You are in: eMedicine Specialties > Dermatology > TECHNOLOGY AND DERMATOLOGY TeledermatologyArticle Last Updated: Feb 27, 2007AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Alice J Watson, MBChB, MRCP, Instructor in Dermatology, Harvard Medical School; Manager of Research Programs, Partners Telemedicine Alice J Watson is a member of the following medical societies: American Telemedicine Association Coauthor(s): Hagit Bergman, MD, Research Fellow, Department of Dermatology, Partners Telemedicine, Harvard Medical School; Joseph C Kvedar, MD, Corporate Director, Partners Telemedicine; Vice Chairman, Assistant Professor, Department of Dermatology, Massachusetts General Hospital, Harvard Medical School Editors: Kathryn Schwarzenberger, MD, Associate Professor of Medicine, Division of Dermatology, University of Vermont College of Medicine; Consulting Staff, Division of Dermatology, Fletcher Allen Health Care; David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Director, Division of Dermatology, Scott and White Clinic; Director Dermatology Residency Training Program, Scott and White Clinic; Amanda Oakley, MBChB, FRACP, Clinical Director, Clinical Associate Professor, Department of Dermatology, Waikato Hospital, Hamilton, New Zealand; Joel M Gelfand, MD, MSCE, Medical Director, Clinical Studies Unit, Assistant Professor, Department of Dermatology, Associate Scholar, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; William D James, MD, Paul R Gross Professor of Dermatology, University of Pennsylvania School of Medicine; Vice-Chair, Program Director, Department of Dermatology, University of Pennsylvania Health System Author and Editor Disclosure Synonyms and related keywords: telemedicine, Internet dermatology, online dermatology, web-based dermatology, web-based diagnosis, Internet diagnosis, teleconference diagnosis, telehealth, tele-health, tele-medicine, tele-dermatology, store and foreword teledermatology, live-interactive teledermatology, e-health, pay-for-performance model, pay for performance model INTRODUCTIONSection 2 of 11
  The use of communications technology to facilitate the provision of health care for persons with skin disease is an area of increasing interest and activity. Following the first article on this topic in 1995, more than 180 publications have reported on active research projects from across the globe (PubMed search "teledermatology"). In 2005, a survey by the American Telemedicine Association reported 62 active teledermatology programs in 37 different US states. Despite this level of interest and activity, questions remain regarding how best to use the available technology and overcome the current adoption challenges, thus allowing teledermatology to become an integral element of mainstream care delivery. The following sections address why telemedicine is a valuable resource for dermatology, the current extent of its practice, the challenges in validating teledermatology as an effective adjunct to conventional care, and the factors limiting widespread adoption. THE PROBLEM OF ACCESSSection 3 of 11
Despite previous concerns that the United States was training too many dermatologists, a workforce shortage is now evident (Resneck, 2004). This has resulted in both aggressive recruiting of graduating US residents and long wait times for patients. In the United States, patients with potentially urgent problems, such as pigmented changing lesions, have reported wait times as long as patients with routine problems (Tsang, 2006). The United Kingdom faces a similar problem, with 20% of consultant posts lying vacant in 2002. Interestingly, the number of categorical dermatology residency positions available in the United States has decreased more than 6% in the last few years (National Residence Matching Program, 2006). The problem, however, is not simply about the number of dermatologists. Both generational differences in practice and geographical distribution of doctors exacerbate the current situation. The dermatology community is clustered around urban areas, limiting access to specialists for many patients in rural locations. Of the US population, 42% is thought to live in areas underserved by dermatologists (Suneja, 2001). Younger dermatologists have been shown to dedicate fewer hours to the practice of medical dermatology than their older counterparts (Jacobson, 2004). The rise of cosmetic and surgical subspecialties and the desire for a better work-life balance may divert younger practitioners away from medical dermatology, which may lead to a contraction in supply despite a rise in the number of qualified practitioners. An increasing proportion of patients with skin disease are being diagnosed and managed without ever seeing a dermatologist. Primary care physicians are attempting to bridge the widening gaps in the care network, despite the fact that many have no formal training in dermatology and that studies show their diagnostic concordance with trained dermatologists is only approximately 57% (Lowell, 2001). A Scottish survey revealed that diseases of the skin or subcutaneous tissue are now the most common reason for both men and women to attend their family doctor (www.isdscotland.org). Therefore, a strong case can be made for increased collaboration between dermatologists and other health care providers in order to address high patient demand and to provide education and support. TELEDERMATOLOGY - A SOLUTION?Section 4 of 11
Consumer-grade technology has significantly altered the banking, retail, travel, and communications industries, and this also provides a similar opportunity to change the way health care is delivered. Scientific societies and governments from around the world have become increasingly interested in communication technologies and their role in providing better access to care while leading to substantial economic and social benefits (Medical University of Graz, 2006). Whether referred to as telehealth, telemedicine, or e-health, health care communications technology offers novel means to deliver dermatological care to patients, independent of time or place, and is increasingly recognized as an important component in the modernization of the health care system (Lee, 2001). Dermatology has been a forerunner in the use of communications technology. As a visual specialty with low mortality and many chronic conditions, dermatology is an ideal candidate to capitalize on the unprecedented rate of technological evolution that has occurred over the last decade. Additionally, with the expensive digital cameras of the 1990s incorporated into the cell phones of 2005 and with more than 75% of Americans having an email address (Harris Interactive, 2005), many opportunities remain to develop innovative methods to facilitate communication between doctors and patients. The opportunity to better use communications technology arises at a time when health care consumers are demanding the same level of convenience, access, and efficiency they experience in other walks of life. Being able to email your physician or send an image by cell phone only became a possibility several years ago, but it has rapidly gained popularity. A recent Harris poll found that 80% of US adults surveyed would like to use online communication to ask their doctor questions without an office visit (Harris Interactive, 2005). In short, patients' expectations regarding access to health care have changed. Dermatology patients are no exception—50% express willingness to send images to their doctor in return for faster diagnosis and treatment (Qureshi, 2003). The multibillion dollar health and wellness market suggests that significant willingness to pay may exist for an expedited, if remote, dermatological consultation service. Nevertheless, proponents of teledermatology have yet to convincingly demonstrate the value of this service to patients and to the skeptics in their own profession. Only 36% of those surveyed in the Harris poll were currently willing to pay for online access to their physician. The convergence of a supply problem, a feasible solution, and changing consumer demands has, however, created an exciting opportunity for teledermatology to show its value. Teledermatology should not purely be defined by what has already been accomplished in this field. The future possibilities to deliver dermatological care in a manner free from geographical and temporal barriers are extensive. Applications are being developed to facilitate diagnosis and ongoing management of patients and to provide training and educational support for doctors. The barriers, incentives, and challenges in this field are rapidly evolving. Although rapid technological advances facilitate the development of newer and better teledermatology systems, such speed of progress can pose a challenge when attempting to validate these services. Reviews on the topic become rapidly outdated, and the technology used in many trials is often obsolete by the time results are published. For this reason, the discussion will not focus on technical requirements; instead, it will focus on areas of current expertise and probable future growth. WHAT IS THE CURRENT SCOPE OF THE FIELD?Section 5 of 11
Although the different applications for teledermatology are numerous, the bulk of research has concentrated on its use as a diagnostic tool. The 2 main approaches used currently are store-and-forward technology and live interactive technology. The former is time and place independent, while the latter operates in real time via a video-conferencing link but bypasses geographical boundaries. The American Academy of Dermatology position statement on telemedicine contains useful recommendations regarding minimum system requirements. Today's low-end digital cameras easily meet the prerequisite that store-and-forward images should be at least of 640 X 480 pixel resolution. Live-interactive technology, however, requires more sophisticated and costly technology. The advantages and disadvantages of these approaches are as follows: Store-and-forward approach
Live interactive approach
A live interactive approach can be incredibly valuable in allowing certain patient groups to benefit from specialist care in situations in which a face-to-face alternative is not available. A live interactive approach has been used to deliver care to patients in outer space, in war zones, and at sea. It solves the issue of access but does not address the issue of dermatologist productivity. Store-and-forward technology can address both these issues but does not permit the direct clinician-patient exchange that is a traditional component of the medical consultation. Perhaps the best approach is to view both techniques as options to be used interchangeably, and in conjunction, with the tried and tested standard model of care delivery. Their use is by no means restricted to diagnosis; supporting ongoing management of existing patients may prove to be one of the most valuable applications of these techniques. This is illustrated by the use of technology to facilitate follow-up of patients with skin disease. This is an area of great potential. Many dermatological diseases, including acne, rosacea, wounds, and leg ulcers, may be satisfactorily assessed and managed through the use of digital images. A number of trials are being conducted in this area. Their scope ranges from examining the ability of patients to self-image and forward photos to their dermatologist to the value of cell phone cameras in providing nurse specialists with wound care information to allow timely adjustment of treatment plans. These approaches are designed to allow patients in the community, under the care of dermatology services, to remain connected to their provider without having to attend an office visit. This delivery model provides ongoing access to care while providing doctors with the flexibility to spend clinic time with those patients who require face-to-face management. Another valuable use of communications technology is in the provision of dermatology training and education. Educational programs may produce a significant increase in dermatology knowledge scores, demonstrating value to the recipients (Williams, 2005). Telemedicine can also be used to train dermatology residents. Residents in one training program used a digital camera to obtain images from all consultations. These images were then viewed and discussed with an attending dermatologist at a distant site. High levels of diagnostic accuracy were demonstrated when these images were combined with a clinical history (American Telemedicine Association, 2006). In the current US system, many patients are managed without input from a dermatologist, making it essential for dermatologists to reach out to their colleagues and ensure they have access to support and educational resources to enable the best diagnostic and management decisions are made. Through the development of decision support tools, nondermatologists have been able to increase their diagnostic expertise in assessing nonmelanoma skin tumors (Gerbert, 2002). Further iterations of these programs that incorporate digital imaging techniques with informatics acumen may allow automatic generation of likely diagnoses. Communications technology can be used to facilitate discussion between different groups. To date, this technology has primarily been used to enable consultations involving generalists and specialists; likely subsequent applications will increasingly involve direct communication between dermatologists and patients. In summary, teledermatology can take a variety of approaches to better enable diagnosis, management, or education for providers or patients. Traditionally, groups have used either live interactive or store-and-forward technology to conduct consultations. New technologies, however, are offering novel ways to deliver care. These approaches are simply tools to be used interchangeably, or in combination, according to the particular circumstances. Communications technology creates a channel whereby patients can be treated without a visit to the office. This approach is likely to be of great value in the ongoing care of patients with chronic skin disease and is likely to be an area of significant focus in the future. TELEDERMATOLOGY VERSUS CONVENTIONAL CARESection 6 of 11
Demonstrating equivalence As with the implementation of any new intervention or technique, demonstrating the equivalence of teledermatology with the current best available practice is essential. Technological interventions should not be exempt from the rigorous process of validation, but they do present particular challenges. Ideally, interventions would be assessed through the measurement of clinical outcomes such as resource utilization (eg, number of appointments), disease management (eg, change in psoriasis area sensitivity index score), and patient-related factors (eg, morbidity, mortality, quality of life). However, the rapid evolution of technology diminishes the utility of lengthy clinical trials to assess such patient-related clinical outcomes. As a result, trials of telemedicine interventions often opt to measure intermediate outcomes, such as diagnostic or treatment concordance. Rapid technological development also underscores the importance of establishing proof of concept with regard to teledermatology interventions rather than attempting to validate a particular set of equipment. Teledermatology faces the same issues any new service or intervention must address in order to be adopted, including (1) whether the clinical outcomes are equivalent or superior to conventional care, (2) whether the intervention is acceptable to patients and providers, and (3) whether the intervention makes economic sense. Ultimately, all interventions must prove their worth within normal clinical settings in order to demonstrate true clinical effectiveness. In comparing teledermatology with conventional care, the metrics by which appropriateness of care is judged must be established. No criterion standard exists within current clinical settings to ascertain whether patients have received the correct diagnosis or management. Histopathological confirmation of the benign or malignant nature of lesions can be recorded, but this approach is clearly not applicable to all conditions. Diagnostic reliability of the store-and-forward technique A number of studies have tried to demonstrate that patients receive the same diagnosis following a telemedicine consultation compared with a clinic appointment. Such studies measure diagnostic reliability, or the degree of reproducibility of assessment results. Rates of complete diagnostic agreement between clinicians using a store-and-forward model and those based in clinics range from 41-89% (American Telemedicine Association, 2006). These figures just compare the single most likely diagnosis. The rate for partial diagnostic agreement, when most likely and differential diagnoses are included, ranges from 51-95%. The wide variation observed in levels of diagnostic agreement between these studies may make convincing skeptics that teledermatology services provide a consistently reliable method of assessment difficult. The interpretation of these findings, however, is clearly complicated by the presence of interobserver variability. Interobserver variability describes the differences between practitioners regardless of setting, making it difficult to isolate the effect of the mode of consultation on the resulting diagnosis and management plan. A study addressing this issue demonstrated complete and partial agreement rates to be similar between dermatologists, regardless of whether the evaluation was performed in a clinic or via teledermatology (Whited, 1999). Nevertheless, establishing whether the same cases produce diagnostic disagreement for each consultation modality is pertinent. In an attempt to remove interobserver variability, a number of studies were conducted using the same examiner to review patients in a clinic and by a teledermatology consultation. These studies also showed variable levels of complete agreement, ranging from 31-88%, and of partial agreement, ranging from 50-95% (www.atmeda.org). These results, which measure intraobserver variability, demonstrate that dermatologists do not always concur with their own previous diagnosis or management plan when consulting via different modalities. Unfortunately, assessing intraobserver variability within a clinic setting is not feasible. Accumulated experience over time may alter a clinician's approach to diagnosis or a recent case might increase a clinician's index of suspicion, thus influencing his or her diagnosis and management plan. A number of techniques can be used to maximize diagnostic reliability. Provision of an adequate history and clinical information increases diagnostic agreement, making these essential parts of any store-and-forward system. Ensuring that the clinician receives high-quality digital images has also been shown to improve diagnostic reliability (High, 2000). A recent study in the United Kingdom found that in 15% of cases, image quality was insufficient to make a diagnosis, illustrating the need for adequate training of those responsible for image capture (Mahendran, 2005). It is noteworthy that a study conducted in the United States showed no difference in the image quality attributes between patients personally trained by staff and those self-taught from an online survey. A patient's ability to take high-quality images creates new opportunities for both teledermatology and population-based research (Qureshi, 2006). Diagnostic reliability of real-time interactive technique The diagnostic reliability rates of real-time interactive consultations have varied from 54-80% when complete agreement is sought. Partial agreement rates were higher, at 80-99%. Complete agreement between doctors seeing patients in clinic settings were higher than those between doctors using 2 different consultation modalities, although partial agreement levels were very similar (100% and 99%, respectively) (Whited, 2006). Management reliability In assessing the adequacy of a teledermatology service, management reliability is of great importance. As with diagnostic reliability, interobserver variability exists between dermatologists regarding the appropriate management of common skin diseases. However, if dermatologists disagree over the nature of a lesion but agree that a biopsy is required, then the clinical outcome should be similar. Several studies have addressed the issue of management variability depending on whether conventional or teledermatology approaches are used. One study showed comparable reliability with medical treatment recommendations but not with biopsy decisions. Dermatologists report they feel less certain of their diagnoses when conducting a store-and-forward consultation compared with a face-to face encounter. This may explain the 10% higher biopsy recommendation rate in the teledermatology group noted in another study (Pak, 2003). Although this represents management variability, it is not necessarily a negative finding. Teledermatology studies aim to demonstrate that this method of assessment is as safe as a clinic encounter. An increased biopsy rate may be a necessary trade-off to ensure this standard of care. As a result, management variability is expected when comparing teledermatology consultations with conventional care. Direction for future studies In order to develop best practice recommendations, it would be useful to identify the skin conditions most suited to teledermatology assessment. Current data on this topic are limited and inconclusive. One study reported similar rates of diagnostic agreement in all categories of skin disease (Kvedar, 1997), while others found higher levels of agreement with eczema and follicular eruptions (Du Moulin, 2003) and lower levels of agreement with benign skin tumors (High, 2000). Ultimately, teledermatology must be judged by its effect on clinical outcomes. At present, little evidence is available on this topic, making this an important focus of future research. Although store-and-forward technology has been shown to decrease the time from referral to initial dermatology consultation and to reduce the duration of the consultation, whether these patients experience equivalent or improved outcomes in terms of morbidity, mortality, or quality of life cannot be determined. Outcomes Clinical outcomes are the least researched area in teledermatology. However, studies examining intermediate clinical outcomes, such as consultations avoided, time to intervention, time to initial contact with a dermatologist, and length of consult, have yielded positive findings (Whited, 2006). Patients undergoing teledermatology store-and-forward consultations reached a point of intervention significantly sooner than the conventional face-to-face group, a median of 41 days compared with 127 days, respectively. Similarly, dermatologists responded to store-and-forward consultations in an average of 2.17 days, compared with a mean wait time of 90 days for clinic-based appointments (Krupinski, 2002). A study published in the British Journal of Dermatology demonstrated that 3 in 10 teledermatology consultations averted face-to-face consultations, thereby acting as a form of triage (Taylor, 2001). The dissemination of this information is necessary for teledermatology to be fully accepted by physicians and patients. Doctor and patient satisfaction Teledermatology will only be accepted as a standard treatment modality if it is acceptable to doctors and patients. Studies assessing satisfaction rates have revealed mixed findings. Telemedicine offers benefits to many patients, such as a shorter wait time or treatment without traveling to a remote clinic; however patients acknowledge that a trade-off exists. A certain number of patients would still prefer a face-to-face consultation, with one study reporting that 40% felt "something was missing" when the dermatologist was not seen in person (Collins, 2004). Store-and-forward approaches raise this issue more than real-time interactive approaches because of the lack of direct doctor-patient interaction. Generational differences may exist amongst patients, with those in younger age groups being more comfortable with this "low-touch" approach. A UK study found that patients with lower quality-of-life scores were less likely to be satisfied with a teleconsultation (Williams, 2001). Identifying the most suitable candidates, in terms of skin condition and temperament, for teledermatology consultations may allow this service to satisfy patient needs and create flexibility for the provider. No standardized questionnaires have been developed to assess patient satisfaction, which makes comparing the responses to different systems difficult. Satisfaction is far from an all-or-nothing event, and responses vary greatly with subtle changes in questioning. A study that found that 93% of patients reported they were happy with their teleconsultation, with 86% reporting it was more convenient than going to the outpatient clinic, also found that 40% of the same patients said they would feel more comfortable seeing the dermatologist in person (Williams, 2001). Regardless of consultation modality, patients want rapid access to an accurate diagnosis and an effective treatment plan (Eminovic, 2006). They also want to be taken seriously and to receive individualized personal care (Qureshi, 2003; Collins, 2004). When these aspects of service are considered, comparably high satisfaction ratings can be achieved by both teledermatology and conventional care. Studies assessing physician satisfaction have focused on dermatologists or referring doctors. Dermatologists are generally enthusiastic, as would be expected given that they have usually initiated the new technique or service. Dermatologists report that they can achieve good rapport with patients using real-time technology. A majority also believed that teledermatology was just as thorough as clinic visits. Satisfaction ratings amongst referring clinicians are more variable, ranging from 21-92% (Whited, 2006). Low satisfaction rates tend to be associated with systems that negatively impact provider workload (Collins, 2004). This illustrates the importance of balancing stringent referral standards with a user-friendly system. Referring physicians must perceive a benefit to using the service in terms of increased convenience, shorter wait time, or better support. Popular systems offered referring doctors educational value and improved access to a specialist opinion (Van den Akker, 2001; Pak, 1999). BUSINESS CONSIDERATIONSSection 7 of 11
A service that is clinically reliable and acceptable to both patients and providers must still demonstrate its economic viability in order to be widely adopted. Here the rapid evolution of technology again poses challenges. Much of the existing work on the economic viability of teledermatology services has become redundant as a result of decreasing equipment costs. Economic analyses are further complicated by the many hidden costs, such as the opportunity cost of a patient's time, and hidden benefits, such as the intangible benefit of an earlier correct diagnosis, that are harder to quantify. Real-time interactive teledermatology has traditionally been found to be more costly than standard care because of the need for 2 providers and complex videoconferencing equipment. However, a recent analysis of the real-time interactive clinic run by Partners Telemedicine to Nantucket Island showed cost savings, related in part to the lower cost of renting hospital space in a rural setting (Armstrong, 2006). Another study reduced the costs of real-time interactive equipment by using multimedia phones to perform conferencing (Yamazaki, 2003). Store-and-forward technology avoids the high provider and equipment costs of a real-time interactive service, while still being less time consuming for patients. More work, however, is required to decide whether it is truly cost-effective. A UK study found that 45% of patients could not be adequately managed by teledermatology alone (Mahendran, 2005). Identifying the most appropriate patients to enter into this type of service may help to demonstrate its true economic value. Lastly, most teledermatology interventions to date have focused on providing a diagnostic service. With the integration of technology into follow-up care, significant, as yet unrealized, cost savings may become apparent. Irrespective of how teledermatology evolves, thorough economic analysis remains essential before payers will embrace this new mode of care. ADOPTION CHALLENGESSection 8 of 11
A number of different areas have obstacles that limit the more widespread introduction of telemedicine services (see Image 1). Although patients are becoming increasingly comfortable using technology to access health care information, telemedicine should be viewed as an adjunct, rather than a replacement, to conventional care. Any service should be tailored to meet patient needs and expectations to promote a positive interaction. Many doctors are also unsure of this new care-delivery model. A solid evidence base and a thoughtful implementation strategy are required to ensure doctors are motivated to participate in telemedicine initiatives. As previously mentioned, the rate of technological development and increased affordability have made the tools of telemedicine more widely available. Many companies have seized on this business opportunity, offering a plethora of devices and services. Interoperability between these technologies is required to allow the development of an integrated information technology network. Consumer-grade technology is of such a standard that patients can now provide their own images and clinical information via the Internet. This introduces new concerns over issues of security and confidentiality. Secure online health care communication services are now available to link patients, doctors, payers, and pharmacies and enable clinically structured and auditable interactions to take place, including online consultations, prescription requests, appointment reminders, and delivery of laboratory results. The Health Information Portability and Accountability Act in the United States has set standards that all initiatives must meet to ensure the protection of personal health information (www.hhs.gov/ocr/hipaa). The Joint Commission on Accreditation of Healthcare Organizations also requires quality and safety assurances in order to provide accreditation for organizations (www.jcaho.org). Providers are advised to liaise with their institution's privacy officer for advice on how best to achieve these required standards. Teledermatology allows consultations to occur across state and national boundaries. This raises issues regarding licensure that must be addressed to ensure doctors are practicing within an appropriate sphere. Although no telemedicine malpractice cases have been filed to date, clarifying how responsibility for decision-making is shared between referring doctors and specialists is essential. Individuals making initial steps in this field are advised to contact their malpractice carrier and inform them of their interest in telemedicine. Reimbursement for services is an important issue in the United States. In this new field, defining what constitutes a consultation and determining at what level should ongoing care using telemedicine be reimbursed are important. Currently, reimbursement is almost exclusively available for real-time interactive services, with store-and-forward system funding only provided on a very limited basis. Medicaid is funding the latter on a trial basis in Alaska and Hawaii, both of which are areas where access to specialist care is a major issue. Interestingly, some progressive international insurance companies have begun endorsing the use of store-and-forward teledermatology between referring physicians abroad and dermatologists in the Partners health care system in Boston (Maccabbi Insurance online, 2006). In addressing this and other barriers, the importance of standards and guidelines for practitioners becomes apparent. The American Academy of Dermatology has released a position statement on telemedicine, which offers guidelines on technology requirements, confidentiality standards, and licensing (www.aad.org). Government-funded, pay-for-performance models are currently being studied in the management of chronic diseases, such as diabetes and hypertension. Markers of quality care, such as blood pressure or lipid levels, do not have ready equivalents in the management of skin disease. This would make the implementation of a similar model in dermatology a more controversial proposition. CONCLUSIONSection 9 of 11
Changing consumer demands, the limited supply of dermatologists, and technological advances are driving interest in teledermatology. Consumers are increasingly keen to obtain rapid access to specialist advice and are seeking the convenience in health care that they enjoy in other service industries. Dermatologists are in short supply and are geographically maldistributed, creating a lack of access to care for patients in many parts of the country. Technological advances over the last decade have transformed the Internet, digital cameras, and videophones from expensive niche products into widely available consumer-grade appliances. These factors present a real opportunity to develop teledermatology into an integral part of the health care system; however, the possibilities must not be overstated or promoted as a panacea for all the current problems in the field. Teledermatology is not about acquiring a digital camera or furnishing a department with videoconferencing equipment. A carpenter's toolkit will not produce a high-quality finished product if put in the hands of an unskilled worker. Similarly, telemedicine technologies are tools in a kit that can be used to build a high quality and efficient care-delivery model when used with thought and expertise. For widespread, sustainable adoption of teledermatology initiatives to occur, efficacy, acceptability, and economic viability must all be demonstrated. Different populations vary in their requirements, and customized, integrated solutions are necessary to engage interest and maintain usage. This flexibility must be coupled with guidelines for practice that ensure a high standard of care for all recipients, especially as the international community becomes increasingly involved. A number of steps are required to ensure that regulatory standards are met, and, although these may seem daunting to newcomers to the field, this mode of practice is steadily moving towards the mainstream. Teledermatology has enormous scope as an adjunct to current practice in all settings and provides a means of access to care for many patients currently denied specialist attention. Much work remains in order to create a solid research base that demonstrates the value of this service for providers and patients. Providing a safe, equitable service that delivers comparable health outcomes to conventional care is the ultimate aim. Ultimately, if teledermatology can deliver a service that is convenient and efficient, it will become something that patients will accept, trust, and then come to expect from providers. Establishing this self-reinforcing dynamic will secure an integral place for teledermatology in the management of patients with skin disease. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
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