Teledermatology Whited, John D
The Medical clinics of North America,
11/2015, Letnik:
99, Številka:
6
Journal Article
Recenzirano
This article provides an overview of teledermatology with an emphasis on the evidence most relevant to referring clinicians, who are often primary care clinicians. Discussion includes the different ...modalities used for teledermatology and their diagnostic reliability, diagnostic accuracy, impact on in-person dermatology visits, clinical outcomes, and user satisfaction.
An important outcome in healthcare, and in particular for dermatologic healthcare, is quality of life. Whereas the literature is well represented by quality of life assessments in dermatology, very ...little information is available that specifically addresses teledermatology's impact on quality of life. This gap in our knowledge of teledermatology is noteworthy precisely because of the importance that quality of life plays in dermatologic disease and healthcare delivery. The goal of this review is to briefly outline the concept of quality of life and its importance to dermatology, describe the different type of instruments that are used to assess quality of life, and to review studies that implemented teledermatology interventions and made quality of life assessments. The available literature has shown that teledermatology interventions do result in improved quality of life, and those changes correlate with improvements in disease severity and clinical course. Integrating quality of life assessments in future evaluations of teledermatology interventions would be valuable to provide a more comprehensive depiction of teledermatology's impact on patients receiving dermatology care via telemedicine.
Teledermatology research review Whited, John D.
International journal of dermatology,
March 2006, Letnik:
45, Številka:
3
Journal Article
Recenzirano
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.
Background
Technology-based systems can facilitate remote decision-making to triage patients to the appropriate level of care. Despite technologic advances, the effects of implementation of these ...systems on patient and utilization outcomes are unclear. We evaluated the effects of remote triage systems on healthcare utilization, case resolution, and patient safety outcomes.
Methods
English-language searches of MEDLINE (via PubMed), EMBASE, and CINAHL were performed from inception until July 2018. Randomized and nonrandomized comparative studies of remote triage services that reported healthcare utilization, case resolution, and patient safety outcomes were included. Two reviewers assessed study and intervention characteristics independently for study quality, strength of evidence, and risk of bias.
Results
The literature search identified 5026 articles, of which eight met eligibility criteria. Five randomized, two controlled before-and-after, and one interrupted time series study assessed 3 categories of remote triage services: mode of delivery, triage professional type, and system organizational level. No study evaluated any other delivery mode other than telephone and in-person. Meta-analyses were unable to be performed because of study design and outcome heterogeneity; therefore, we narratively synthesized data. Overall, most studies did not demonstrate a decrease in primary care (PC) or emergency department (ED) utilization, with some studies showing a significant increase. Evidence suggested local, practice-based triage systems have greater case resolution and refer fewer patients to PC or ED services than regional/national systems. No study identified statistically significant differences in safety outcomes.
Conclusion
Our review found limited evidence that remote triage reduces the burden of PC or ED utilization. However, remote triage by telephone can produce a high rate of call resolution and appears to be safe. Further study of other remote triage modalities is needed to realize the promise of remote triage services in optimizing healthcare outcomes.
Protocol Registration
This study was registered and followed a published protocol (PROSPERO: CRD42019112262).
Background
Innovative technology can enhance patient access to healthcare but must be successfully implemented to be effective.
Objective
We evaluated Department of Veterans Affairs’ (VA’s) ...implementation of
My VA Images
, a direct-to-patient asynchronous teledermatology mobile application enabling established dermatology patients to receive follow-up care remotely instead of in-person.
Design /Participants/Approach
Following pilot testing at 3 facilities, the app was introduced to 28 facilities (4 groups of 7) every 3 months using a stepped-wedge cluster-randomized design. Using the Organizational Theory of Implementation Effectiveness, we examined the app’s implementation using qualitative and quantitative data consisting of encounter data from VA’s corporate data warehouse; app usage from VA’s Mobile Health database; bi-monthly reports from facility representatives; phone interviews with clinicians; and documented communications between the operational partner and facility staff.
Key Results
Implementation policies and practices included VA’s vision to expand home telehealth and marketing/communication strategies. The COVID-19 pandemic dominated the implementation climate by stressing staffing, introducing competing demands, and influencing stakeholder attitudes to the app, including its fit to their values. These factors were associated with mixed implementation effectiveness, defined as high quality consistent use. Nineteen of 31 exposed facilities prepared to use the app; 10 facilities used it for actual patient care, 7 as originally intended. Residents, nurse practitioners, and physician assistants were more likely than attendings to use the app. Facilities exposed to the app pre-pandemic were more likely to use and sustain the new process.
Conclusions
Considerable heterogeneity existed in implementing mobile teledermatology, despite VA’s common mission, integrated healthcare system, and stakeholders’ broad interest. Identifying opportunities to target favorable facilities and user groups (such as teaching facilities and physician extenders, respectively) while addressing internal implementation barriers including incomplete integration with the electronic health record as well as inadequate staffing may help optimize the initial impact of direct-to-patient telehealth. The COVID pandemic was a notable extrinsic barrier.
Clinical Trials Registration
NCT03241589
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.
Background
Telehealth employs technology to connect patients to the right healthcare resources at the right time. Women are high utilizers of healthcare with gender-specific health issues that may ...benefit from the convenience and personalization of telehealth. Thus, we produced an evidence map describing the quantity, distribution, and characteristics of evidence assessing the effectiveness of telehealth services designed for women.
Methods
We searched MEDLINE
®
(via PubMed
®
) and Embase
®
from inception through March 20, 2018. We screened systematic reviews (SRs), randomized trials, and quasi-experimental studies using predetermined eligibility criteria. Articles meeting inclusion criteria were identified for data abstraction. To assess emerging trends, we also conducted a targeted search of
ClinicalTrials.gov
.
Results
Two hundred thirty-four primary studies and three SRs were eligible for abstraction. We grouped studies into focused areas of research: maternal health (
n
= 96), prevention (
n
= 46), disease management (
n
= 63), family planning (
n
= 9), high-risk breast cancer assessment (
n
= 10), intimate partner violence (
n
= 7), and mental health (
n
= 3). Most interventions focused on phone as the primary telehealth modality and featured healthcare team-to-patient communication and were limited in duration (e.g., < 12 weeks). Few interventions were conducted with older women (≥ 60 years) or in racially/ethnically diverse populations. There are few SRs in this area and limited evidence regarding newer telehealth modalities such as mobile-based applications or short message service/texting. Targeted search of
clinical.trials.gov
yielded 73 ongoing studies that show a shift in the use of non-telephone modalities.
Discussion
Our systematic evidence map highlights gaps in the existing literature, such as a lack of studies in key women’s health areas (intimate partner violence, mental health), and a dearth of relevant SRs. With few existing SRs in this literature, there is an opportunity for examining effects, efficiency, and acceptability across studies to inform efforts at implementing telehealth for women.
To improve patient access to skin care, the Department of Veterans Affairs (VA) developed a patient-facing asynchronous mobile teledermatology application (app), which allows patients to follow up ...remotely with dermatologists. To understand how the app would be received in VA, we examined Organizational Readiness for Change (ORC), an important prelude to effective implementation, which includes the shared resolve and collective ability of organizational members to implement a change.
We used a mixed-methods multiple case study approach to assess ORC at three VA facilities. Data derived from a site process call, surveys, and semistructured telephone interviews of VA staff, field notes, and administrative data.
Participants at all three facilities supported the intervention and recognized the value of using the app to increase patients' access to dermatologists, but expressed concerns largely related to disruption of the pre-existing clinical workflow. Participants at the facility most actively using the app had the highest overall ORC score and reported the most facilitators. Facility leadership support when guided by a clinical champion minimized barriers by recognizing the complexities of health care provision at specialty clinics.
While provider buy-in remained a barrier, leadership, guided by the clinical champion, played a critical role instituting implementation strategies. The strong association between the ORC survey score and the presence of facilitators and barriers suggests that the ORC survey may be a rapid, convenient, and effective tool for health care systems to identify favorable sites for wider implementation of mobile telehealth care. Clinical Trials Identifier: NCT03241589.
While teledermatology is well-established in the Department of Veterans Affairs (VA), its implementation is far from complete. To facilitate consultative teledermatology and extend its reach, VA ...introduced a mobile teledermatology application (app) at three VA sites.
We evaluated the initial implementation process using a mixed-methods, multiple case study approach to assess organizational readiness for change (ORC), which included examining facilitators, barriers, and contextual factors that affected implementation. We conducted: (1) group interviews and bimonthly reports to understand site processes; (2) semistructured interviews and surveys of individual participants representing a range of implementation roles; and (3) a review of internal organizational documents. We identified themes from interviews using an iterative process, and computed an ORC score based on surveys.
Forty-three individuals participated in the study. Qualitative data from all sites, corroborated by survey data available from one site, revealed a high readiness for change with an ORC score of 4.2, where 5 = maximal readiness for change. Facilitators included support from leadership and clinical champions, active telehealth programs, and an understanding and appreciation of the program and the resources needed. At all sites, however, technical issues negatively affected adoption; these included a suboptimal information technology infrastructure, which led to the inoperability of the app at two sites, and technical inefficiencies related to users' unfamiliarity with new devices and inconsistent internet access.
Although a strong commitment to change and a confidence to effect change existed, these alone were insufficient to surmount barriers to implementation effectiveness. Clinical Trials Registration: NCT03241589.
Although research on quality of life and dermatologic conditions is well represented in the literature, information on teledermatology's effect on quality of life is virtually absent.
To determine ...the effect of store and forward teledermatology on quality of life.
Two-site, parallel-group, superiority randomized controlled trial.
Dermatology clinics and affiliated sites of primary care at 2 US Department of Veterans Affairs medical facilities.
Patients being referred to a dermatology clinic were randomly assigned, stratified by site, to teledermatology or the conventional consultation process. Among the 392 patients who met the inclusion criteria and were randomized, 326 completed the allocated intervention and were included in the analysis.
Store and forward teledermatology (digital images and a standardized history) or conventional text-based consultation processes were used to manage the dermatology consultations. Patients were followed up for 9 months.
The primary end point was change in Skindex-16 scores, a skin-specific quality-of-life instrument, between baseline and 9 months. A secondary end point was change in Skindex-16 scores between baseline and 3 months.
Patients in both randomization groups demonstrated a clinically significant improvement in Skindex-16 scores between baseline and 9 months with no significant difference by randomization group (P = .66, composite score). No significant difference in Skindex-16 scores by randomization group between baseline and 3 months was found (P = .39, composite score).
Compared with the conventional consultation process, store and forward teledermatology did not result in a statistically significant difference in skin-related quality of life at 3 or 9 months after referral.
clinicaltrials.gov Identifier: NCT00488293.
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