Evaluation

Audit and quality control

So far there have been poor systems established for the training in, and quality control of, teledermatology. Individual audits of new services would be expected as part of any service, but it is difficult to measure the central question hanging over the process without it being in the guise of continued research. Namely, does the dermatologist get the diagnosis and management right as often when delivering teledermatology as when seeing the patients face to face. In most instances, correct management is of greatest priority and the reduction in diagnostic certainty associated with teledermatology often results in a broader, more comprehensive plan to cover differential diagnoses.

eg. suggest curettage of an actinic keratosis rather than cryosurgery in order that the diagnosis can be corroborated and that in situ or invasive SCC is not missed.

Accuracy of diagnosis and management plan is a function of all the components in the teledermatology process:

• the skills of the dermatologist in their face to face and remote capacity
• the history taking and examination skills of the GP
• the photography skills of the GP
• the technical adequacy of the equipment
• the effective transmission, reading and collating of the information at both ends of the service
• effective communication of the consultation with the patient

All these elements and others are open to both research and audit.

Within any dermatology department, it is probably best if the teledermatology is shared. This helps cover for absences and also facilitates open discussion of the process and individual cases.

Sensitivity and specificity

This is difficult to assess with normal audit and would be the subject of research. There is a substantial body of data on different aspects of this issue.

Analysis of cost/quality of life benefits and drawbacks

In a recent study on the efficiency of resource allocation in teledermatology it took one consultant session and 2 sessions of specialist dermatology nurses to see 18 patients. 60% of these were then required to attend the hospital. This compares poorly with normal clinic allocation of resources. It applies to the model of teledermatology as "substitute for consultation" rather than as "supplement to telephone".

A benefit deriving from teledermatology is its use as a teaching tool. It can be used for medical students, GPs and SpRs, providing a form of access to genuine dermatological material and given that patient confidentiality is not compromised. Some centres have developed GP CPD based on this model. Established teledermatology cases can be used as part of training for those taking up the service.