Setting up a Teledermatology Service

If you have got to the stage of planning a teledermatology service, the following points are important to consider:

Obtaining funding

Examples include:

• Local IT investment funds
  • Trust modernisation programmes
  • Strategic Health Authorities
  • Primary Care Trusts
  • Practice Based Commissioning Groups
  • Action on Dermatology funds
• Research funds
• Charitable funds

Consultant time

Time for teledermatology clinical activity should be built into the job plan of the Consultant Dermatologist from an early stage. Secretarial and clerical support time also needs to be considered. Individual store and forward cases have several components:

1. downloading and saving the attachments/text in dedicated archive

2. viewing the images (usually 1-4 images)

3. writing the response

4. attaching or linking supplementary information for the GP eg from other relevant websites or online guidelines

5. Saving and archiving your reply

6. Possibly forwarding the reply to your secretary for printing out and filing in hospital notes where relevant. 

Each teledermatology referral can take between 5 and 25 minutes to reply to, depending on the system used. A further element to consider is time spent dealing with technical aspects e.g. maintaining the equipment which sometimes fails or needs adjustment, replacing software, re-organising files, retrieving lost materials and coordinating back-up.

Who should carry out the teledermatology?

Currently consultant dermatologists are the main end point of teledermatology.

SpRs should be encouraged to be involved for educational benefit. In some areas in the UK teledermatology has been used to supplement the on-call service provided by SpRs and Consultants.

Nurse role

In some settings nurses play a role, such as:

• going to specified GP practices to obtain images and fill in a proforma in order to achieve a standardised input
• working in an intermediate care setting to obtain images/information and to deliver preliminary care
• acting as recipients of teledermatology feedback in order to interpret it to the patient and GP
• community dermatology nurses requesting input from dermatology department staff

User training: both ends

This has been largely ignored, with the process of learning being left to the people delivering and receiving the service

There are examples where nurses have been given additional training to equip them to deal with the roles described above

There are some examples of GPs being given tuition on taking images

Audit has a role in user training

Skills for participants include:

GP/nurse

1. selecting cases amenable to teledermatology

2. taking adequate images of relevant sites

3. collecting relevant clinical details

4. attaching/saving/archiving/sending materials and keyboard skills

5. interpreting feedback

Dermatologist

1. interpreting images

2. attaching/saving/archiving/sending materials and keyboard skills

3. constructing useful action plans for GP

 

Effects on total work load: GP, nurse and dermatologist

GP

If the GP is taking the images, there is a period of consent, photography, image handling and archiving that can take 5-10 minutes per patient in addition to the consultation.

Acting upon feedback can take a further period

 

Nurse

One service allocates 20 minutes for each nurse consultation for the photography and documentation.

If a nurse is acting at several locations, there is travel time between these sites.

Where a nurse acts as the recipient and interpreter of teledermatology feedback, additional consultation time is needed

Dermatologist

When collected into "clinics", time per patient is reduced, but individual cases can take up to 25 minutes when accompanied by thorough GP education and background materials.

A percentage of patients will end up coming to hospital and this will depend on local factors and patient selection. When used as a triage process, 100% of patients might be expected to come. In other settings, 13-60% have proceeded to secondary care.

Guidelines on use

Have you put together some guidelines for users of the service?

Many services have evolved on a casual basis as an extension of e-mail without formal guidelines. However, some core guidance is advisable to address legal, technical and data issues. Additional guidelines would be recommended for services designed to take a significant clinical burden.

Uses

Exclusion clauses

Malignancy is a controversial aspect of teledermatology. In some services it is excluded for fear of false negatives. In others, it is included and may be used as a means of triaging patients rather than delivering advice on management.

Some services exclude:

• Genital images
• Images of children (often difficult to photograph) 

Not amenable to teledermatology

It becomes apparent quite quickly that certain things do not lend themselves to teledermatology. Whilst it may seem unnecessary to formally exclude these, it is sometimes difficult to gain useful images in:

• Lesions within hair-bearing skin
• Eruptions on dark skins
• Dermatological problems where symptoms are the problem, rather than visual signs

In this last category, it should be remembered that teledermatology does not by definition require an image and it can still be helpful making e-mail enquiries concerning patient symptoms.