In the Swiss healthcare system, telemedicine has been an important tool in acute medical care for 20 years. For acute and general health concerns, digital offerings are the first port of call for many people and are now also firmly part of the health insurers’ portfolio. Due to morphological image-based diagnostics, dermatology is predestined for the application of such technologies like hardly any other discipline.
In the Swiss healthcare system, telemedicine has been an important tool in acute medical care for 20 years. For acute and general health concerns, digital offerings are the first point of contact for many people and are now also firmly established in the portfolio of health insurers [1].
Due to its morphology-image-based diagnostics, dermatology is predestined for the application of such technologies like hardly any other discipline. Accordingly, the use of telecommunication technologies is increasingly finding its way into dermatological work [2]. A comprehensive body of scientific knowledge can be drawn upon in diagnostics as well as in consultation and triage.
The purpose of this article is to provide dermatologists with knowledge of the scientifically evaluated areas of application of teledermatology and to inform them about its integration into medical practice in everyday life. The training is suitable for dermatological specialists in clinics and practices as well as for assistants in further training.
The content will deal with the forms of teledermatological applications, highlight the requirements for digital work, present scientifically evaluated areas of application and describe practical integration using a practical example.
Forms of teledermatology
The Swiss Society of Dermatology and Venereology is in favor of telemedical consultations in the dermatological field and rates them as a good alternative to direct patient contact. According to the company, the top priorities are the quality and safety of the offerings. In addition, the economic efficiency of the application must be ensured [3].
The term telemedicine stands as a collective term for various medical care concepts in which medical services in the areas of diagnostics, therapy and rehabilitation as well as medical decision-making consultation are carried out over spatial distance using information and communication technologies [4]. Telemedicine services in dermatology can be differentiated into synchronous and asynchronous consultations. In synchronous telemedicine, commonly known as video consultation, medical staff is directly connected to a patient. There is therefore a temporal synchronicity with local separation.
The advantages of synchronous telemedicine are primarily on the side of the persons being treated: Medical consultations or specialized patient training sessions are possible without the need for travel or waiting time. The advantages for the practice staff are a reduction in personal patient contact, e.g. at the registration desk, and a quieter working atmosphere due to a reduction in the flow of patients. From the physician’s point of view, one essential point remains unchanged with synchronous telemedicine: Both parties still have to be present at the same time for the doctor-patient consultation – a fixed appointment is still required and the time required for the doctor-patient consultation remains unchanged. The result is that video consultation maps existing processes in a digital environment without changing them or making them more efficient on the physician side [5].
Time-shifted offers create efficiency gains in practice
During asynchronous consultations, patients describe their concerns in writing. This time-shifted telemedicine allows physicians to interact with affected individuals without the need to be available at the same time. The medical history is taken using a digital solution – for example, along an intuitive chatbot or a medical history form. In this context, the digital application asks about the most important factors such as symptoms, allergies and previous illnesses. Prior therapies are also taken into account. In addition to the medical history, patients upload photos of their skin lesions. The digital solution processes the information and documents obtained and transmits them to the relevant physicians. Thus, the parties do not have to process the request at the same time. Patients receive feedback on their request in written form in the case of an asynchronous telemedicine service. This is protected according to current standards of the new Swiss data protection law and the DSGVO, secured by appropriate authentication and authorization factors. For this purpose, the assessing specialist sends an individualized document with diagnosis and corresponding therapy recommendation within a predefined period of time. Thanks to the written documentation, it is possible to look at a recommendation again at a later time and to communicate sequential therapy algorithms to patients more easily. Recent surveys indicate a high level of satisfaction among patients who have used such teledermatology consultation [6]. For those affected by a skin problem, this results in the rapid availability of comprehensible information and recommendations, as well as easier access to dermatological care and a high degree of participation [7]. In a study by Otten et al. 86.6 percent of respondents indicated that their concerns had been clarified by the inquiry [8].
Unlike the classic video consultation, time-shifted consultations can change the processes in the dermatology practice: The medical staff can independently structure when the digital cases are to be processed. Thanks to the digital tools available, processes and workflows can thus be made more efficient – allowing more capacity for challenging cases in the practice and thus directly improving care [6]. In addition, the image quality is significantly higher compared to a video phone call, which greatly contributes to the quality of diagnostics in dermatological practice. When taking photos, smartphones are now capable of delivering acceptable image quality even when the image is not well lit, without distorting color fidelity at the same time.
Different concepts of care in asynchronous telemedicine.
In the field of asynchronous, i.e. time-delayed teledermatology, a distinction can be made between closed and open platform models. In closed models, employed physicians process patient inquiries asynchronously digitally. This allows bundling of requests to a small number of specialized personnel.
This is contrasted with the open platform model, where every dermatologist has the ability to digitally adjudicate existing and/or new cases. If a request cannot be answered digitally due to ambiguities or insufficient image quality, or if a biopsy is necessary, the patient is presented in the presence of the physician in the practice. This creates a link between the company’s own analog and digital practices.
The benefits for participating practices come from efficiency gains and easy participation in the digital transformation. In contrast to the closed approaches of asynchronous telemedicine, where a few physicians benefit from teledermatology cases, the platform model allows easier access for all participants. Easily treatable, profitable cases thus remain in the care of physicians in private practice. In contrast, a digitization of dermatology detached from local care structures leads to a dichotomy: people with a skin problem receive digital diagnoses and recommendations for action. However, when a presentation to a doctor’s office is necessary, they are again bound by the regular waiting times for an appointment and experience a high degree of loss of information, since the case must be worked up again by a doctor.
General conditions and requirements
There is dermatologic expert consensus that quality-assured teledermatologic care can add value to care. The use is dependent on whether a relevant additional benefit can be expected for patients without disadvantages for them or the medical staff. Requirements can be derived accordingly. It must be ensured in advance that the software and hardware equipment for the use of teledermatological procedures is available and secured in terms of data protection. The technical implementation must also comply with data protection regulations in terms of documentation, storage and transfer of information. For example, unencrypted e-mails and messenger services do not meet the corresponding requirements. Furthermore, it is necessary that all persons involved are familiar with the specifics of teledermatological products. This includes not only the medical staff but also the practice staff and the patients [7].
Possible uses and areas of application
The use of teledermatology is diverse and the study base is extensive. Scientific evaluations are available for diagnosis, triaging, follow-up and postoperative care.
Within the framework of teledermatological triage, physicians can assess which cases need to be examined on site in the practice according to digital presentation and in which cases digital diagnostics with recommendations for action is sufficient. If the tool is used efficiently, this eliminates avoidable on-site consultations and frees up practice capacity [9].
There is also a high degree of concordance in the context of diagnosis. A study by Sondermann et al. was able to show, for example, that in cases that were initially diagnosed by teledermatology, the diagnosis was concordant in 97 percent of the cases when a second assessment was carried out [10]. Additionally, a diagnosis can be made digitally in the majority of affected individuals. Figures from OnlineDoctor, the market leader for teledermatology in Switzerland, show that 85 percent of all cases are completed digitally. This is consistent with the completion rates of other teledermatology providers [8].
Additional areas of application for asynchronous teledermatology in a platform model include follow-up of chronic diseases and postoperative follow-up and wound control [11]. Travel and waiting times are eliminated for patients with a chronic disease through regular teledermatological checks. Here, monitoring takes place on an as-needed basis, making it possible to intervene more quickly in the event of a lack of therapeutic success or deterioration. On the physician side, time savings, flexibility and economic incentives are noted. Therapy monitoring for long-term systemic therapies has also been scientifically evaluated and can be mapped teledermatologically: Dose adjustments, information about possible side effects, and the time and extent of the expected therapeutic success can be carried out in a digitally and analogously comparable manner [6].
State of research on the use of digital progress controls
With regard to teledermatological follow-up, the quality of care for psoriasis, acne, and atopic dermatitis has been extensively researched [13–15]. Randomized controlled trials demonstrate equivalent. For example, in a U.S. study, psoriasis sufferers and their primary care physicians were able to share queries, images, and other information digitally with dermatological, specialist medical staff. As a result, digital progress monitoring was equally effective [13]. Similar study designs show the same effects for atopic dermatitis and acne: Sufferers showed equivalent clinical treatment outcomes compared to the control group that received analogous consultations [15].
Teledermatology in practice
In Switzerland, every fourth dermatology practice uses the OnlineDoctor product for teledermatology consultations. The platform allows specialist medical staff to efficiently report on existing and new cases in compliance with data protection regulations. For this purpose, the dermatologist registers free of charge with OnlineDoctor with a descriptive text and a photo. People with a skin disease select via the website www.-onlinedoctor.ch which dermatological specialist should make the diagnosis. For the request, the affected person pays CHF 55, of which OnlineDoctor retains a portion to operate the platform. The rest is paid to the dermatologists per case at the end of the month.
For the collection of the findings, OnlineDoctor uses an interactive chat assistant that adapts to the skin disease to be clarified and is tailored to the specifics of the request. The chat assistant also guides patients when taking photos to ensure that the viewing angles and exposure are optimal.
The evaluation of common teledermatological clinical pictures is performed in 48 hours or less. For this purpose, physicians have at their disposal formulated, structured text modules that can be understood by laypersons. The content is adapted to the specifics of digital communication and includes therapy recommendations that are possible and implementable for the affected person in the home environment. In addition, there are templates for sequential progressions that can be applied depending on the severity and improvement of the disease state. Beyond the individual diagnosis and therapy recommendations, additional information can be sent to patients. This includes, for example, information on relapse prevention, therapy intensification and complex applications of therapeutic agents. Every dermatologist has access to a personal archive via OnlineDoctor in which all work steps are documented. In this way, former inquiries can be referred back to should any queries arise. If needed, a physical presentation appointment can be offered at the practice.
Application in everyday practice
Based on a survey of 30 medical users, each of whom digitally diagnosed at least 30 cases per month, findings can be derived from everyday practice. Only in one percent of cases is further information missing, making it necessary to contact the patient again by e-mail, telephone or text message. The use of existing text modules is possible in 75 percent of all cases, so that only minor adjustments need to be made to the text. Only in 15 percent of patients does the digital consultation result in a recommendation for a physical visit to the practice, for example to perform a biopsy or dermoscopic examination.
Practical integration in everyday practice
In the sense of a so-called digital-first approach, OnlineDoctor’s tool allows a dermatology practice to make broad use of teledermatology. Patients can keep their appointments as digital consultations if this makes medical sense and is desired by the patient. Based on demand, the practice team decides which new and existing cases are suitable for digital processing. In this way, on-site medical expertise can be combined with rapid digital diagnostics. Personal support can be efficiently and individually combined with digital. Medical staff thus actively manage patient flows, can offer faster diagnosis and medical assistance in unclear cases, and process cases more quickly.
Increase in number of cases and increased time freedom through digital-first
Dr. Paul Scheidegger, co-founder of OnlineDoctor and dermatologist with his own practice in Brugg, has structured his activities in line with this digital-first approach and can thus deploy human resources in the best possible way for the benefit of his patients.
The central driver is active management of the patient population from a practice perspective. A so-called smart check-in makes it possible to efficiently decide which cases need to be seen on site in terms of triage. The basis is a comprehensive communication of the offer on the part of the entire practice staff: For this purpose, the practice staff has participated in MPA trainings of OnlineDoctor. Via the teledermatology link on the website and by telephone, the team proactively and comprehensively informs about the possibility of digital consultation in terms of digital triage. In addition, teledermatology links exist on the practice’s Google profile. A questionnaire is available for the staff in the practice for the telephone conversation with patients, on the basis of which they decide which cases can be processed teledermatologically. This training massively increases efficiency in the practice and enables high quality direct patient communication. For existing patients who are on site at the practice, there is also easy-to-understand information material in the form of brochures, flyers and business cards. In this way, not only acute cases but also chronically ill patients can benefit from the practice’s teledermatology services. Dr. Scheidegger and his staff discuss individually whether, for example, a digital consultation is suitable and desired by the patient for a follow-up or control appointment. The consistent implementation of the digital-first strategy allows Dr. Scheidegger to make the best possible use of his own medical expertise for the benefit of those affected. Thus, in terms of his medical specialization, he actively defines which patients he would like to treat in the on-site practice. The efficiency gains also enabled him to hire additional medical staff and significantly reduce waiting times for patients. The fast and convenient access to medical help also significantly increased the satisfaction of those treated in his practice since the introduction of the teledermatology service.
Take-Home Messages
- Dermatology is predestined for the application of telemedical technologies due to its morphology-image-based diagnostics.
- Quality-assured teledermatology treatment can add value to care.
- Unlike the classic video consultation, time-shifted consultations optimize processes in the dermatology practice.
- The use of teledermatology is diverse and the study base is extensive. Scientific evaluations are available for diagnosis, triaging, follow-up and postoperative care.
- Personal patient care can be efficiently and individually combined with digital through the use of teledermatology. Medical staff thus actively manage patient flows, can offer faster diagnosis and medical assistance in unclear cases, and process cases more quickly.
Literature:
- von Gossler C, Klauser C: Telemedicine in Switzerland – the example of Medgate. Dtsch Med Wochenschr 2017; 142(05): 334-339; doi: 10.1055/s-0042-111357.
- Maltagliati-Holzner P: Teledermatology in Switzerland. Application examples for the treatment of dermatological issues based on a telemedical center. Dermatologist 2019; 70: 329-334; doi: 10.1007/s00105-019-4401-0.
- Swiss Society of Dermatology and Venereology. Position paper telemedicine: dermatologists on telemedicine. October 2021; www.derma.ch/dam/jcr:d6f86c98-f3fa-4e36-9e66-7863425c4cbd/211020_Positionspapier_Telemedizin-2.pdf (accessed March 04, 2022).
- Federal Medical Association. Telemedicine methods in patient care – Conceptual location. On the Internet: www.bundesaerztekammer.de: www.bundesaerztekammer.de/fileadmin/user_upload/downloads/pdf-Ordner/Telemedizin_Telematik/Telemedizin/Telemedizinische_Methoden_in_der_Patientenversorgung_Begriffliche_Verortung.pdf (as of 11/26/2021).
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- Otten M, Greis C, Reich K: Evaluation of a teledermatological store-and-forward application in Germany – patients’ view. J Dtsch Dermatol Ges 2021 Oct: 109; doi: 10.3205/21dkvf276.
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- Sondermann W, von Kalle C, Utikal JS, et al: External scientific evaluation of the first teledermatology app without direct patient contact in Germany (“Online Hautarzt – AppDoc”). Hautarzt 2020; 71(11): 887-897.
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- Frühauf J, Kröck S, Quehenberger F, et al: Mobile teledermatology helping patients control high-need acne: a randomized controlled trial. J Eur Acad Dermatol Venereol 2015; 29(5): 919-924; doi: 10.1111/jdv.12723.
DERMATOLOGIE PRAXIS 2022; 32(2): 14-18
