Remote viewing: Teledermatology increases access to specialists in Canada

August 1, 2008

With constraints on healthcare human resources in some geographic areas in Canada, teledermatology offers advantages, such as increasing access to dermatological expertise. The use of store-and-forward technology avoids the logistical challenges associated with real-time teledermatology.

Key Points

Montreal - Telemedicine in dermatology diminishes wait time for seeing a dermatologist, and has demonstrated an adequate level of diagnostic assessment, a prospective evaluation presented here has found.

"There is a big challenge in health human resources in dermatology all across Canada," says Nicole Hawkins, B.Sc., a fourth-year medical student at Queen's University in Kingston, Ontario, Canada, in an interview here at the annual meeting of the Canadian Dermatology Association.

"There are remote, northern regions of provinces, like Ontario and Alberta, where you don't have the specialists (dermatologists) that you need, but most of the time there are primary care providers available," she says. "With that in mind, we wanted to examine the efficacy of using teledermatology."

With most of Canada's population based in larger, urban centers, less populated, remote regions in more northern geographic areas may not have ready access to specialist healthcare.

While real-time dermatology using teleconference can offer patient interaction and the potential for immediate diagnosis, it also demands coordination of the schedules of the patient and physician, as well as the available resources.

Store-and-forward

By contrast, the application of store-and-forward technology does not require an equivalent level of coordination.

"You can get good images using store-and-forward technology," Ms. Hawkins says. "There is not a problem with the resolution. There is a much lower barrier of entry to using store-and-forward technology. It's really just the cost of the camera.

"When you conduct a live teledermatology consult, you have to have the remote site set up. The dermatologist has to be there and ready to go.

"For many people, it's a logistical nightmare. Store-and-forward technology can be a more efficient use of time," Ms. Hawkins says.

Investigators compared the gold standard - which Ms. Hawkins describes as in-person dermatology clinic visits - to store-and-forward dermatology using a secure, Web-based system.

Study parameters

There were 128 male and female participants in the study, who were seen in a private dermatology center in Calgary, Alberta, Canada.

Primary care physicians had referred the subjects to the dermatology center.

Digital images of lesions, using a Sony Cybershot 6.0 megapixel handheld camera, were captured.

A consultant dermatologist saw the subjects in a face-to-face clinic visit.

Meanwhile, three independent, board-certified dermatologists based at the University of Alberta viewed the digital images and medical history that had been uploaded to the store-and-forward teledermatology system.

They were blinded to the diagnoses provided through the in-person consultation.

The three dermatologists provided their own diagnoses for each subject, as well as up to two differential diagnoses for each subject.

"We used a simple percentage agreement to measure the agreement between the gold standard diagnosis and our teledermatologist diagnosis," Ms. Hawkins says.

The average diagnostic agreement between the preferred diagnosis and of the consultant dermatologist in a private dermatology center and that of the three University of Alberta dermatologists was 78 percent, with agreements being 74 percent, 79 percent and 82 percent, respectively.

In another measurement, investigators included differential diagnoses when calculating the diagnostic agreement. The diagnostic agreement then yielded an average of 89 percent, with 86 percent, 88 percent and 93 percent, respectively.

The average time to prepare a teledermatology consultation was nine minutes. The average wait time for each participant to be seen face-to-face was 104 days. The average wait time from consultation submission to assessment by the three teledermatologists was four days.

"This is a very useful tool," Ms. Hawkins says. "It won't replace in-person consultation, because you are missing a human factor, but it can alleviate some of the stress on the healthcare system.

"It will assist with teletriage of patients with skin lesions, and it will improve access."

Investigators will study the efficacy of teledermatology in specific subpopulations in Canada that are regarded as underserved, such as members of the armed forces, residents of long-term care facilities and prison inmates.

Follow-up role

Ms. Hawkins says patients need to first meet with their primary healthcare provider, who can make a clinical assessment based on patient history and evaluate the symptoms.

Moreover, teledermatology is suitable for follow-up visits to ensure continuity of care.

Most participants in the study (88 percent) were satisfied with their teledermatology experience.

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