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Introduction: One of the challenges faced by the Colombian Health System is to improve access to health services for the dispersed and isolated rural population, particularly in the field of dermatology. This article examines the implementation of a teledermatology service using a PC and camera versus smartphone technology. Methods: A total of 542 teledermatology visits were conducted, involving 478 patients, in addition to 64 visits for clinical follow-up for patients as per the dermatologist's recommendation. Out of the 478 patients, 461 met the inclusion criteria and agreed to participate in the study. The data collection instrument from the general practitioner or referring provider covered three consultation moments: (1) sending an initial consultation, (2) providing a response to the patient, and (3) sending a follow-up consultation. Seven hundred forty-seven records were completed by the general practitioner for the three consultation moments. Furthermore, 372 consultations were documented by the dermatologist or referring provider for two moments: (1) response to the initial consultation by the dermatologist, and (2) response to the follow-up consultation by the dermatologist. After validating the information reported in the instruments, a descriptive analysis of the data was conducted, utilizing absolute frequencies and percentages for qualitative variables and measures of central tendency (mean, median, standard deviation, and interquartile range) for quantitative variables. The data were analyzed from 747 records of the referring provider instrument related to 461 patients, between 18 and 98 years of age, with a predominantly female representation. Results: The results indicated that for teleconsultations conducted using a mobile device, the average total duration of the teleconsultation was longer on the traditional platform compared with the mobile device (13.03 vs. 8.27 min). Additionally, it was observed that the time taken to store, send, and capture a single image (clinical or dermoscopic) using the mobile device was three times lower than that on the conventional platform (25 vs. 75 s). Similar findings were noted for teleconsultations carried out by the dermatologist, predominantly utilizing a mobile device. The average consultation time was shorter for the mobile device compared with the traditional platform (8.14 vs. 12 min). Conclusions: The cost reduction suggests that the operation of the service is more efficient with smartphone technology in comparison to the use of a PC and camera. Teledermatology with smartphones provides a streamlined, efficient, and technically sound process for obtaining clinical and dermoscopic images.

Introduction: Teledermatology adoption continues to increase, in part, spurred by the COVID-19 pandemic. This study analyzes the utility and cost savings of a store-and-forward teledermatology consultative system within the Veterans Health Administration (VA). Methods: Retrospective cohort of 4,493 patients across 14 remote sites in Tennessee and Kentucky from May 2017 through August 2019. The study measured the agreement between the teledermatology diagnoses and follow-up face-to-face clinic evaluations as well as the cost effectiveness of the teledermatology program over the study period. Results: Fifty-four percent of patients were recommended for face-to-face appointment for biopsy or further evaluation. Most patients, 80.5% received their face-to-face care by a VA dermatologist. There was a high level of concordance between teledermatologist and clinic dermatologist for pre-malignant and malignant cutaneous conditions. Veterans were seen faster at a VA clinic compared with a community dermatology site. Image quality improved as photographers incorporated teledermatologist feedback. From a cost perspective, teledermatology saved the VA system $1,076,000 in community care costs. Discussion: Teledermatology is a useful diagnostic tool within the VA system providing Veteran care at a cost savings.

Telemedicine has the potential to deliver high-quality, affordable health care to underserved populations that otherwise would not have adequate access to care. The authors provide a snapshot of several telemedicine initiatives that have used information and communication technologies to connect patients with health care providers across various Asian countries with differing socioeconomic statuses. They highlight several factors thought to contribute to the success of telemedicine programs, such as financial sustainability, ease of use, and utilization of existing resources. Challenges these programs have faced include lack of technological infrastructure, limitations in funding, and conflicting health system priorities., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Teledermatology, the form of telemedicine directed toward dermatology patients, is one of the earliest technological innovations that advanced remote medical care. Developed in 1995, teledermatology was established with the mission of increasing healthcare access among patients in rural geographic locations who had limited access to specialist care.1.

The rapidly increasing number of COVID-19-infected patients and evidence of human-to-human transmission even within the asymptomatic incubation period prompted the attention of the entire world. The field of dermatology and procedural dermatology is not exempt from this global issue. We cannot deny the fact that this situation will have a lasting impact on the health-seeking behaviors of our patients. It is necessary for dermatologists and dermatologic surgeons to be aware of the potential risks and precautions when re-emerging their practices after COVID-19., (© 2020 Wiley Periodicals, LLC.)

There has been rapid growth in teledermatology over the past decade, and teledermatology services are increasingly being used to support patient care across a variety of care settings. Teledermatology has the potential to increase access to high-quality dermatologic care while maintaining clinical efficacy and cost-effectiveness. Recent expansions in telemedicine reimbursement from the Centers for Medicare & Medicaid Services (CMS) ensure that teledermatology will play an increasingly prominent role in patient care. Therefore, it is important that dermatologists be well informed of both the promises of teledermatology and the potential practice challenges a continuously evolving mode of care delivery brings. In this article, we will review the evidence on the clinical and cost-effectiveness of teledermatology and we will discuss system-level and practice-level barriers to successful teledermatology implementation as well as potential implications for dermatologists., (Copyright © 2020 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Teledermatology is a rapidly developing field of dermatological care, giving the opportunity to deliver more efficient healthcare to patients in remote areas. Live interactive (LI) teledermatology uses videoconferencing and, hence, allows for direct communication. A current overview on effectiveness, costs, feasibility and accuracy of LI applications compared to standard care is missing. The present systematic review provides this overview on LI teledermatology. Two databases were searched until April 2019, followed by title, abstract and full-text screening. Additionally, reference lists of the detected eligible articles were screened for further eligible studies. Studies comparing LI applications with standard care were included. Data on study design, sample size, country, objectives, main findings and characteristics of LI applications were extracted. Results on time effectiveness, costs, accuracy and feasibility of LI applications were synthesized. Additionally, the quality of included studies was assessed. Twenty-three publications were included in the final analysis: seventeen case-control studies and six randomized controlled trials. Included studies were published between 1997 and 2017. Study quality differed across studies. The studies were carried out in eight different countries. Eleven studies focused on patient consultation, three on patient organization and nine on combined applications of the aforementioned. Nine studies investigated applications facilitating patient-provider interaction. Fourteen studies evaluated applications combining patient-provider and provider-provider interaction, meaning the patient sits next to one provider while using LI applications to interact with another provider. This review reveals that LI applications can be a time effective substitute of or supplement to standard dermatological care. Results demonstrated that LI and standard care are comparable with regard to feasibility and accuracy. No clear tendencies can be reported with regard to costs. However, there is a lack of current comparative studies., (© 2019 The Authors. Journal of the European Academy of Dermatology and Venereology published by John Wiley & Sons Ltd on behalf of European Academy of Dermatology and Venereology.)

The regulation of telemedicine in the United States is evolving, with new legislation expanding reimbursement and cross-state licensing capabilities. As telemedicine grows, communities with limited access to traditional dermatologic care may find a solution in teledermatology. A search of the medical literature and online health care law resources published within the past decade was performed to assess the current status of telemedicine availability, health record integration and security, reimbursement policy, and licensure requirements in the United States, with a focus on teledermatology. The majority of states have implemented policies requiring private insurance coverage. Medicaid reimburses some form of telemedicine in all states but restricts which modalities can be used and by which specialties. Medicare places the heaviest limitations on telemedicine coverage. Twenty-four states and Guam are members of the Interstate Medical Licensure Compact (IMLC), and 27 states offer alternative cross-state practice options. With the advent of publicly and privately funded programs, volunteer efforts, and mobile applications, teledermatology is more readily available to rural and underserved communities., (Copyright © 2019 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Background: The cost of developing a new drug is approximately USD 2.6 billion, and over two-thirds of the total cost is embedded in the clinical-testing phase. Patient recruitment is the single biggest cause of clinical trial delays, and these delays can result in up to USD 8 million per day in lost revenue for pharmaceutical companies. Further, clinical trials struggle to keep participants engaged in the study and as many as 40% drop out. To overcome these challenges pharmaceutical companies and research institutions (e.g., universities) increasingly use an emerging concept: virtual clinical trials (VCT) based on a remote approach., Summary: VCT (site-less) are a relatively new method of conducting a clinical trial, taking full advantage of technology (apps, monitoring devices, etc.) and inclusion of web platforms (recruitment, informed consent, counselling, measurement of endpoints, and any adverse reactions) to allow the patient to be home-based at every stage of the clinical trial. Studies have shown that VCT are not only operationally feasible, but also successful. They have higher recruitment rates, better compliance, lower drop-out rates, and are conducted faster than traditional clinical trials. The visual nature of dermatological conditions, the relative ease in evaluating skin diseases virtually, and the fact that skin diseases often are not life-threatening and rarely require complex examinations make VCT very attractive for dermatological research. Further, making correct diagnoses based on photographs and patient symptomatology has always been part of the dermatologist's routine. Thus, VCT are in many ways made for dermatology. Herein we describe VCT and their implications in dermatological research., (© 2020 S. Karger AG, Basel.)

In order to deliver equal healthcare access to resource-poor settings, sustainable, cost-effective systems of communication should be used. As mobile phone use increases, remote care can be delivered via teledermatology using Apps. This commentary covers how WhatsApp could be used by dermatologists seeking to deliver healthcare in this context., (© 2018 The International Society of Dermatology.)

Teledermatology plays a vital role within Aneurin Bevan University Health Board. Alongside Consultant Dermatologists we developed Teledermatology to meet clinical needs. This article illustrates the implementation process of the service, highlighting legal and ethical issues that were considered along with the success and scope of the service. The Teledermatology service rapidly reduced waiting times for patients and increased access to specialist care which is cost effective for the Health Board. Following successful implementation and increased demand, there is the scope for expansion. The service is developing additional Teledermatology clinics within the Health Board, evolving telemedicine.

Purpose: Store-and-forward teledermatology can improve access to dermatology by enabling asynchronous consults. This study assesses it on access, satisfaction, utilization, and costs in a commercial health plan setting., Methodology: In this prospective observational study with matched control, 47,411 individuals were provided access to teledermatology services staffed by board-certified, licensed dermatologists for 6 months. Two hundred forty-three individuals used the service. One hundred fifty-two participants successfully matched to similar users of in-person services for comparison. Average number of dermatology-related visits and dermatology-related costs in 30, 60, and 90 days postvisit, most frequent diagnoses, time to consult, patient satisfaction, and number of procedures were measured., Results: Average time to consult for the teledermatology group was 16.31 h. Patient satisfaction was 4.38/5. Total dermatology utilization in the postvisit period for the teledermatology and the control groups respectively was 9 and 21 visits at 30 days (p = 0.074), 15 and 46 visits at 60 days (p = 0.005), and 26 and 74 at 90 days (p = 0.001). The dermatology-related spend for the teledermatology and control groups, respectively, was $59 and $113 on the day of the initial consult (p < 0.01), $70 and $202 for 30 days (p = 0.03), $78 and $ 221 for 60 days (p = 0.02), and $86 and $307 for 90 days (p = 0.08) following initial visit. Total number of procedures conducted in the control group at the index visit was 26. In the postvisit period, the total number of procedures in the study and control groups, respectively, were 5 and 15 at 30 days (p = 0.053), 10 and 26 at 60 days (p = 0.088), and 14 and 32 at 90 days (p = 0.082)., Conclusions: Teledermatology services are accessible within hours and associated with high patient satisfaction. There is no evident increased utilization or costs postvisit.

Teledermatology has emerged as a promising solution for pediatric and adult patients accessing dermatologic care in a health care environment fraught with barriers to access. Teledermatology has been extensively evaluated in terms of diagnostic accuracy, clinical outcomes, patient and provider satisfaction, and costs, relative to traditional health care delivery models. Current research indicates that teledermatology is effective and efficient in diagnosis and management of skin diseases. The majority of studies on the subject, however, rely on adult patient data. Pediatric patients, with their unique clinical features and challenges, may interact with telemedicine differently than their adult counterparts. Maximizing the benefits of teledermatology in pediatric dermatologic care is dependent on future research. We review and analyze the commonalities and differences between pediatric and adult patient care using teledermatology., (Copyright © 2017. Published by Elsevier Inc.)

Background: Teledermoscopy involves the use of dermoscopic images for remote consultation and decision-making in skin cancer screening., Objective: We sought to analyze the potential benefits gained from the addition of dermoscopic images to an internet-based skin cancer screening system., Methods: A randomized clinical trial assessed the diagnostic performance and cost-effectiveness of clinical teleconsultations (CTC) and clinical with dermoscopic teleconsultations., Results: A total of 454 patients were enrolled in the trial (n CTC  = 226, n clinical with dermoscopic teleconsultation  = 228). Teledermoscopy improved sensitivity and specificity (92.86% and 96.24%, respectively) compared with CTC (86.57% and 72.33%, respectively). Correct decisions were made in 94.30% of patients through clinical with dermoscopic teleconsultations and in 79.20% in CTC (P < .001). The only variable associated with an increased likelihood of correct diagnosis was management using teledermoscopy (odds ratio 4.04; 95% confidence interval 2.02-8.09; P < .0001). The cost-effectiveness analysis showed teledermoscopy as the dominant strategy, with a lower cost-effectiveness ratio (65.13 vs 80.84)., Limitations: Potentially, a limitation is the establishment of an experienced dermatologist as the gold standard for the in-person evaluation., Conclusions: The addition of dermoscopic images significantly improves the results of an internet-based skin cancer screening system, compared with screening systems based on clinical images alone., (Copyright © 2017 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.)

Introduction Direct-to-consumer (DTC) teledermatology is radically changing the way patients obtain dermatological care. Now, with a few clicks, patients can obtain dermatological consultations and prescription medications without a prior physician-patient relationship. To analyse all DTC teledermatology services available to US patients. Methods We performed Internet searches to identify DTC teledermatology services available through Internet webpages or through smartphone applications. For each service, the scope of care provided, cost, wait times, prescription policies and other relevant information were recorded. Results Twenty-two DTC teledermatology services are available to US patients in 45 states. Six (27%) services offer care from international physicians. Sixteen (73%) services allow patients to seek care for any reason, while six (27%) limit care to acne or anti-aging. The median reported response time for DTC teledermatology services is 48 hours from the time of patient request. The median consultation fee for companies providing care from US board-certified physicians is US$59. Across all services, consultation fees range from US$1.59 to US$250. Conclusions DTC teledermatology services are readily available to patients in most states. These services may reduce the cost of patient visits, expand access to care and increase patient convenience. However, the presence of services staffed by physicians who are not US board-certified, as well as the use of incautious language regarding prescription medications, is concerning.

Background: Since 2012, "Direct to Consumer" mobile teledermatology apps have become more available, relinquishing many data collection tasks normally done by healthcare professionals directly to patients., Introduction: To determine user friendliness, diagnostic quality, and service of commercially available mobile teledermatology apps., Materials and Methods: All mobile teledermatology apps available at the Apple App Store were reviewed. The two most popular mobile teledermatology apps were identified and tested together with three apps having similar functionality using a single case of a patient who was also examined by a dermatologist in-person., Results: Apps varied in diagnostic scope, data gathering methods, services, rendered results, and in geographic coverage and cost., Discussion: None of the apps take a history as thoroughly as recommended by textbooks. Key medical questions like current medications and allergies are not asked often. Most apps rendered concordant results, except for the one having the least thorough history taking., Conclusions: Mobile teledermatology application interfaces, services, and cost vary, with some risking medical errors and possible distribution of continuity of care. The American Telemedicine Association's guidelines for teledermatology need to address the use of direct to consumer apps. To protect consumers, app regulation, certification, or guidelines suggesting appropriate development and use might be considered.

Importance: Teledermatology is a topical clinical approach being tested in Australia and elsewhere. With most dermatologists residing in metropolitan areas, teledermatology provides an apparent low-cost and convenient means of access for individuals living outside these areas. It is important that any proposed new addition to a health care system is assessed on the grounds of economic cost and effectiveness., Objective: To summarize and evaluate the current economic evidence comparing store-and-forward teledermatology (S&FTD) with conventional face-to-face care., Evidence Review: Search terms with appropriate amendments were used to identify S&FTD articles that included economic analysis. Six databases were searched, and title, abstract and full-text reviews were conducted by 2 researchers. References of all unique returned articles were searched by hand. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist was used to evaluate quality of the included articles., Findings: Eleven articles were selected for inclusion, including 1 cost analysis, 4 cost-minimization analyses, 4 cost-effectiveness analyses, and 2 cost-utility analyses. CHEERS scores ranged from 7 to 21 out of a possible 24 points, with a median score of 17., Conclusions and Relevance: Current evidence is sparse but suggests that S&FTD can be cost-effective. It appears to be cost-effective when used as a triage mechanism to reduce face-to-face appointment requirements. The cost-effectiveness of S&FTD increases when patients are required to travel farther distances to access dermatology services. Further economic research is required for the emerging S&FTD, which uses dermoscopes in combination with smartphone applications, as well as regarding the possibility and consequences of patients self-capturing and transmitting images.

Technological advances in the fields of information and telecommunication technologies have affected the health care system in the last decades, and lead to the emergence of a new discipline: telemedicine. The appearance and rise of internet and smart phones induced a rapid progression in telemedicine. Several new applications and mobile devices are published every hour even for medical purposes. Parallel to these changes in the technical fields, medical literature about telemedicine has grown rapidly. Due to its visual nature, dermatology is ideally suited to benefit from this new technology and teledermatology became one of the most dynamically evolving fields of telemedicine by now. Teledermatology is not routinely practiced in Hungary yet, however, it promises the health care system to become better, cheaper and faster, but we have to take notice on the experience and problems faced in teledermatologic applications so far, summarized in this review.

Background: A major benefit offered by telemedicine is the avoidance of travel, by patients, their carers and health care professionals. Unfortunately, there is very little published information about the extent of avoided travel. We propose to undertake a systematic review of literature which reports credible data on the reductions in travel associated with the use of telemedicine., Method: The conventional approach to quantitative synthesis of the results from multiple studies is to conduct a meta analysis. However, too much heterogeneity exists between available studies to allow a meaningful meta analysis of the avoided travel when telemedicine is used across all possible settings. We propose instead to consider all credible evidence on avoided travel through telemedicine by fitting a linear model which takes into account the relevant factors in the circumstances of the studies performed. We propose the use of stepwise multiple regression to identify which factors are significant., Discussion: Our proposed approach is illustrated by the example of teledermatology. In a preliminary review of the literature we found 20 studies in which the percentage of avoided travel through telemedicine could be inferred (a total of 5199 patients). The mean percentage avoided travel reported in the 12 store-and-forward studies was 43%. In the 7 real-time studies and in a single study with a hybrid technique, 70% of the patients avoided travel. A simplified model based on the modality of telemedicine employed (i.e. real-time or store and forward) explained 29% of the variance. The use of store and forward teledermatology alone was associated with 43% of avoided travel. The increase in the proportion of patients who avoided travel (25%) when real-time telemedicine was employed was significant (P = 0.014). Service planners can use this information to weigh up the costs and benefits of the two approaches.

Many rural and underserved communities face a shortage of dermatologists and long patient wait times. Teledermatology systems have the potential to accommodate increasing demands for dermatologists. With the current shortage of dermatologists in many communities, teledermatology complements conventional face-to-face dermatologic care where access to specialty care is limited. Teledermatology involves the use of communications technology to remotely provide skin care, and it is an extensively investigated branch of telemedicine. The overall goal of this review is to discuss the current literature on: 1) teledermatology technology; 2) accuracy and reliability of teledermatology; 3) healthcare delivery models, clinical outcomes, and satisfaction data; 4) economic considerations; and 5) future research considerations and implications of teledermatology.

Background: Access to dermatology and dermatopathology services is scarce in sub-Saharan Africa. Teledermatology provides consultations for healthcare providers in resource-limited settings where specialty medical services are difficult to obtain, and the African Teledermatology Project has helped to bridge the gap in dermatological care in Africa. This program also allows for biopsy specimens to be sent to the USA for processing in cases where the clinical diagnosis is difficult and definitive diagnosis has implications for patient management. This study characterizes conditions diagnosed through clinicopathological correlation in conjunction with photos and tissue submitted to the African Teledermatology Project., Materials and Methods:   Retrospective case review of tissue specimens submitted over three years., Results: Fifty-five biopsy specimens met inclusion criteria and represent cases of malignancy (35%), infection (7%), suspected infection (15%), lichenoid tissue reaction (5%), dermatitis (15%), and other various conditions (18%). Three biopsy specimens were non-diagnostic (5%). Clinicopathological concordance between submitting clinician and biopsy results occurred in 32 out of 55 cases (58%). Clinical and pathological diagnoses differed in 21 out of 55 cases (38%). Kaposi sarcoma (KS) represents the clinical diagnosis most often suspected in the evaluated biopsy specimens (42%) and was correctly recognized clinically in 13 out of 23 cases (57%)., Conclusion: Clinical images may not provide sufficient information to definitively diagnose certain infectious and malignant dermatological conditions submitted through telemedicine consultation. Microscopic examination of skin biopsy specimens is an important adjunct for accurate diagnosis of disease and determination of appropriate treatment strategies., (© 2011 The International Society of Dermatology.)

Background: Despite increasing practice of teledermatology in the U.S., teledermatology practice models and real-world challenges are rarely studied., Methods: The primary objective was to examine teledermatology practice models and shared challenges among teledermatologists in California, focusing on practice operations, reimbursement considerations, barriers to sustainability, and incentives. We conducted in-depth interviews with teledermatologists that practiced store-and-forward or live-interactive teledermatology from January 1, 2007 through March 30, 2011 in California., Results: Seventeen teledermatologists from academia, private practice, health maintenance organizations, and county settings participated in the study. Among them, 76% practiced store-and-forward only, 6% practiced live-interactive only, and 18% practiced both modalities. Only 29% received structured training in teledermatology. The average number of years practicing teledermatology was 4.29 years (SD±2.81). Approximately 47% of teledermatologists served at least one Federally Qualified Health Center. Over 75% of patients seen via teledermatology were at or below 200% federal poverty level and usually lived in rural regions without dermatologist access. Practice challenges were identified in the following areas. Teledermatologists faced delays in reimbursements and non-reimbursement of teledermatology services. The primary reason for operational inefficiency was poor image quality and/or inadequate history. Costly and inefficient software platforms and lack of communication with referring providers also presented barriers., Conclusion: Teledermatology enables underserved populations to access specialty care. Improvements in reimbursement mechanisms, efficient technology platforms, communication with referring providers, and teledermatology training are necessary to support sustainable practices.

Background: Although store-and-forward teledermatology is increasingly becoming popular, evidence on its effects on efficiency and costs is lacking. The aim of this study, performed in addition to a clustered randomised trial, was to investigate to what extent and under which conditions store-and-forward teledermatology can reduce costs from a societal perspective., Methods: A cost minimisation study design (a model based approach) was applied to compare teledermatology and conventional process costs per dermatology patient care episode. Regarding the societal perspective, total mean costs of investment, general practitioner, dermatologists, out-of-pocket expenses and employer costs were calculated. Uncertainty analysis was performed using Monte Carlo simulation with 31 distributions in the used cost model. Scenario analysis was performed using one-way and two-way sensitivity analyses with the following variables: the patient travel distance to physician and dermatologist, the duration of teleconsultation activities, and the proportion of preventable consultations., Results: Total mean costs of teledermatology process were €387 (95%CI, 281 to 502.5), while the total mean costs of conventional process costs were €354.0 (95%CI, 228.0 to 484.0). The total mean difference between the processes was €32.5 (95%CI, -29.0 to 74.7). Savings by teledermatology can be achieved if the distance to a dermatologist is larger (> = 75 km) or when more consultations (> = 37%) can be prevented due to teledermatology., Conclusions: Teledermatology, when applied to all dermatology referrals, has a probability of 0.11 of being cost saving to society.In order to achieve cost savings by teledermatology, teledermatology should be applied in only those cases with a reasonable probability that a live consultation can be prevented., Trial Registration: This study is performed partially based on PERFECT D Trial (Current Controlled Trials No. ISRCTN57478950).

Background: Teledermatology is a rapidly growing field with studies showing high diagnostic accuracy when compared with face-to-face diagnosis. Teledermoscopy involves the use of epiluminescence microscopy to increase diagnostic accuracy. The utility of teledermoscopy as a triage tool has not been established., Objectives: To assess teledermoscopy as a triage tool for a hospital skin lesion clinic., Methods: Patients referred to a dermatology skin lesion clinic were recruited. Digital and dermoscopic photographs were taken of skin lesions of concern and the patients were then seen independently face-to-face by two out of three dermatologists. The digital images were evaluated 4 weeks later, as a teledermoscopy consultation, by two of these dermatologists. The diagnosis and management from both types of consultation were compared., Results: Two hundred patients with a total of 491 lesions were seen. There was excellent agreement between teledermoscopy and face-to-face diagnosis with only 12.3% of lesions having disparate diagnoses of clinical significance. Twelve of 491 (2.4%) lesions appeared to have been under-reported by teledermoscopy when compared with face-to-face diagnosis. However, when histopathology became available, only one malignant lesion had been missed (a basal cell carcinoma diagnosed as solar keratosis) by teledermoscopy. Teledermoscopy approximated 100% sensitivity and 90% specificity for detecting melanoma and nonmelanoma skin cancers. Importantly, 74% of all lesions were determined to be manageable by the general practitioner without needing to be seen face-to-face by a dermatologist., Conclusions: This use of teledermoscopy as a triage tool offers the potential to shorten waiting lists and thus improve healthcare access and delivery.

Abstract Economic considerations are an important component in the planning and execution of a telemedicine program. The goal of this review is to familiarize readers with economic concepts relevant to the analysis of telemedicine programs. Economic perspectives, cost attribution, types of economic analysis, and commonly encountered problems will be discussed as they pertain to telemedicine. Societal perspectives, healthcare system perspectives, patient perspectives, fixed versus variable costs, labor costs, and distinctions between cost-effectiveness analyses and other types of economic analysis also will be examined. Examples from the teledermatology literature will be used as a paradigm to illustrate how these concepts are integrated into existing analyses of teledermatology systems. Teledermatology shows promise as a cost-saving healthcare delivery system with outcomes comparable to or better than those of conventional care processes. The literature also points out the importance of economic perspectives in the findings and interpretation of an analysis.

TeleDerm is a web-based service designed to provide general practitioners (GPs) with rapid assessment of dermatoscopic images of pigmented lesions and moles. During a 12-month period, GPs at the Hastings and Rother primary care trust referred a total of 660 lesion images from patients exhibiting less typical symptoms of cancer, who would otherwise have been routinely referred to hospital. The images were assessed by remote expert dermatologists. Of that total, 493 images (75%) were reported as displaying no suspect dermatoscopic structures, resulting in the GP discharging the patient. In addition, seven lesions (1%) were reported as displaying suspect dermatoscopic structures, resulting in the GP urgently referring the patient to hospital with a subsequent histological confirmation of melanoma. The overall costs per patient were reduced by 50%. In an independent survey, all 11 patients rated their experience as good to excellent. The results show that tele-dermatoscopy can provide GPs with an expert second opinion to increase the quality of diagnosis in primary care, reduce the costs of dermatology provision and provide a highly rated patient experience.

The aim of this study was to perform a cost minimization analysis of store-and-forward teledermatology compared to a conventional dermatology referral process (usual care). In a Department of Defense (DoD) setting, subjects were randomized to either a teledermatology consult or usual care. Accrued healthcare utilization recorded over a 4-month period included clinic visits, teledermatology visits, laboratories, preparations, procedures, radiological tests, and medications. Direct medical care costs were estimated by combining utilization data with Medicare reimbursement rates and wholesale drug prices. The indirect cost of productivity loss for seeking treatment was also included in the analysis using an average labor rate. Total and average costs were compared between groups. Teledermatology patients incurred $103,043 in total direct costs ($294 average), while usual-care patients incurred $98,365 ($283 average). However, teledermatology patients only incurred $16,359 ($47 average) in lost productivity cost while usual-care patients incurred $30,768 ($89 average). In total, teledermatology patients incurred $119,402 ($340 average) and usual-care patients incurred $129,133 ($372 average) in costs. From the economic perspective of the DoD, store-and-forward teledermatology was a cost-saving strategy for delivering dermatology care compared to conventional consultation methods when productivity loss cost is taken into consideration.

Teledermatology offers a means of providing specialist care to underserved patients. The objectives of this study were to compare the costs of interactive teledermatology with conventional care, and to evaluate from a healthcare provider perspective whether interactive teledermatology is economically viable in the northeastern region of the United States. We studied the interactive teledermatology practice at Nantucket Cottage Hospital on Nantucket Island and the ambulatory clinics at the Massachusetts General Hospital in Boston, Massachusetts. The cost-minimization analysis compared the costs of an interactive teledermatology practice with that of a face-to-face dermatology clinic. One-way sensitivity analyses examined the effect of varying the costs of technology, physician compensation, or clinic space on the overall cost of interactive teledermatology. We also assessed the economic viability of the interactive teledermatology practice by comparing the operating costs with reimbursements. The total hourly operating costs for the interactive teledermatology practice on Nantucket Island and the face-to-face clinic in Boston were $274 and $346, respectively. Three separate one-way sensitivity analyses showed that, for the cost of the teledermatology practice to equal that of the conventional clinic, the cost of teledermatology technology could increase by 9.3-fold, dermatologists working at the teledermatology practice could be compensated up to $197 an hour, or the cost of teledermatology clinic space could reach $57 an hour. Our analysis also showed that the hourly reimbursement for the teledermatology practice was $487, which exceeded its hourly operating cost of $274. The cost of operating an interactive teledermatology practice in a remote region may be less than that of a conventional clinic in a nearby urban center in the northeastern area of the United States. From a healthcare provider perspective, interactive teledermatology can be an economically viable means of providing dermatological care to remote regions.

Teledermatology consultations can be performed using either store-and-forward or real-time technology. The best-studied aspect of teledermatology is diagnostic reliability, also known as diagnostic agreement. A good level of diagnostic reliability is achieved by dermatologists using both store-and-forward and real-time modalities and is comparable to that found between clinic-based examiners. Less information is available regarding diagnostic accuracy. Current data suggest that teledermatologists reviewing store-and-forward consults achieve accuracy comparable to that of clinic-based dermatologists. When store-and-forward consult systems are used, approximately one in four in-person clinic appointments are averted. Real-time consult systems avoid the need to schedule approximately one in two clinic visits. Store-and-forward technology results in timelier interventions for patients when compared to a conventional referral process. To date, surveys of both store-and-forward and real-time teledermatology consult modalities suggest that patients, referring clinicians, and dermatologists are all highly satisfied with teledermatology consults. Very little has been published about the economic impact of store-and-forward teledermatology, whereas several studies have evaluated real-time modalities. Teledermatology has ranged from a cost-saving strategy to an intervention that incurs greater costs than conventional care, depending on the health care setting and economic perspective. Future research focusing on diagnostic accuracy, clinical outcomes using clinical course or disease status as outcome measures, development of reliable and valid teledermatology-specific survey instruments, and economic analyses that assess cost-effectiveness will help guide future teledermatology program assessments and policy.

Although teledermatology has been beneficial and cost-effective in some settings, many programmes have failed, not because of the technology but because teledermatology was implemented in isolation. A thorough understanding of an organization's business process and business model is crucial before teledermatology is begun. Unless teledermatology is integrated into the current business process and model, the likelihood of success is greatly reduced. Important steps therefore include: (1) understanding how the organization delivers care; (2) analysing the alternatives, including cost-benefit analysis; (3) obtaining organizational support; (4) formulating an execution plan; (5) training staff and monitoring the process. If implemented correctly in the appropriate setting, teledermatology can significantly improve access and quality of care, while reducing or containing costs.

We examined the costs of telehealth in Nova Scotia from a societal perspective. The clinical outcomes of telepsychiatry and teledermatology services were assumed to be similar to those for conventional face-to-face consultations. Cost information was obtained from the Nova Scotia Department of Health, the Canadian Institute for Health Information, and questionnaires to patients, physicians and telehealth coordinators. There were 215 questionnaires completed by patients, 135 by specialist physicians and eight by telehealth coordinators. Patient costs for a face-to-face consultation ranged from $240 to $1048 (all costs in Canadian dollars), whereas patient costs for telehealth were lower, from $17 to $70. However, from a societal perspective, the overall cost of providing face-to-face services was lower than for telehealth: the total costs for face-to-face services ranged from $325 to $1133, while the total costs for telehealth services ranged from $1736 to $28,084. A threshold analysis showed that, above a certain patient workload, telehealth services would be more cost-effective than face-to-face services from a societal perspective. This workload is attainable in Nova Scotia.

This study evaluated the accuracy, access time, cost, and acceptance by patients and physicians of asynchronous teledermatology referrals in an urban primary care practice. Primary care physicians in a multi-specialty group referred patients for a teledermatology consult. Same-day history and digital images taken by a nurse were electronically sent to a dermatologist who rendered a diagnosis to the physician. Fifty-two patients completed the study. History was adequate for diagnosis in 81% of cases; images were adequate in 75% of cases. Accuracy of the teledermatology diagnosis in cases with adequate images was 97%; accuracy for all cases was 92%. A dermatology visit was recommended in 26% of cases with adequate images, and 42% of all cases. Access time for a teledermatology opinion was 1.9 days versus 52 days for a regular dermatology appointment. Patient and referring physician were highly in favor of teledermatology. Cost evaluations for 20% of patients suggested the cost of a remote consult to be significantly less than the cost of performing an in-person referral. Asynchronous teledermatology may serve as a valuable tool for triage of dermatology referrals and possibly for delivering care to more patients than in urban areas. It can decrease waiting time for a dermatology diagnosis. In an urban multi-specialty clinic-based primary care practice, results suggest the cost of a teledermatology consult is less than that of an in-person service.

Telemedicine emerged as a possible solution to New Zealand health providers in reaching out to rural patients, by offering medical services and conducting administrative meetings and training. However, despite the rapid growth and high visibility of these projects in countries like the United States, relatively few patients are now being seen through telemedicine. Accordingly, this research attempts to investigate telemedicine's effectiveness in New Zealand by using a theoretical framework. Thus, the purpose of this paper is to explain factors influencing the adoption and diffusion of telemedicine utilising the video conferencing technology (TMVC) for dermatology within Health Waikato Ltd. (HW). Findings indicate weak presence of critical assessment into technological innovation prior to adoption. Factors like complexity, compatibility, and trialability were not assessed extensively by HW, and would have hindered its adoption. Teledermatology was mainly assessed according to its relative advantage and cost effectiveness. While essential this should be alongside other factors pertaining to as addressed within this research. On the other hand, the wide diffusion of teledermatology relied on its economical benefit to HW and on its effectiveness as a diagnostic tool. This research highlights the importance of the product champion for the successful adoption and diffusion of teledermatology.

Background: Increasing use of teledermatology should be based on demonstration of favourable accuracy and cost-benefit analysis for the different methods of use of this technique. Objectives To evaluate the clinical efficacy and cost-effectiveness of real-time and store-and-forward teledermatology., Methods: Patients attended their own health centre and in the company of a general practitioner (GP) were seen by a hospital dermatologist over the videolink (real-time). Before the videolink consultation commenced, the GP took instant photographs of the skin lesion and posted them along with a standard referral letter to a different hospital dermatologist (store-and-forward). In total, 96 patients were seen by both real-time and store-and-forward teledermatology. Comparative diagnoses, clinical management plans, clinical outcomes and associated costs were made between the two types of teledermatology consultation., Results: There was agreement between the videolink diagnosis and the still image diagnosis in 51% of cases. The same or similar management plan was recommended at both types of consultation in 44% of cases. Following the store-and-forward consultation the dermatologist recommended that 69% of patients required at least one hospital appointment compared with 45% of those patients seen in real-time. The net societal cost of the initial real-time consultation was pound132.10 per patient compared with &pound26.90 per patient for the initial store-and-forward consultation., Conclusions: The store-and-forward consultation was cheaper, but less clinically efficient, compared with the real-time consultation. The absence of interaction in a store-and-forward consultation limits the dermatologist's ability to obtain clinically useful information in order to diagnose and manage a patient satisfactorily.

The clinical effectiveness of realtime teledermatology, store-and-forward teledermatology and conventional outpatient dermatological care were evaluated in a randomized control trial. A total of 204 patients took part--102 patients were randomized to the realtime teledermatology consultation, 96 of whose cases were also referred using a store-and-forward technique, and 102 to the conventional outpatient consultation. There were no differences in the reported clinical outcomes of realtime teledermatology and conventional dermatology. Of those randomized to the realtime teledermatology consultation, 46% required at least one subsequent hospital appointment compared with 45% of those randomized to the conventional outpatient consultation. In contrast, the dermatologist requested a subsequent hospital appointment for 69% of those seen by store-and-forward teledermatology. An analysis of costs showed that realtime teledermatology was clinically feasible but more expensive than conventional care, while the store-and-forward teledermatology consultation was less expensive but its clinical usefulness was limited. Sensitivity analysis indicated that realtime teledermatology was as economical as conventional care when less artificial assumptions were made about equipment utilization, costs and travel distances to hospital.

Objective: This study compares the costs of offering outpatient care to primarily orthopedic and dermatology patients via live, interactive telemedicine to the estimated costs of direct face-to-face care for the same patients., Materials and Methods: A simple, yet detailed methodology was used to evaluate the cost of adding telemedicine to a health care delivery system, using a "hub-and-spoke" model located in Minnesota. The costs and cost savings of telemedicine were evaluated from the perspectives of patients, providers, insurers, employers, and society as a whole. Sensitivity analysis was used to investigate the impact of various factors on the model., Results: The variable cost of a telemedicine referral was $144, versus an estimated face-to-face referral cost of $183. Reductions in patient travel costs and in lost employee productivity were the principal benefits of the system. The break-even point, where total costs equal total cost savings, equalled 1,449 consultations annually. Sensitivity analyses indicated that the breakeven point varies from a low of 152 telemedicine consultations for a "best case" scenario to no possible breakeven point for a "worst case" scenario., Conclusions: At the system's current level of 300 consultations per year, the telemedicine system is estimated to add $45,000 to society's costs of providing medical care for these patients. The additional cost is primarily due to personnel expenses and an increase in the volume of specialty care. Patients see specialists more often due to improved access to care and lower transportation costs. Providers bear the cost while patients and employers enjoy substantial savings.