Overall, the spread and acceptance of telemedicine services have increased in recent years. As a strongly visual subject, dermatology is particularly well suited for telemedicine applications. International studies show a clear benefit of teledermatological care for various application areas. This includes diagnosis, follow-up and triaging of patients with different skin diseases.
According to the current s2k guideline (box) , teledermatological applications can be recommended for those dermatoses that are suitable based on the primarily morphological diagnosis in conjunction with anamnestic and clinical information [1]. These include, for example, infectious skin diseases such as mycoses, acute and chronic eczema, and benign skin tumors, if these can be clearly assigned [1]. But also skin changes such as acne, contact allergies or urticaria can thus be quickly subjected to a specialist evaluation without losing valuable time [2]. And teledermatological follow-up of chronic inflammatory skin diseases such as psoriasis and atopic dermatitis has also proven successful [3].
| s2k guideline “Teledermatology The trend towards increased use of teledermatological applications has led, among other things, to the publication of the guideline “Teledermatology” in 2020, which defines evidence-based quality standards for telemedical care of dermatological patients as a basis for sustainable implementation in everyday care [1]. The Swiss Society of Dermatology and Venereology (SGDV) was also involved in the preparation of the guideline published by the Professional Association of German Dermatologists (BVDD) together with the German Dermatological Society (DDG) [1]. The SGDV’s “Teledermatology” working group is currently concerned, among other things, with improving nationwide access to teledermatology services and regulating the legal framework. These include developments in artificial intelligence and the regulation of tariff regulations [10]. |
Patient satisfaction is a key success factor for sustainable implementation of teledermatology services. According to a review published in 2023, patients are generally very satisfied with both store-and-forward systems and live video consultations in terms of accessibility and quality of care [4]. Overall, most patients see more benefits, but not all populations are positive about teledermatology services; for example, there are differences depending on age, “digital literacy,” socioeconomic situation, and type of dermatologic condition. Points of criticism from some patients include technical difficulties and privacy concerns.
Store-and-forward systems
The method of store-and-forward technology is very popular in the visual field of dermatology, since skin diseases can often be recorded as “eye diagnosis” and even small anamnestic information is sufficient. The Swiss-based companies “derma2go” and OnlineDoctor (box) also use store-and-forward technologies [5,11]. Prior to the Covid 19 pandemic, most patient satisfaction studies in the context of teledermatology focused on store-and-forward technology [4]. Patient satisfaction was mostly determined using self-developed questionnaires and included the following factors: barrier-free access, quality of care and technical quality. In a systematic review of patient satisfaction in teledermatology with publications from 2010 to 2020 from nine different countries, 21 of 23 studies addressed the store-and-forward method [6]. Patients who required frequent follow-up appointments, such as those with acne, psoriasis, and wound monitoring, were often very satisfied with the store-and-forward method. However, several studies reported that about 10-25% of patients have concerns about sending photos. Some are uncomfortable or embarrassed about being photographed, while others expressed concerns about social, religious, and privacy issues [6].
| Derma2go and OnlineDoctor The teledermatology provider Derma2go has set itself the goal of helping patients achieve an accurate diagnosis and therapy within a few hours [5]. The online platform offers high-quality online advice from leading experts at renowned university hospitals and medical practices. Derma2go was founded in Switzerland in 2018. As the idea of virtual diagnoses by proven dermotology experts successfully established itself among affected individuals, derma2go is now strongly represented in the DACH region and has been expanding its service in the European region since 2023 [5]. OnlineDoctor, another telemedicine provider in Switzerland, launched a pilot project for e-prescriptions in 2022 [11]. For example, dermatologists can issue digital prescriptions with electronic signatures via the platform. People with a skin problem thus receive an e-prescription in addition to a specialist diagnosis and recommended course of action. OnlineDoctor is working with HIN as the standard for secure communications and HCI Solutions on the rollout [11]. |
Live video consultations
Only one study in the review by Hadeler et al. 2021 addressed the evaluation of patient satisfaction in relation to live teledermatology video consultations [6,7]. Most patients were very satisfied with the ease of application and perceptions changed to positive after the appointment [7]. However, some patients also noted points of criticism. The majority of these related to technical difficulties and lack of physical examination by an on-site dermatologist [7]. Another secondary analysis of patient satisfaction with live video teledermatology was published in 2022 by Miller and Jones [8]. A total of 15 studies involving 7871 patients and 146 providers from 2020-2022 were identified in which the vast majority of participants were satisfied with quality of care, barrier-free access, and patient-provider relationships [8]. Patients were generally satisfied with the technical quality, whereas providers more often considered the video/photo quality unsatisfactory. Overall, however, providers and patients agreed that the majority of patients’ needs were met by live video teledermatology. Six of the studies analyzed reported a high willingness on the part of patients to revisit teledermatology services, while in two studies face-to-face consultations were more preferred. Those patients who expressed reservations were more likely to have used a teledermatology consultation in the past, with which they were dissatisfied either because of technical difficulties or for other reasons [4,8]. The latter may concern, for example, the lack of direct interaction between patient and practitioner or the lack of availability of immediate diagnostic/treatment procedures [4,8].
Older and younger patients have different preferences
A team from a dermatology department in Italy conducted a survey of patient satisfaction with teledermatology during the Covid 19 pandemic [9]. In total, evaluable data were available from 252 patients.
As a condition, acne was the most common, with 98 video and 43 telephone consultations, followed by psoriasis (55 and 50 consultations, respectively), hidradenitis suppurativa (30 and 13, respectively), alopecia (25 and 18, respectively), and other skin conditions (23 and 19, respectively). High levels of satisfaction were found regarding both video- and telephone-based dermatology consultations, with video consultations tending to be preferred, but the difference did not prove significant. Younger patients were more satisfied with both video- and telephone-based consultations than older patients, who tended to prefer in-person consultations at the clinic.
| What are the limits of teledermatology? When microscopic images, tissue or blood samples are necessary to make a diagnosis, or in the presence of certain clinical manifestations, such as growing or bleeding nodules, a face-to-face consultation is advisable for a definite evaluation. An office visit is also still required for phototherapy or certain other forms of therapy. But telemedicine can also be helpful in cases where a doctor’s visit is ultimately necessary. For example, initial assessment of a medical condition is often possible using telemedicine assessment. The fact that the psychological barrier is usually smaller than in a visit to the doctor’s office or clinic is a factor that facilitates uncomplicated initial contact. |
| to [12] |
How do the perspectives of dermatologists and practice staff differ?
In order to identify barriers and facilitating factors regarding the implementation of digital applications in dermatological practices, a team of the Institute for Health Services Research of the University Medical Center Hamburg-Eppendorf conducted a survey of focus groups [13]. The idea was to include the perspectives of dermatologists and other clinic and practice staff, in addition to the patient perspective, to find out more about how the development of digital applications can be designed to meet needs and implemented successfully.
For this purpose, six online focus groups with 4-6 participants each were conducted per group (dermatologists, patients, and clinic/practice staff) and evaluated by content analysis. A total of 34 dermatologists, 30 patients, and 34 other clinic/practice staff were interviewed [13]. While patients and clinic/practice staff predominantly cited added value (e.g., time savings), dermatologists pointed to an additional workload and information overload. All three groups addressed low digital literacy among older patients as an important barrier. Dermatologists also noted the integration of digital applications into their stressful workday as an obstacle. Data protection was a key issue and was cited as a barrier for various reasons (data misuse, uncertainty, complexity). This topic is also addressed in fact sheets published by the umbrella organization of the Swiss medical profession (FMH) [14]. Among other things, it points out that when digitizing outpatient healthcare, care must be taken to ensure that data protection and data security are adequately safeguarded. In Switzerland, the legal framework for this is provided by the revised Data Protection Act (DSG) [15].
Literature:
- Augustin M, Strömer K, et al. S2k guideline teledermatology. AWMF Register No.: 013-097; www.awmf.org/leitlinien/detail/ll/013-097.htm,(last accessed 18.08.2023).
- “Dermatologist online: teledermatology consultation,” www.usz.ch/fachbereich/dermatologie/angebot/teledermatologie,(last accessed Aug. 18 , 2023).
- Reinders P, et al: Application areas of teledermatology [Areas of application for teledermatology]. Dermatologist 2022; 73(1): 47-52.
- Santiago S, Lu J: Patient Satisfaction in Teledermatology: an Updated Review. Curr Dermatol Rep 2023; 12(1): 23-26.
- derma2go, www.derma2go.com/de/unternehmen,(last accessed Aug. 18, 2023).
- Hadeler E, Gitlow H, Nouri K: Definitions, survey methods, and findings of patient satisfaction studies in teledermatology: a systematic review. Arch Dermatol Res 2021; 313(4): 205-215.
- Moore B, et al: Patient satisfaction of real-time teledermatology: a cross-sectional survey. Int J Dermatology 2022 Feb; 61(2).
- Miller J, Jones E: Shaping the future of teledermatology: a literature review of patient and provider satisfaction with synchronous teledermatology during the COVID-19 pandemic. Clin Experimental Derm 2022; 47(11): 1903-1909.
- Ruggiero A, et al: Video and telephone teledermatology consultations during COVID-19 in comparison: patient satisfaction, doubts and concerns. Clin Experimental Derm 2022; 47(10): 1863-1864.
- “Working Group,” www.derma.swiss/sgdv/arbeitsgruppen,(last accessed Aug. 18, 2023).
- “OnlineDoctor launches pilot for e-prescription in Switzerland,” www.onlinedoctor.ch/pressemitteilung/onlinedoctor-startet-piloten-fuer-das-e-rezept-in-der-schweiz,(last accessed Aug. 18, 2023).
- “Doctor to go,” Switzerland Ärzteztg 2023; 104(09): 18-21.
- Reinders P, et al: Acceptance, barriers and facilitators of digital applications in dermatology from the perspective of dermatologists, patients and the clinic and practice staff. P053, DDG Conference, 26-29.04.2023
- “Digitization of Outpatient Health Care,” FMH, www.fmh.ch/files/pdf22/digitalisierung_der_ambulanten_gesundheitsversorgung.pdf,(last accessed Aug. 21, 2023).
- “Data Protection and Security,” www.fmh.ch/themen/ehealth/datenschutz.cfm,(last accessed Aug. 21, 2023).
