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:

• No funds
• Local IT investment funds
  • Trust modernisation
  • Strategic Health Authorities
  • PCTs/PCGs
• Action on Dermatology funds
• Research funds
• Charitable funds

Consultant time

"Spare time" has been overemphasised in initial stages of gauging the potential of this service. 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 response

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

5. Saving and archiving your reply

6. Possibly forwarding reply to your secretary for printing out and filing in hospital notes where relevant. Then there is secretarial and clerical time.

7. The doctor process can take between 4 and 25 minutes; most time when stage 4 is done with care.

A further element in the time spent entails dealing with technical aspects of maintaining the equipment which sometimes fails or needs adjustment. Eg new software, re-organising files, retrieving lost materials, coordinating back-up.

When do you do it?

• When there is a flow of cases on a regular basis, specified time needs to be set aside
• This is clinical activity

Who does it?

• Currently consultant dermatologists are the main end point of teledermatology.
• SpRs should be encouraged to be involved for educational benefit - both from experience of seeing the material and the process.

Nurse role

In some settings nurses play a role, such as:

• Going to specified GP practices to obtain images and fill 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

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.