BAD
Working Party Report 1999
Report of
the British Association of Dermatologists' (BAD) Working Party on
Teledermatology
The Working
Party comprising Professor C E M Griffiths (Chairman, Manchester),
Dr K L Dalziel
(Nottingham), Dr D J Eedy (Belfast), Dr E Gilmour (Birmingham),
Dr D Harris
(London), Dr P Harrison (Lancaster), Dr A McDonagh (Sheffield),
Dr R Pye (Cambridge) and Dr J P Vestey (Inverness) met at BAD House,
London, on Thursday 15th April 1999.
Valuable advice
was provided by Professor R Wootton (Professor of Telemedicine and
Telecare, Queen’s University, Belfast.
The remit
of the Working Party was to provide a consensus statement for the
BAD on the way forward for implementing teledermatology in the U.K.
The teledermatology
experience of members of the Working Party varied from none to "hands
on" involvement in teledermatology studies, either as real
time video conferencing and/or store and forward digital images.
The Working Party members represented a variety of dermatology practices,
ranging from densely populated urban areas to sparsely populated
rural areas, i.e. the Highlands and Islands. The need for a consensus
statement is borne out of a widespread and probably justified perception
that teledermatology appears, specifically at least, to be a ‘good
idea’. This as yet unproven and non-evidence based assumption
may led to management pressure for introducing teledermatology without
due process. It was agreed that there are a number of key issues
to be addressed prior to wholesale introduction of teledermatology
in the clinical dermatology services U.K.
1. Will
teledermatology be in use as an N.H.S. service in five years'
time?
There is little
doubt that teledermatology will be in use in the N.H.S. in five
years' time1 and will probably have taken on a different
format from that currently promulgated. Indeed research to-date
indicates that patients are accepting of teledermatology.2-4
It is possible that there are other applications for teledermatology
that are neither currently under consideration nor discussed in
this statement.
2. What
are the advantages of teledermatology?
It is likely
that digital images in a "store and forward" format
are accurate enough to diagnose dermatological conditions.5
This has been shown in controlled studies in which the management
plan of cases assessed by face-to-face traditional consultation
has a high concordance with management plans derived through teleconsultation.6
Teledermatology provides an opportunity to improve provision of
dermatological care for patients living at some distance from
service providers, particularly in remote communities, such as
the Highlands and Islands of Scotland. In addition, the provision
of teledermatology services would allow prioritisation of waiting
list cases and indeed waiting lists could perhaps be significantly
shortened by assessment of suitable cases by teledermatology,
thereby obviating the need for a patient to travel to hospital.
Teledermatology is a faster process than conventional referral
and as a consequence it increases educational feedback so that
GP’s learn some dermatology. Triage of patients could be
achieved with teledermatology, particularly store and forward
still images, so that individual cases can be appropriately prioritised
or alternatively referred more appropriately, i.e. to surgeons
if the lesion was deemed too large for excision by a dermatologist.
Patient acceptance of teledermatology, in the few studies that
have been performed, is high with most patients liking this means
of consultation.
Store and
forward provision could be implemented either by sending images,
via ISDN lines, to the service provider or by the service provider
sending technicians/specialist nurses to individual G.P. practices
to interview referred patients and take images. This model would
certainly provide continuity and involvement with the service
provider and ensure that important necessary images were taken,
rather than just of a single site. For instance if a basal cell
carcinoma on the forehead is imaged there would also be a need
to image other suspicious lesions on an above waist examination.
It cannot be overemphasised that teledermatology services should
ideally be an integrated part and just one facet of dermatology
services for which the local department has overall responsibility.
Real-time
video conferencing has been shown to be more time-consuming than
still images for patient diagnosis.3 However this technology
does offer some advantages for diagnosis, case conferencing and
education.
3. What
are the disadvantages of teledermatology?
The main disadvantages
of teledermatology are
(i) the uncertainty
of diagnosis, as compared with the "gold standard" of
a traditional face-to-face consultation. However, a caveat is
that there are very few studies comparing the concordance of diagnosis
of traditional face-to-face consultation!
(ii) the image
assessed is of a single area of skin and thus the diagnosis is
only applicable to the area of skin seen. In teledermatology there
appears to be a tendency towards uncertainty of diagnosis and
thus to "overdiagnose" as a defence mechanism against
"missing" skin cancers etc.
(iii) Potential
loss of "hands on" clinical services ie teleconsultations
performed at the expense of traditional clinic time.
(iv) There
are potential medicolegal problems7, although both
the Medical Protection Society and the Medical Defence Union indicate
that the same medicolegal standards would apply to teleconsultations
as they are used for traditional medical consultations. Medicolegal
cases must be assessed on a case-by-case basis.
(v) Security
and maintenance of patient confidentiality is a major concern,
although this may be circumvented by encryption, coding and use
of the N.H.S. net.
(vi) Furthermore,
there are potential disadvantages unique to use of images i.e.
the potential for loss of images or assessment of an image misappropriated
to another patient.
4. Is the preferred medium for teledermatology real-time video
conferencing or store and forward still images?
Research,
to date, indicates that store and forward digital still images
will probably be the preferred technology for teledermatology1
and it is unlikely that this will change over the next five years.
The major foreseeable role for real-time video conferencing would
be for case conferences and education.
5. Who
should take the images?
The images
could be taken by either an appropriately trained G.P., a technician
or possibly a dermatology specialist nurse. The only private,
commercial teledermatology service currently operating in the
U.K. trains nurses to visit G.P. practices, take up to four images
and fill in a questionnaire. However, this private system does
not provide a complete package of care in that the patient is
still managed/investigated/treated by the local hospital after
the diagnosis has been made by the teledermatologist. Potential
advantages of a dermatologically trained nurse taking the images
rather than a GP are they are better at working to protocols and
may be more aware of the importance to image other areas of the
skin. They may also be the more appropriate people to inform patients
of the diagnosis and management plan produced by the teleconsultant
at the base hospital.
6. What
evidence exists for the capability of teledermatology, economics
etc.?
There is no
place for enforced introduction of teledermatology. It should
be introduced in those centres who are both willing to embrace
the system and to integrate service provision with research in
this area. There is tremendous potential for abuse of teledermatology
as N.HS. management and government view this as a "quick
fix" to long waiting lists1. If teledermatology is to be
introduced in this way it must be shown to be much quicker for
dermatologists than conventional practice.
7. What
further research needs to be done?
The committee
agreed that well-funded research needs to be undertaken in the
following areas:-
Further work
on:
(i) acceptance
of teledermatology by dermatologist, GP and patient.
(ii) impact
of teledermatology on demand, i.e. on quality and quantity of referrals
and on length of waiting lists
(iii) assessment
of cost/benefit for patient, G.P. and service provider8
Ideally the
BAD should have as one of its highest priorities the remit to initiate
and co-ordinate clinically relevant research in teledermatology.
References
1.
Wootton R. Telemedicine in the National Health Service. J R Soc
Med 1998; 91: 614-21.
2. Loane MA, Bloomer SE, Corbett R et al. Patient satisfaction
with realtime teledermatology in Northern Ireland. J Telemed Telecare
1998; 4: 36-40.
3. Gilmour E, Campbell SM. Loane MA, Esmail A, Griffiths
CEM, Roland MO, Parry E, Corbett R, Eedy D, Gore HE, Mathews C,
Steele K, Wootton R. Comparison of teleconsultations and face-to-face
consultations: Preliminary results of the UK multicentre Teledermatology
Study. Br J Dermatol 1998; 139: 81-87.
4. Lowitt MH, Kessler II, Kauffman CL, Hooper FJ, Siegel
E, Burnett JW. Teledermatology and in-person examinations: A comparison
of patient and physician perceptions and diagnostic agreement.
Arch Dermatol 1998; 134/4: 471-476.
5. Zelickson BD, Homan L. Teledermatology in the nursing
home. Arch Dermatol 1997; 133/2: 171-174.
6. Lewis K, Gilmour E, Harrison PV, Patefield S, Dickinson
Y, Manning D and Griffiths CEM. Digital teledermatology for skin
tumours: a preliminary assessment using a Receiver Operating Characteristic
(ROC) analysis. J Telemedicine & Telecare. 1998; 4: 111-114.
7. Brahams D. The medicolegal implications of teleconsulting
in the UK. J Telemed Telecare. 1995; 1: 196-201.
8. Lobley D. The economics of telemedicine. J Telemed Telecare
1997; 3: 117-25.
C E M Griffiths
(Chairman)
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