teledermatology can produce high-quality care at low cost

Dis Manage Health Outcomes 2003; 11 (4): 209-215CURRENT OPINION 1173-8790/03/0004-0209/$30.00/0

© Adis Data Information BV 2003. All rights reserved.

Teledermatology Can Produce High-Quality Careat Low CostKeng Chen,1 Stephen Shumack1 and Richard Wootton2

1 St George Dermatology, Kogarah, Sydney, New South Wales, Australia2 Centre for Online Health, University of Queensland, Brisbane, Queensland, Australia

Teledermatology can provide both accurate and reliable specialist care at a distance. This article reviewsAbstractcurrent data on the quality of care that teledermatology provides, as well as the societal cost benefits involved inthe implementation of the technique. Teledermatology is most suited to patients unable to access specialistservices for geographical or social reasons. Patients are generally satisfied with the overall care that telederma-tology provides. Real-time teledermatology is more expensive than conventional care for health services.However, significant savings can be expected from the patient’s perspective due to reduced travel. Appropriatepatient selection, improved technology and adequate clinical workloads may improve both the quality and costeffectiveness of this service.

Teledermatology is the practice of dermatology at a distance, 1. Accuracy and Reliability in Diagnosisand has recently been reviewed.[1] Interest in this area is fueled by

An acceptable standard of care in teledermatology requiresthe experiences of certain populations who have poor access to

both accuracy and reliability in diagnosis, together with healthspecialist services due to geographical or social reasons.[2] Tele-

outcomes comparable to conventional care. In teledermatologydermatology has the potential to improve access by providing research, accuracy is defined as the degree of concordance be-high-quality care at a distance. Relevant issues include its accura- tween teledermatology and face-to-face diagnoses. Reliability iscy, reliability, cost and security. Medico-legal and ethical issues reflected in how consistent the diagnoses are across differentrelating to telemedicine are important and have been discussed clinicians.[4,5]

previously.[3] This article reviews current data on the quality of2. Real-Time Teledermatologycare that teledermatology provides, as well as the societal cost

benefits involved in the implementation of the technique.

The two main forms of teledermatology practice involve the 2.1 Accuracy and Reliabilityactivity taking place in real-time and the activity taking place ‘off

Real-time teledermatology offers a high degree of accuracyline’, commonly called store-and-forward. Real-time systems in-(table I) and reliability, with an agreement of 59–80% comparedvolve the use of video conferencing equipment, where sound andwith face-to-face diagnoses. The accuracy increases to 75–86% if

visual information is relayed between specialist and patient inthe teledermatology differential diagnosis is included.[6-9] The

real-time during the consultation. A nurse or general practitionerconfidence level of the teledermatologist is a significant factor that

(GP) usually accompanies the patient during the consultation. In influences accuracy. One study has suggested that the correlationstore-and-forward systems, one or more static digital images of the between the video and face-to-face diagnoses is 89% when thepatient are transmitted to the dermatologist, together with a short teledermatologist is confident of the diagnosis, but drops to 33%clinical history, and the data are reviewed at a later time. Readers when the teledermatologist is less confident.[10] Cases where theinterested in a discussion on the equipment and technology in- teledermatologist is not confident of the diagnosis should thereforevolved in these two systems are referred to a recent review.[1] be considered for a face-to-face consultation. As experience with

210 Chen et al.

may be improved by education of primary caregivers, for example,in the excision of simple skin lesions. Using teledermatology inthis way shifts the care of the patient back to the primary careprovider and this may reduce the burden on specialist services.

A high-quality teledermatology service should provide clinicaloutcomes comparable to traditional face-to-face consultations.The majority of studies to date have focussed on the concordancerates of diagnoses and management plans, with the assumptionthat if these are in agreement with a face-to-face assessment, thenhealth outcomes will be similar. It is therefore important to notethat long-term follow-up studies on the health outcomes of pa-

Table I. Accuracy of real-time and store-and-forward teledermatology com-pared with face-to-face consultations[4,6-18]

Variable Real-time Store-and-forward

Diagnostic accuracy (primary 59–80% 59–88%diagnosis alone)

Diagnostic accuracy (including 75–86% 81–96%differential diagnoses)

Wrong diagnosis 6–12% 16–17%

Management plans 64–84% 87%

Sub-optimal management plans 8%

Inappropriate management plans 9% 13%

tients involved in teledermatology services have not been done,and these studies are required to better assess the overall caretelediagnosis increases, the confidence and accuracy of cliniciansprovided by teledermatology.can also be expected to improve.

In terms of management plans, studies have demonstrated thatStudies on the accuracy of teledermatology usually compare64–72% of real-time and face-to-face consultation managementthe diagnosis with the arbitrary gold standard of a face-to-faceplans are identical.[6,8]This figure was higher (79–81%), if casesconsultation. However, the degree of inter-observer variabilitywhere the teledermatologist was unable to offer a managementamong dermatologists, even in a face-to-face consultation, isplan were excluded. In one study, 8% of management plans wereunclear and may vary significantly.[19,20] Therefore, the degree ofassessed as sub-optimal.[8] Sub-optimal plans were either over- ordiscrepancy in the accuracy of teledermatology attributed to theunder-aggressive and over half of these cases involved the man-technology alone is unclear. As is often the case in telemedicineagement of tumors. To some extent, these variations in manage-generally, focusing on the accuracy of a new technique (i.e.ment plans may reflect variations in experience, training andteledermatology) highlights the dearth of knowledge about thepreferences of different dermatologists. Of more concern is theperformance of conventional practice.finding that 9% of management plans were inappropriate.[8] InApproximately 3–11% of cases cannot be diagnosed with real-over half of these cases the management plans were inappropriatetime teledermatology[6-8] and will therefore require an in-persondue to an inaccurate diagnosis, while other cases were due to thereview. In trials, the conditions that appeared most difficult tounderlying severity of the disease being misleading over thediagnose were eczematous and acneiform lesions. Wrong diagno-video-link. Eczematous conditions accounted for a third of inap-ses were made in 4–12% of cases[6-8] and included conditions suchpropriate management plans. However, the consequences of inap-as basal cell carcinoma, actinic keratoses, dermatitis and melano-propriate management of a skin tumor are more serious. Furtherma in situ.[7] Areas covered with hair (scalp, axilla, genitalia) arestudies are required to assess how the proportion of inappropriateless satisfactorily viewed by teledermatology.[9] Studies evaluatingmanagement plans may be reduced. Importantly, the same caveatthe role of selecting patients with lesions or rashes that are suitableapplies to the accuracy of management plans as to the accuracyfor telediagnosis are currently unavailable, but may be one methodof diagnoses: there is little published information about inter-of improving the accuracy of teledermatology and optimizingobserver variation between dermatologists.patient care and outcomes.[21]

2.3 Patient and Physician Perceptions2.2 Clinical Management Plans

Patients who benefit most from teledermatology are those with Patient satisfaction with real-time teledermatology is difficultskin conditions that can be diagnosed accurately using to assess due to the nature of trial conditions, e.g. in some studiestelemedicine, and managed locally by the primary care provider. If patients were aware that they were to be assessed by both tele-the patient is required to travel to the dermatologist following dermatology and face-to-face consultations on the same day.[6,7]

diagnosis, the benefit of teledermatology is obviously diminished. Patient satisfaction, however, appears to be high (table II). WhileOne study has reported that 50% of real-time teledermatology some patients would still prefer a traditional face-to-face consulta-referrals could be managed using a single videoconference ses- tion,[10] more than half of them felt that a teleconsultation was assion, with no further specialist intervention required, by providing good as a face-to-face consultation.[22] There is evidence to sug-the primary care provider with a management plan.[6] This rate gest that younger patients are more accepting of the technology.[10]

© Adis Data Information BV 2003. All rights reserved. Dis Manage Health Outcomes 2003; 11 (4)

Teledermatology and Quality Care 211

study using pairs of clinicians has demonstrated that the accuracyand reliability of store-and-forward teledermatology is compara-ble to a face-to-face consultation when inter-observer variability istaken into account.[5] The diagnostic agreement between face-to-face diagnoses by a pair of clinicians (0.92, CI 0.88–0.96), wascomparable to that between a face-to-face clinician and ateledermatologist in private practice (0.84, CI 0.79–0.90); or be-tween the same face-to-face clinician and two academic-basedteledermatologists (0.83, CI 0.78–0.89 and 0.95, CI 0.92–0.98,respectively).

Non-dermatologists perform poorly in the diagnosis of cutane-ous diseases.[26-28] A study involving 256 patients with biopsy-confirmed diagnoses demonstrated a mean GP diagnostic accuracyof 37%, compared with 81% for dermatologists.[29] It is importantto appreciate that dermatologists using store-and-forward systemshave been shown to be more accurate in diagnosis than primarycare providers in face-to-face consultations.[4] While store-and-forward systems may not be as clinically efficient as real-timesystems,[30] they may still contribute to an increased standard ofcare in circumstances where face-to-face specialist dermatologyconsultations are unavailable.

The confidence of the teledermatologist in making a diagnosis

Table II. Patient satisfaction with real-time and store-and-forwardteledermatology[6,7,9,22,23]

Percentage of patients Real-time Store-and-forward

Felt uncomfortable with the camera 18% 12%

Felt embarrassed with the video link or 17% 14%being photographed

Felt they could talk freely to doctors 93–98% N/A

Could see and hear clearly >91% N/A

Would prefer to see a dermatologist 42% 40%face-to-face

Felt a teleconsultation was as good as 54–59% 68%a face-to-face consultation

Felt a teleconsultation would save them 79–92% No datatime

Felt a teleconsultation would save them 63–65% No datamoney

Felt a teleconsultation would reduce 71–74% No datastress

Felt happy with the consultation No data 93%

Felt it was more convenient than going No data 86%to an outpatient clinic

N/A = not applicable

is a significant factor.[12,14,16] The impact of disease category ondiagnostic accuracy is unclear, with some studies suggesting noThe depersonalization involved in a teledermatology consulta-effect,[14] while others suggested that benign neoplasms and rashestion and the consequent erosion of the doctor-patient relationshipwere associated with reduced accuracy.[12,15]has been raised as a concern by some physicians.[24,25] Physicians

involved with real-time teledermatology have, however, reportedhigh levels of satisfaction with the teleconsultation, although face-

3.2 Clinical Management Plansto-face consultations are still preferred.[10] It is possible that somedegree of bias towards the technology may be present in reported

Studies evaluating the clinical management plan of store-and-satisfaction levels. Primary care providers who were present withforward systems compared with conventional care are less readilythe patient at the time of the teleconsultation reported that theavailable than with real-time teledermatology. There is no evi-experience was educational.[6]

dence that store-and-forward teledermatology clinicians ordermore tests than face-to-face clinicians.[14] However, in one study

3. Store-And-Forward Teledermatologyup to 69% of patients seen by by clinicians in a store-and-forwardsystem required an in-person dermatology review.[31] This sug-gests that store-and-forward systems may be less efficient than3.1 Accuracy and Reliabilityreal-time systems or conventional care. Education on the interpre-tation of still digital images may be necessary to optimize patientThe reported accuracy of store-and-forward systems is compa-outcomes.[32]

rable to real-time teledermatology (table I). One study demonstrat-ed that the concordance between digital diagnosis and biopsy Store-and-forward systems may be useful as a triage system toresult (gold standard) was 76%, with no significant difference reduce outpatient referrals and to improve the accessibility ofbetween in-person versus biopsy diagnosis and digital versus dermatology clinics to those that most require it. One studybiopsy diagnosis.[16] The reliability of store-and-forward systems evaluating store-and-forward systems as a means of triaging der-has been demonstrated in one study where the mean concordance matology outpatient referrals suggested that 31% of cases wouldachieved by four dermatologists was 79%, increasing to 86% not require an outpatient appointment, while 50% of referred caseswhen differential diagnoses were taken into account.[11] Another were inappropriately labeled as ‘urgent’.[15]


212 Chen et al.

3.3 Patient Perceptions distances of about 800km.[38] With an annual workload of 375teledermatology patients for a clinic, the authors calculated that

Patient perceptions of store-and-forward systems are summa-the annual cost of a teledermatology service was 470 780 Norwe-

rized in table II. The results are generally similar to real-timegian kroner (NOK), the cost of a visiting dermatologist was

teledermatology. One recent study has suggested that quality ofNOK880 530, the cost of patient travel to the specialist was

life, as assessed by the Dermatology Life Quality Index (DLQI),NOK635 075 and the cost of a locally employed dermatologist

may be a significant factor associated with patient satisfactionwas NOK958 660 (1998 values). If the annual workload was

with store-and-forward teleconsultations.[33] Patients with lowerbelow 85 teledermatology patients, patient travel would have been

quality of life were more likely to prefer a face-to-face consulta-the cheapest method. If the workload was between 85 and 195

tion, and to experience anxiety about being photographed. Selec-patients, a visiting service was the cheapest method. Telederma-

tion of patients suitable for store-and-forward teledermatologytology was the cheapest method for workloads greater than 195

might therefore also consider the severity of the skin disease.patients per year.

The importance of workload has also been demonstrated in a4. Coststudy from Finland where savings occurred when 92 patients wereseen annually using a teledermatology service which was 55km

4.1 Real-Time Teledermatology away from where the patients were based.[39] Data from NewZealand suggest that for teledermatology to be economically via-A randomized control trial conducted in Northern Ireland com-ble from the hospital’s viewpoint, an average of 28 patients wouldparing real-time teledermatology with conventional outpatientneed to be seen per week.[36]

care demonstrated that, in the context of the research trial, real-A significant but poorly measured cost is the cost to the patienttime teledermatology was more expensive than conventional

associated with diagnosis and management of their skin conditioncare.[34] However, the distance traveled per patient in this studyprior to specialist review. These patients may wait for severalwas short, and sensitivity analysis suggested that greater patientmonths prior to review, during which the costs of over-the-countertravel distances and reduced equipment prices at current standards(OTC) medications, and medications prescribed by their primarywould make real-time teledermatology a viable and cost-effectivecare provider, may accumulate. A study from Tennessee in the USalternative. The break-even round-trip distance, where telederma-suggested that the average duration of a patient’s skin conditiontology was as cheap as conventional care, was approximatelywas 17 months prior to teledermatology review.[40] Taking into200km in this study. Using a sensitivity analysis of a real-worldaccount the cost of provider fees, medications and diagnostic tests,scenario in a subsequent trial, the same group demonstrated thatthe authors suggested that the average cost of care for the skinthe marginal costs of a teleconsultation were less than a conven-condition was $US294 for the 8 months prior to teledermatologytional consultation for rural patients.[35] A New Zealand trialreview, as opposed to $US141 for the 6 months after diagnosis byreported that the average societal cost of a teledermatology consul-teledermatology (1996 values). Health outcomes were not as-tation was $NZ279 compared with $NZ284 (2001 values) for asessed in this study but were assumed to be better followingconventional hospital consultation.[36] The patients randomized toteledermatology review due to more accurate diagnosis comparedhospital consultation in this study traveled an average 267km.with diagnosis by the primary care provider.There is evidence to suggest that cost savings attributable to

real-time teledermatology accrue to the patient rather than thehealth service due to reduced patient travel distances.[35,36] Indeed, 4.2 Store-And-Forward Teledermatologyreduced travel and waiting times have been demonstrated forpatients using teledermatology services.[37] From the healthcare Store-and-forward teledermatology is cheaper and simpler toprovider’s view, teledermatology is more expensive. Most of the arrange than real-time teledermatology. However, data examiningincreased cost of teledermatology services are experienced by the the overall societal cost effectiveness of store-and-forward sys-primary care provider, due to equipment costs.[35,36] If the cost of tems are not complete. The United Kingdom Multicentre Trialtravel is entirely to the health service (for example, for patients in Group has demonstrated that store-and-forward teledermatology isstate institutions, nursing homes or the military), then cost savings cheaper but less clinically efficient than real-time telederma-can be expected for the health service.[17] tology.[30] The net societal cost of an initial real-time consultation

The cost of teledermatology in relation to alternative methods was £132.10 per patient compared with £26.90 for a store-and-of healthcare delivery for rural patients, and the significance of forward system (1995 values). However, only 45% of real-timepatient workload, were assessed in a Norwegian study involving teledermatology patients required a face-to-face follow-up review



Table III. Comparison of real-time and store-and-forward teledermatology

Variable Real-time Store-and-forward

Medical aspects High level of agreement with face-to-face diagnosis Comparable to real-time

High level of agreement with face-to-face management Good but less efficient than real-timeplans

Greater clinical information available; able to elicit ‘live’ Limited history and examination availablehistory and focus examination

Provide immediate feedback and education to patient and/ Delayed and/or limited feedback and educationor primary care provider

Suitable for monitoring therapy and follow-up of chronic Monitoring and follow-up much less appropriateconditions

Altered doctor-patient relationship Lack of doctor-patient relationship

Improve and provide specialist services to rural or remote Simpler infrastructure and technical requirements maycommunities potentially provide even broader access

Less suitable as a triage tool for referrals Potentially useful as a triage tool to rationalize specialistaccess

Patient acceptability Generally high; potentially save time and expense related Comparable to real-timeto travel

Some patients, particularly older patients, may be Severe and/or socially disabling conditions may benefit moreembarrassed or uncomfortable with video/audio link from inter-personal doctor-patient contact

Cost Cost effective over larger distances and with appropriate With smaller workloads, store-and forward probably moreworkload/demand cost effective

Expensive to set-up and maintain Cheaper

Technical Requires high level of coordination between sites to Information collected, relayed and interpreted at relativelysynchronize teleconsultation more convenient times

Equipment failure frustrating, time-consuming and Lesser impact with equipment failureexpensive

compared with 69% of patients seen with the store-and-forward beyond the trial period.[42] This highlights the importance ofsystem. establishing a coherent infrastructure that addresses the concerns

of patients, doctors, remuneration, medical indemnity bodies, tele-Repeat visits to GPs can be the expected consequence ofcommunication organizations, technological enterprise, privateinaccurate initial diagnosis and management, adding to the socie-business sectors and government. Multinational technological andtal cost. In one study, patients were four times more likely to havetelecommunication organizations, in negotiation with govern-multiple (three or more) GP visits, when a given dermatologicalments and healthcare organizations, are actively forging alliancescondition remained undiagnosed or incorrectly diagnosed after 1to deliver high-quality care at low cost.[43] Progressive elaborationmonth from its onset, prior to specialist management.[41] The sameof this ‘ecosystem’ will allow doctors to concentrate on thestudy also demonstrated that the longer a given skin conditionmedical, rather than the technical and economic aspects ofremained undiagnosed or incorrectly diagnosed, the more likelytelemedicine; and very likely shift the cost-benefit ratio in favor ofmoney would be spent by the patient on inappropriate OTCteledermatology as a cost-effective adjunct to conventional derma-products. Patients tried up to four times as many different OTCtology.products when the duration of their skin condition exceeded 1

month.[41]

6. Conclusion5. Future Directions

Both real-time and store-and-forward teledermatology can beA comparison of real-time and store-and-forward telederma- accurate and reliable methods of diagnosing skin disorders. It is

tology is presented in table III. While most teledermatology important to appreciate that these techniques are not meant toprograms have been successfully implemented during the initial replace conventional care. Teledermatology is more appropriatelyfunded and protected period, many have had difficulty in operating used as an adjunct to conventional care, for selected patients in


214 Chen et al.

8. Loane MA, Corbett R, Bloomer SE, et al. Diagnostic accuracy and clinicalareas where specialist services are scarce or unavailable, or as amanagement by realtime teledermatology: results from the Northern Ireland

triage system where waiting lists for specialist review are long. In arms of the UK Multicentre Teledermatology Trial. J Telemed Telecare 1998; 4(2): 95-100these circumstances, teledermatology is likely to improve the

9. Nordal EJ, Moseng D, Kvammen B, et al. A comparative study of teleconsulta-current levels of care provided to patients. Teledermatology ap- tions versus face-to-face consultations. J Telemed Telecare 2001; 7 (5): 257-65pears to be acceptable to both patient and doctor, although – other 10. Lowitt MH, Kessler II, Kauffman L, et al. Teledermatology and in-person

examinations: a comparison of patient and physician perceptions and diagnosticfactors being equal – conventional face-to-face consultations areagreement. Arch Dermatol 1998 Apr; 134 (4): 471-6

still preferred. While short-term management plans appear to be 11. Tait CP, Clay CD. Pilot study of store and forward teledermatology services inPerth, Western Australia. Australas J Dermatol 1999 Nov; 40 (4): 190-3no different between real-time teledermatology and conventional

12. High WA, Houston MS, Calobrisi SD, et al. Assessment of the accuracy of low-care, long-term follow-up studies are required to better evaluatecost store-and-forward teledermatology consultation. J Am Acad Dermatol

the effectiveness of teledermatology care. 2000 May; 42 (5 Pt 1): 776-8313. Zelickson BD, Homan L. Teledermatology in the nursing home. Arch DermatolThe cost effectiveness of teledermatology remains a significant

1997 Feb; 133 (2): 171-4issue limiting its widespread adoption. Current data suggest that14. Kvedar JC, Edwards RA, Menn ER, et al. The substitution of digital images for

real-time systems are more expensive from the health service’s dermatologic physical examination. Arch Dermatol 1997 Feb; 133 (2): 161-715. Taylor P, Goldsmith P, Murray K, et al. Evaluating a telemedicine system to assistperspective, but cheaper for patients. The cost effectiveness of

in the management of dermatology referrals. Br J Dermatol 2001 Feb; 144 (2):store-and-forward systems is largely unknown. Continued ad- 328-33vances in technology, appropriate patient selection, and clinical 16. Krupinski EA, LeSueur B, Ellsworth L, et al. Diagnostic accuracy and image

quality using a digital camera for teledermatology. Telemed J 1999 Fall; 5 (3):demand (i.e. physician workload) may contribute to increasing257-63

both the quality and cost effectiveness of all types of telederma- 17. Chan HH, Woo J, Chan WM, et al. Teledermatology in Hong Kong: a cost-effective method to provide service to the elderly patients living in institutions.tology systems. While further economic studies are required toInt J Dermatol 2000 Oct; 39 (10): 774-8clarify the cost effectiveness of teledermatology, it is worth noting

18. Phillips CM, Burke WA, Shechter A, et al. Reliability of dermatology telecon-that such studies are difficult to perform. Local variations in sultations with the use of teleconferencing technology. J Am Acad Dermatol

1997 Sep; 37 (3 Pt 1): 398-402factors such as disease patterns, available medical services, and19. Whited JD, Horner RD, Hall RP, et al. The influence of history on interobservercost of travel and equipment, can all influence the cost both in

agreement for diagnosing actinic keratoses and malignant skin lesions. J Amfavor of, and against, teledermatology. Administrators should take Acad Dermatol 1995 Oct; 33 (4): 603-7

20. Leffell DJ, Chen YT, Berwick M, et al. Interobserver agreement in a communitythese local variations into account when assessing data fromskin cancer screening setting. J Am Acad Dermatol 1993 Jun; 28 (6): 1003-5

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36. Loane MA, Oakley A, Rademaker M, et al. A cost-minimization analysis of theAbout the Author: Richard Wootton is the head of research at the Centre forsocietal costs of realtime teledermatology compared with conventional care:

results from a randomized controlled trial in New Zealand. J Telemed Telecare Online Health at the University of Queensland in Queensland, Australia.2001; 7 (4): 233-8 His main research interests concern the diffusion of telemedicine into

37. Loane MA, Bloomer SE, Corbett R, et al. Patient cost-benefit analysis of mainstream health service delivery which necessitates the performance ofteledermatology measured in a randomized control trial. J Telemed Telecare research trials in order to obtain evidence for cost effectiveness. Professor1999; 5 Suppl. 1: 1-3

Wootton is the Editor of the Journal of Telemedicine and Telecare, an interna-38. Bergmo TS. A cost-minimization analysis of a realtime teledermatology service intional peer-reviewed journal.northern Norway. J Telemed Telecare 2000; 6 (5): 273-7

39. Lamminen H, Lamminen J, Ruohonen K, et al. A cost study of teleconsultation for Correspondence and offprints: Richard Wootton, Centre for Online Health,primary-care ophthalmology and dermatology. J Telemed Telecare 2001; 7 (3):

Royal Children’s Hospital, Level 3, Foundation Building, Herston 4029,167-73Queensland, Australia.40. Burgiss SG, Julius CE, Watson HW, et al. Telemedicine for dermatology care in

rural patients. Telemed J 1997 Fall; 3 (3): 227-33 E-mail: [email protected]


teledermatology can produce high-quality care at low cost

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