviewed simultaneously. Access to the time interactive dermatology has traditionally been internet is usually through ISDN, ISDN2 or found to be more costly than standard care because Broadband and these facilities are needed to of the need for 2 providers and complex download images without undue delay. Telephone videoconferencing equipment. In the opinion of lines should not be on the National Health System several authors [4-5], store and forward net (NHSnet) and a separate encryption process is teledermatology could be more cost-effective than necessary for patient identifiable material. Normal real-time consultation due to its speed and telephone lines are unacceptably slow for large convenience. It avoids the high provider and image files. Access to network for back up or equipment costs of real time interactive service, alternatively a CD or DVD writer within the PC is while still being less time consuming for patients. essential. In order to make a diagnosis, certain demographic details are required, including the patient’s age, sex, ethnicity and geographic residence. The referral should outline the suspected 5 Doctor satisfaction diagnosis, location and distribution of the In the U.K., GPs reported very high levels of lesion/eruption, duration, size, features, aggravating satisfaction (> 80 %) with real-time consultation and and relieving factors, and any previous treatment. stated that 75 % of teleconsultations were of General medical information should include educational benefit [7]. In a larger study, GPs significant concurrent and past health problems, estimated the knowledge transfer effect of real-time prescribed and non-prescribed medications and consultation to be the equivalent of 6 days training allergies, and the family history. Results of per year [10]. Dermatologists are generally investigations such as mycology and skin enthusiastic and report that they can achieve good may be important. In addition, the reason for referral rapport with patients using real-time technology. In should be indicated. The dermatologist should be a study using high bandwidth videoconferencing, able to obtain further information if required [8]. where image quality is likely to have been better, dermatologists were highly satisfied with the interpersonal aspects of video consultations and

ISSN: 1790-5125 118 ISBN: 978-960-474-110-6 Proceedings of the 2nd WSEAS International Conference on BIOMEDICAL ELECTRONICS and BIOMEDICAL INFORMATICS

tended to be surer of their diagnoses [1]. A majority patients with chronic skin conditions, such as also believed that teledermatology was just as for example, may also benefit from thorough as clinic visits. Criticisms were usually teledermatology applications, such as online concerned with picture quality and inability to information leaflets, online forums etc, which can palpate lesions or carry out diagnostic tests. provide patients with educational information and a supportive environment where they can communicate with others about the stresses 6 Patient satisfaction associated with their chronic dermatological Most patients are pleased that their condition is conditions. being diagnosed and treated as soon as possible and almost 90 % [3] agreed that a teleconsultation saves time and expenditure in travelling to hospital. A 8 Security and legal issues certain number of patients would still prefer a face- Dermatologists have expressed concerns that to-face consultation, with one study reporting that teledermatology is risky in a medico-legal sense. 40 % felt ‘something was missing’ when the The legal implications of telemedicine have been dermatologist was not seen in person [13]. extensively debated and are not specific to Generational differences may also exist amongst dermatology. Most legal and ethical issues are the patients, with those in younger age groups more same as those of medicine in general [18]. Breaches accepting of the new technology than the elderly in the confidentiality of sensitive medical [14]. Patients who probably are less tolerant or do information could cause distrust in telemedicine not do so well include the elderly, small infants, generally [19]. Patients should, at the very least, those who are shy and embarrassed at being know what information is being collected about videoed, and those with genital rashes [15]. them how it is going to be transmitted, to whom, and Regardless of consultation modality, patients want how it is going to be used [20]. It would be rapid access to an accurate diagnosis and an considered good practice to obtain written consent effective treatment plan [16]. They also want to for storing and transmission of patient information, receive individualized personal care [13, 17]. When and certainly this is mandatory when the data these aspects of service are considered, comparably collected are to be used for research [21]. It is high satisfaction ratings can be achieved with either expected that when patients consent to a teledermatology or conventional care. teledermatology consultation, they understand that there can be a difference in diagnostic accuracy and diagnostic certainty between a face to face 7 Teledermatology for education consultation and teledermatology.

Another valuable use of teledermatology is the provision of dermatology training and education to physicians and support to patients. Teledermatology 9 The future can be used to train dermatology residents and teach With the rapid evolution of communications undergraduate medical students. Increasing numbers technology and decreasing equipment costs, several of hospital departments and universities arrange new applications of teledermatology have emerged, regular interactive tutorials and case discussions by such as mobile teledermatology, teledermoscopy videoconference. In the current UK health system and teledermatopathology. the majority of patients with dermatological problems are initially managed by their General 9.1 Mobile teledermatology Practitioner who might have had some or no training Studies have already begun to focus on the role of in dermatology over the years, making it essential mobile phones and personal digital assistants (PDA) for dermatologists to reach out to their colleagues in areas such as remote patient monitoring, triage and ensure they have access to support and and follow-up of patients with chronic skin disease. educational resources to enable the best diagnostic Mobile devices have the ability to send data and and management decisions to be made. In addition images from remote areas where internet connection communication technology can be used for is not available. discussion between a GP and the dermatologist; however it is likely that in the future, subsequent 9.2 Teledermoscopy applications could involve direct communication Dermoscopy is a non invasive method to evaluate between dermatologists and patients. Dermatology the skin surface. The dermatoscope is the simplest

ISSN: 1790-5125 119 ISBN: 978-960-474-110-6 Proceedings of the 2nd WSEAS International Conference on BIOMEDICAL ELECTRONICS and BIOMEDICAL INFORMATICS

and best recognized piece of equipment used to [6] A.M.M. Oakley, D.R. Astwood, M. Loane, et al., perform a dermoscopy examination. A camera can Diagnostic accuracy of teledermatology: results of a be used to photograph the images seen with a preliminary study in New Zealand, N Z Med J, Vol. dermatoscope. These images can then be sent to 110, 1997, pp. 51-53. other specialists for evaluation, diagnosis and [7] E. Gilmour, S.M. Campbell, M.A. Loane, et al., recommendations. Teledermoscopy can be also used Comparison of teleconsultations and face-to-face to provide images to remote teledermatologists for consultations: preliminary results of a United teaching and training. Kingdom multicentre teledermatology study, Br J Dermatol, Vol. 139, 1998, pp. 81-87. 9.3 Teledermatopathology [8] R. Wootton, A. Oakley, Teledermatology, Royal Teledermatopathology refers to the transmission of Society of Medicine Press Ltd, 2002. images of histopathologic sections (either static or [9] J.D. Whited, Teledermatology special interest real time) for telediagnosis. In current practice, group. Summary of the status of teledermatology teledermatopathology is not used to replace research, American Telemedicine Association, 2008. diagnosis by conventional microscopic examination. [10] R. Wootton, S.E. Bloomer, R. Corbett, et al., It has the potential however to provide a diagnosis to Multicentre randomised control trial comparing real- patients in areas of the world where time teledermatology with conventional outpatient dermatopathologists are not available. dermatological care: a societal cost-benefit analysis, Br Med J, Vol. 320, 2000, pp. 1252-1256. [11] M.A. Loane, S.E. Bloomer, R. Corbett, et al., 10 Conclusion Patient cost-benefit analysis of teledermatology Teledermatology has been advocated as a mode of measured in a randomised control trial, J Telemed health care delivery that may diminish inequalities Telecare, Vol. 5, No. 1, 1999, pp. S1-S3. in the provision of an overstretched service and [12] A.M. Oakley, P. Kerr, M. Dunfill, et al., Patient improve access to dermatological care, especially cost-benefits of realtime teledermatology - a for remote or isolated communities, currently denied comparison of data from Northern Ireland and New specialist attention. For widespread sustainable Zealand, J Telemed Telecare, Vol. 6, 2000, pp.97- adoption of teledermatology practice to occur, 101. efficacy, acceptability and economic viability must [13] K. Collins, I. Bowns, S. Walters, General all be demonstrated. Further research into the practitioners’ perceptions of asynchronous outcomes and limitations of teledermatology is telemedicine in a randomized controlled trial of required in order to demonstrate the value of this teledermatology, J Telemed Telecare, Vol. 10, No. service for health care providers and patients. 2, 2004, pp. 94-98. [14] J.L. Lesher, L.S. Davis, F.W. Gourdin, et al., Telemedicine evaluation of cutaneous diseases: a blinded comparative study, J Am Acad Dermatol, References: Vol. 38, 1998, pp. 27-31. [15] D.R. Elford, Teledermatology, J Telemed [1] M.H. Lowitt, II Kessler, C.K. Kauffman, et al., Telecare, Vol. 3, 1997, pp. 4-6. Teledermatology and in person examination, Arch [16] N. Eminovic, L. Witkamp, N.F. de Keizer, J.C. Dermatol., Vol. 134, 1998, pp. 471-476. Wyatt, Patient perceptions about a novel form of [2] C. Phillips, W.A. Burke, M.H. Allen, et al., patient-assisted teledermatology, Arch Dermatol, Reliability of telemedicine in evaluating skin Vol. 142, No. 5, 2006, pp. 648-649. tumours, J Telemed, Vol. 4, 1998, pp. 5-9. [17] A.A. Qureshi, J.C. Kvedar, Patient knowledge [3] M.A. Loane, S.E. Bloomer, R. Corbett, et al., and attitude toward information technology and Patient satisfaction with real-time teledermatology teledermatology: some tentative findings, Telemed J in Northern Ireland, J Telemed Telecare, Vol. 4, E Health, Vol. 9, No. 3, 2003, pp. 259-264. 1998, pp. 36-40. [18] B. Stanberry, Telemedicine: barriers and [4] M. D’Souza, D. Shah, K. Misch, L. Ostlere, opportunities in the 21st century, Journal of Internal Dermatology opinions via intranet could reduce Medicine, Vol. 247, 2000, pp. 615-628. waiting times, Br Med J, Vol. 318, 1999, p. 737 [19] B. Stanberry, The legal and ethical aspects of (Letter). telemedicine. Confidentiality and the patient's rights [5] P.V. Harrison, B. Kirby, Y. Dickinson, R. of access, J Telemed Telecare, Vol. 3, 1997, pp. Schofield, Teledermatology-high technology or not? 179-187. J Telemed Telecare, Vol. 4, 1998, pp. 31-32.

ISSN: 1790-5125 120 ISBN: 978-960-474-110-6 Proceedings of the 2nd WSEAS International Conference on BIOMEDICAL ELECTRONICS and BIOMEDICAL INFORMATICS

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ISSN: 1790-5125 121 ISBN: 978-960-474-110-6