Telemedicine evaluation of cutaneous diseases: A blinded comparative study

Jack L. Lesher, Jr., MD,a Loretta S. Davis, MD,a Frederick W. Gourdin, MD,a Debra English, MD,b and William O. Thompson, PhDc Augusta, Georgia

Background: Numerous telemedicine programs have been created in the United States, but studies documenting the fidelity and effectiveness of telemedicine for evaluation of diseases are lacking. Objective: We attempted to determine the percentage of encounters in which two differ- ent dermatologists, one using telemedicine and one on-site, could independently arrive at the same primary diagnosis. Methods: Two clinical telemedicine sites linked through the Georgia Statewide Telemedicine Program were used in this study of 60 patients with skin problems. One der- matologist evaluated the patients on telemedicine (interactive television) and a second then took the patients into a separate examination room and evaluated them on-site. Each investigator recorded their diagnoses with no discussion with each other. As a control group, the investigators independently and in a blinded fashion (to each other's diagnoses) recorded diagnoses for a group of patients from a third dermatologist's clinic. Raw data were evaluated and classified by this third dermatologist who assigned diagnoses to cat- egories of complete agreement, partial agreement, or disagreement. Results: There were no significant differences with regard to disagreement. However, there was a higher probability of complete agreement between the two dermatologists when each examined the patient on-site and in person than when one evaluated the patient on telemedicine and one examined the patient on-site and in person. Conclusion: Our results suggest that telemedicine is an effective means of diagnosing cutaneous diseases. However, because partial interobserver agreement on diagnoses was greater for the telemedicine group than for the control group (p < 0.05), it is likely that optimum use of medical assistants at the remote site will be necessary to increase the like- lihood of complete agreement on diagnoses among dermatologists using interactive tele- vision. (J Am Acad Dermatol 1998;38:27-31.)

Telemedicine uses computers and telecommu- cialty care to underserved areas represents more nications technology to provide medical informa- efficient use of existing medical resources, or a tion and services. This form of remote electronic misallocation of scarce health care dollars. clinical consultation is increasingly accepted in Studies documenting the fidelity and effective- Georgia as a means for primary care physicians to ness of telemedicine in the evaluation of cuta- obtain consultations. Telemedicine programs are neous diseases are lacking (see Addendum). In a used in more than 40 states in the United States.1 previously published comparative unblinded There is debate whether this tool to provide spe- observational study, one of us examined a group of 22 patients via telemedicine and then evaluated

a the patient in person within 3 days of the telemed- From the Section of , Department of Medicine, the 2 Department of Family Medicine,b and the Office of Biostatistics,c icine evaluation. The same diagnosis or differen- Medical College of Georgia. tial diagnosis was obtained in 21 of the 22 Accepted for publication Sept. 29, 1997. patients. The purpose of the present study was to Supported by the Telemedicine Center of the Medical College of Georgia and the Georgia Statewide Telemedicine Program. expand the pilot study to 60 patients to determine Reprint requests: Jack L. Lesher, Jr., MD, Section of Dermatology, the percentage of encounters in which two differ- Medical College of Georgia, 1004 Chafee Ave., Augusta, GA ent dermatologists (one using telemedicine and 30912-3190. Copyright © 1998 by the American Academy of Dermatology, Inc. one on-site) could independently arrive at the 0190-9622/98/$5.00 + 0 16/1/86467 same primary diagnosis.

27 Journal of the American Academy of Dermatology 28 Lesher et al. January 1998

Table I. Investigators' diagnoses and agreement status for telemedicine/local cases Problem No. Investigator 1 Investigator 2 Results 1 Dermatofibroma CA 2 /Folliculitis CA 3 Eczema Eczema/ CA 4 Tinea versicolor CA 5 keloidalis Acne keloidalis CA 6 Postinflammatory Postinflammatory hyperpigmentation CA 7 Dermatofibroma Dermatofibroma CA 8 Actinic keratosis CA 9 Cutaneous horn Hypertrophic actinic keratosis CA 10 Actinic keratosis Actinic keratosis CA 11 Seborrheic Seborrheic dermatitis CA 12 Furuncle Furuncle CA 13 Basal cell carcinoma Basal cell carcinoma CA 14 Actinic keratosis Actinic keratosis CA 15 Dermatofibroma Dermatofibroma CA 16 Nummular eczema PA 17 Bites Bites CA 18 /Lichen simplex chronicus Eczema/Tinea PA 19 Tinea/Eczema Eczema/Tinea PA 20 Psoriasis Psoriasis CA 21 Urticaria Urticaria CA 22 Postinflammatory hyperpigmentation Postinflammatory hyperpigmentation CA 23 Atopic dermatitis CA 24 Actinic keratoses/Factitious /Sarcoid D 25 Acne Acne CA 26 Stasis/Eczema Eczema PA 27 Vitiligo CA 28 Furunculosis/Hidradenitis Hidradenitis CA 29 Scabies CA 30 Seborrheic dermatitis Seborrheic dermatitis CA 31 Onychomycosis CA 32 Postinflammatory hyperpigmentation Postinflammatory PA caused by hyperpigmentation/Photosensitivity 33 Eczema/Atopic Xerosis/ PA 34 Basal cell carcinoma Actinic keratosis PA 35 Basal cell carcinoma Hypertrophic actinic keratosis/ PA Basal cell carcinoma 36 Epidermal inclusion cyst Epidermal inclusion cyst CA 37 Bites/Factitious Excoriations/Bites CA 38 Tinea versicolor Tinea versicolor CA 39 Healed Postinflammatory hyperpigmentation CA 40 Rosacea Rosacea CA 41 Acne Acne CA 42 /Eczema Eczema/Tinea PA 43 Seborrheic keratosis CA 44 Punctate keratoderma Punctate keratoderma CA 45 Nummular eczema Eczema CA 46 Postinflammatory hyperpigmentation/ Actinic keratosis/Seborrheic PA keratosis/Lentigo 47 Psoriasis/Eczema Eczema/Psoriasis PA 48 Basal cell carcinoma Sebaceous hyperplasia/ PA Basal cell carcinoma 49 Nevus CA 50 Telangiectasia Telangiectasia CA 51 Stucco keratosis Seborrheic keratosis CA 52 Acne Acne CA Journal of the American Academy of Dermatology Volume 38, Number 1 Lesher et al. 29

Table I. Cont’d Problem No. Investigator 1 Investigator 2 Results 53 Tinea versicolor Tinea versicolor CA 54 Seborrheic dermatitis Seborrheic dermatitis CA 55 Bite Folliculitis/Bite CA 56 Seborrheic dermatitis/Eczema Eczema CA 57 Scabies Scabies CA 58 Scabies Scabies CA 59 Acne Acne CA 60 Nummular Eczema Eczema CA 61 Basal cell carcinoma Basal cell carcinoma CA 62 Skin tags/Seborrheic keratoses Seborrheic keratoses/Skin tags CA 63 Dermatofibroma Dermatofibroma CA 64 Seborrheic keratoses Seborrheic keratoses CA 65 Scabies Xerosis/Scabies PA 66 Seborrheic dermatitis Seborrheic dermatitis CA 67 Hand eczema CA 68 Psoriasis Trauma/Psoriasis PA CA, Complete agreement; D, Disagreement; PA, Partial agreement.

METHOD AND DESIGN at the Tri-County Health System. Informed consent The telemedicine sites used for this study included was obtained from each participant. One dermatologist the Tri-County Health System in Warrenton, Georgia (J. L. L.) evaluated patients via interactive television and the Medical College of Georgia in Augusta. These from the Medical College of Georgia site. Immediately two sites are linked through the Georgia Statewide afterward, a second dermatologist (L. S. D.) on-site in Telemedicine Program by means of a dedicated T-1 Warrenton evaluated the patient in person. Each inves- line (1.5 megabytes per second or the equivalent of 24 tigator independently recorded their observations and telephone channels); the full T-1 line is used except diagnosis or differential diagnosis for each patient. After 30 patients were evaluated, the investigators when communication between computers is estab- switched locations. Case notes were not discussed lished (i.e., for image capturing and annotation). The through the data collection phase of the study. system uses a Video Telecom Mediamax CODEC dig- No written historical or demographic material was ital communication video coder-decoder device. The provided to investigators. The dermatologists were per- video uses 30 frames per second. The device also pro- mitted to question patients randomly. In live encoun- vides full duplex audio. The evaluating physicians and ters, palpation was permitted but no other methods for patient are able to view one another on Sony Trinitron augmenting the examination were used. (PVM-2030) color monitors with a standard resolution To provide a control group at the conclusion of the of 560 TV lines. The cameras used included a single telemedicine portion of this study, the two investigators chip JVC TK-1280U remote-controlled room camera independently evaluated 36 on-site patients whom they with a Computar TV zoom lens H1020812 MP with had never seen before, again recording their primary focal length of 8 to 80 mm, and a three-chip Panasonic diagnosis or differential diagnosis in a blinded fashion WV-E550 remote-controlled patient camera with a (i.e., with no discussion of findings). Again, palpation × Fujinon TV zoom lens S16 6.7 BMD-D24 with focal of lesions was permitted. length of 6.7 to 107 mm. The amount of lighting in For study and control groups there was no time lim- each telemedicine room is dictated by the size of the itation. Investigators made an effort to record time for room, and the anticipated clinical uses of the room. The each encounter, but this was not uniformly accom- goal is to create a "daylight" atmosphere while elimi- plished; therefore these data were not statistically eval- nating any external light source from windows. This is uated. necessary to ensure the integrity of the color balance In the telemedicine and control groups, if a partici- set for each camera and the computer during system pant had more than one cutaneous problem or lesion validation. A ceiling-mounted, daylight, 4-bulb fluores- that were clearly unrelated, these were treated as sepa- cent fixture is required. Close-up lighting is not gener- rate pieces of data, and diagnoses were recorded sepa- ally used. rately. Sixty patients at least 18 years of age with a skin The raw data were evaluated and classified by an problem were recruited randomly from among patients unbiased, independent third dermatologist (F. W. G.), Journal of the American Academy of Dermatology 30 Lesher et al. January 1998

Table II. Investigators' diagnoses and agreement status for local/local cases Problem No. Investigator 1 Investigator 2 Results 1 Bowen's disease Bowen's disease CA 2 Ruptured epidermal inclusion cyst Cyst/Epidermal inclusion cyst CA 3 / Stasis dermatitis CA 4 Nummular eczema Nummular eczema CA 5 Actinic keratosis Actinic keratosis CA 6 Basal cell carcinoma vs squamous Basal cell carcinoma/Actinic keratosis/ CA cell carcinoma Squamous cell carcinoma 7 Venous lake Venous lake CA 8 Tinea cruris CA 9 Actinic keratosis Actinic keratosis CA 10 Seborrheic dermatitis Seborrheic dermatitis CA 11 Stasis dermatitis Stasis dermatitis CA 12 Seborrheic dermatitis Seborrheic dermatitis CA 13 Seborrheic keratosis Seborrheic keratosis CA 14 Basal cell carcinoma Basal cell carcinoma CA 15 Sebaceous hyperplasia Sebaceous hyperplasia CA 16 Tinea manuum CA 17 Nummular eczema Lichen simplex chronicus/Eczema CA 18 Basal cell carcinoma/Irritated actinic keratosis Actinic keratosis/Basal cell carcinoma PA 19 Onychomycosis Tinea unguium CA 20 Ichthyosis Ichthyosis CA 21 Basal cell carcinoma Basal cell carcinoma CA 22 Lichen planus CA 23 Contact/Eczema Eczema PA 24 Diabetic dermopathy Diabetic dermopathy CA 25 Hemangioma Venous lake/Hemangioma CA 26 Folliculitis Folliculitis CA 27 Venous dermatitis Stasis dermatitis CA 28 Folliculitis Folliculitis CA 29 Postinflammatory hyperpigmentation Postinflammatory hyperpigmentation CA 30 Rosacea Rosacea CA 31 Nummular eczema Nummular eczema CA 32 Folliculitis/Acne Acne/Folliculitis CA 33 Epidermal inclusion cyst Epidermal inclusion cyst CA 34 Tinea Tinea CA 35 Tinea pedis Tinea pedis CA 36 Psoriasis Sebopsoriasis/Psoriasis CA 37 Paronychia Paronychia CA 38 Preauricular sinus Congenital anomaly CA 39 Vitiligo Vitiligo CA 40 Postinflammatory hyperpigmentation Postinflammatory hyperpigmentation CA 41 Actinic elastosis Solar elastosis CA 42 Nummular eczema Eczema CA 43 Bowen's disease/Eczema Seborrheic keratosis/Bowen's disease PA 44 Tinea versicolor Tinea versicolor CA 45 Ecthyma Traumatic CA 46 Irritant dermatitis Irritant dermatitis CA 47 Favre-Racouchot Milia CA CA, Complete agreement; PA, partial agreement. who assigned the diagnoses to categories of "complete ential diagnosis for lesions but no definite agreement agreement," "partial agreement," or "disagreement" on a single primary diagnosis, diagnoses were placed in (Tables I and II). Criteria for assignment into these cat- the "partial agreement" category; and (3) if there was egories were as follows: (1) If the primary diagnosis no agreement or overlap in primary diagnoses or dif- was identical, diagnoses were placed in the "complete ferential diagnoses, diagnoses were placed in "dis- agreement" category; (2) if there was a similar differ- agreement" category. There was only one case of dis- Journal of the American Academy of Dermatology Volume 38, Number 1 Lesher et al. 31 agreement, so patient outcomes in cases of partial Table III. Comparison of investigator agreement agreement or disagreement were combined before sta- for telemedicine and control groups tistical analysis, testing the hypothesis that the proba- Complete Partial bility of examiners arriving at the same diagnosis group Type of visit agreement agreement Disagreement would be equal regardless of type of examination. Fisher's exact test was used to determine statistical sig- Telemedicine/ 53 (78%) 14 (21%) 1 (1.0%) nificance of the diagnosis outcomes, with significant Local Local/Local 44 (94%) 3 (6%) 0 (0.0%) differences defined as p < 0.05.

RESULTS Diagnosis outcomes are listed in Table III. The well to use of telemedicine. To our knowledge, visit labeled "telemedicine/local" represents the ours is the first study to compare, in a blinded group examined by one dermatologist on interac- fashion, telemedicine diagnoses to local, on-site tive television and one dermatologist on-site, with (in person) diagnoses, also using a local/local con- a total of 68 cutaneous problems evaluated. The trol group for comparison. We found that exami- visit labeled "local/local" represents the control nation of patients by both dermatologists in a group, in which both dermatologists examined local, in-person setting gave rise to a higher prob- patients on-site with a total of 47 problems evalu- ability of complete agreement of diagnosis on the ated. first visit compared with the telemedicine/local If the assumption is made that diagnosis out- comparison group. A greater proportion of come does not depend on which type of visits patients fell into the "partial agreement" category enter into the comparison of diagnosis, then the when examined with telemedicine; specifically, results of our trial—with ratios of 53:15 in the with telemedicine evaluation, 21% of the cuta- telemedicine group versus 44:3 in the control neous problems or lesions fell into a partial agree- group (complete agreement: partial agreement or ment category, compared with 6% of lesions disagreement)—have to be considered a rare out- examined on-site by both investigators in the con- come (Fisher's exact test, p < 0.05). More likely, trol group. There may be several explanations for the results of our trial indicate that the type of visit this (e.g., the investigators believed there were influences the probability of similar diagnosis out- instances when palpation enabled them to make a comes. more secure primary diagnosis). However, the In our table of results, there is no significant finding of complete agreement in 78% of the diag- difference in comparative visits with frank dis- noses comparing telemedicine with local, in-per- agreement. Rather, the local/local comparison son diagnosis is encouraging. We suspect that this gives rise to a higher probability of complete percentage could be increased with optimum use agreement of diagnosis on the first visit (94% of of medical assistants at the remote site. diagnoses) than the telemedicine/local compari- ADDENDUM: Since submission of our article, a teleder- son (78% of diagnoses). With the telemedicine/ matology study appeared in the September 1997 issue local comparison, there was a higher probability of this Journal (Phillips CM, Burke WA, Shechter A, of partial agreement on diagnoses (21% of diag- Stone D, Balch D, Gustke S. 1997;37:398-402) that noses) among examiners than with the local/local also compared diagnosis by a “live” dermatologist ver- sus a teledermatologist. The authors found a reasonable (control) group (6% of diagnoses). degree of agreement between the two examining physi- Of the 41 study group encounters for which cians and observed that despite a high concordance rate investigators recorded evaluation time, telemedi- on diagnosis, the teledermatologist had a lower degree cine required a longer time for evaluation in 37 of of confidence in his diagnosis. 41 cases (90%). REFERENCES 1. Perednia DA, Allen A. Telemedicine technology and clini- DISCUSSION cal applications. JAMA 1995;273:483-7. Some early work with telemedicine in derma- 2. Warren FM, Lesher JL Jr., Hall JH Jr., Ward DF, Sanders tology was published in 1972 and documented the JH, Tison J. Telemedicine. J Fam Pract 1995;41:17,20. 3 3. Murphy RLH, Fitzpatrick TB, Haynes HA, Bird KT. usefulness of this technique. Accuracy of dermatologic diagnosis by television. Arch Dermatology, as a visual specialty, lends itself Dermatol 1972;105:833-5.