- Email: [email protected]
Teledermatology: How to Start a New Teaching and Diagnostic Era in Medicine
Dermatol Clin 26 (2008) 295–300
Teledermatology: How to Start a New Teaching and Diagnostic Era in Medicine Elisabeth M.T. Wurm, MD, Terri M. Campbell, BBmedSc (Hons), H. Peter Soyer, MD, FACD* Dermatology Group, School of Medicine, Southern Clinical Division, The University of Queensland, Princess Alexandra Hospital, Brisbane, QLD 4102, Australia
Telemedicine or e-health is not as recent a development as it may appear. In fact, telecommunication methods have been used for a long time in medicine, at least dating back to the invention of telephone and radio [1–4]. The rapid technical advances of the last decade, such as the emergence of the World Wide Web, digital imaging, and mobile telecommunication, have led to increased interest in this field. ‘‘Telemedicine’’ is defined as the use of telecommunication technologies for the exchange of medical information across distances. Applications include patient management as well as research and education. Telemedicine provides easy access to expert knowledge for everyone. From the very beginning the central aims of telemedicine have been to provide health care to underserved areas and to individuals to whom no medical service is available for various reasons. Thus, the first telemedicine projects were established on space shuttles, ships, and remote islands [5,6]. Telemedicine, however, also can help to save costs for the health care system and save time and inconvenience for patients in urban centers [6]. Teledermatology is a steadily growing category of telemedicine. General aspects of telemedicine such as modes of data transmission, and practical
H. Peter Soyer is co-founder of e-derm-consult GmbH, a spin-off company of the Medical University of Graz, Graz, Austria, with emphasis on holistic solutions in teledermatology. * Corresponding author. E-mail address: [email protected] (H.P. Soyer).
applications are presented in the following sections, with a special emphasis on their significance for teledermatology. Modes of data transmission Real-time and store-and-forward telemedicine The modes of data transmission in telemedicine include store-and-forward (SAF) and real-time systems and combinations of both [6]. Real-time telemedicine usually is performed as a patient interview via a videoconference. Applications also encompass robotic microscopy and even robotic surgery over distances. Videoconferences are a good substitute for face-to-face evaluation because they allow direct interaction in which participants can ask and answer questions directly. They are, however, time consuming with the prerequisite that all participants be available at the same, predetermined time. In addition, the costs of the technical equipment for real-time systems usually are higher than for SAF systems. In SAF systems, prerecorded medical information and still images are sent to remote experts who can retrieve them time independently. As such, this method is not reliant on participant availability. Furthermore, it is cost effective and easy to perform via e-mail or Web applications especially designed for this purpose, and both methods of data transmission have been found to be accurate and effective [7]. These modes also can be combined, for example in a discussion via e-mail of a previously performed videoconference. In teledermatology, the most commonly used method is the SAF mode
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et al
for transmission of images of skin conditions in combination with patient data.
clinical teledermatology, fields with special interest are teledermoscopy and teledermatopathology.
Stationary and mobile telemedicine
Teledermoscopy
‘‘Mobile telemedicine’’ refers to telemedicine applications in which the participants are remotely located with respect to each other and are mobile [1,8–10]. Rather than stationary equipment, small portable telecommunication devices are used for health care delivery. In recent years, the applicability of mobile telecommunication devices such as cellular telephones and personal digital assistants for telemedicine has been examined [9–12]. The increasing quality and power of these and other mobile devices are initiating an era of mobile telemedicine. Mobile telemedicine has practical potential as a screening and triage tool as well as for aftercare of patients. Other benefits are patient management during transport and supply of health care for individuals who are traveling as well as those in disaster areas.
Dermoscopy, dermatoscopy, or epiluminiscence microscopy is a method through which melanomas can be detected in earlier stages and with more diagnostic accuracy than on clinical grounds. In teledermoscopy, digital dermoscopic images combined with macroscopic images of skin lesions and medical data are used for consultation of experts and for educational means. Digital dermoscopic images can be acquired in different ways. A low-cost solution is simply to place a conventional digital camera or even a mobile telephone-camera over a conventional handheld dermatoscope, thus acquiring the images through the lens of the dermatoscope. The best image quality can be acquired with suitable dermoscopic lenses that can be directly attached to a digital camera. An all-in-one but relatively expensive solution is to obtain dermoscopic images via a video camera connected to a computer [11]. Dermoscopy is especially suited for digital imaging, because diagnosis in direct, physical examination is likewise restricted to observation of a two-dimensional image. A disadvantage of teledermoscopy is that the remote expert can analyze only the lesions preselected by someone else. This preselection can cause difficulties in identifying the ‘‘ugly duckling’’ sign, that is, detecting lesions that do not resemble the other nevi in one individual (and could be melanomas) [9]. The first feasibility study concerning teledermoscopy, published by Piccolo and colleagues [4] in 1999, revealed an agreement of 91% between direct dermoscopic diagnoses and telediagnoses. In 2000, Piccolo and colleagues [3] conducted a multicenter study in which telediagnoses in melanocytic lesions by 11 physicians with different degrees of experience in dermoscopy and face-toface diagnosis were compared with histopathologic diagnosis (the reference standard). The diagnostic concordance was 77% to 95%. Remarkably, the diagnostic accuracy of the three most experienced dermoscopists was superior to the accuracy of dermatologists who performed the face-to-face diagnosis (85%). This report underlines the importance of continuous education in this field. A recent development is the availability of online courses, computer-based training, and Web applications for the exchange of expert knowledge in dermoscopy.
Teledermatology Because image transfer is an integral part of telemedicine, dermatology as a visual field of expertise is ideally suited for practical application, especially in SAF systems. The term ‘‘teledermatology’’ was introduced in 1995 by Perednia and Brown [13] who described a teledermatology project in a vast rural area in Oregon (USA) where dermatologic care was supplied by only two local dermatologists. Since then numerous publications have dealt with diagnostic agreement between telediagnoses and face-to-face diagnoses in skin conditions. This agreement was found to be between 54% and 95% (mean, 75%) [7,14–21]. In most teledermatologic studies, the face-to-face diagnosis represented the pragmatic reference standard. The use of face-to-face diagnosis as the reference standard is a limitation to all these studies and probably hides the true potential of telemedicine, because it is based on the unrealistic assumption that face-to-face diagnosis is always correct. Morphology-based diagnosis can be very subjective, especially when it comes to the boundaries of diseases in one category. Generally, terminology problems create an intrinsic difficulty in making dermatologic diagnosis. Still, these studies illustrate that a high number of skin conditions can be diagnosed remotely. In addition to classical
A NEW TEACHING AND DIAGNOSTIC ERA
Teledermatopathology Histopathologic images can be transmitted in real-time via a robotic microscope or as still images. The latter method has been improved recently through the introduction of virtual slide systems in which pathologic images are scanned and digitized, allowing the user to view a specimen at different levels of magnification. The feasibility of both methods of teledermatopathology has been proven mainly on nonmelanoma skin cancer and on melanocytic lesions. with less focus on inflammatory skin disease [15,18–24]. These methods remain diagnostically inferior to common microscopy in detecting the subtle pathologic information of inflammatory skin disease and the delicate cytologic features in dysplastic nevi [25–34]. Applications of telemedicine and teledermatology Telemedicine in underserved areas As mentioned earlier, the first and most obvious benefit of telemedicine is to compensate for infrastructural deficits in rural and disaster areas [5,22]. Several telemedicine pilot projects have been performed in Africa, on remote islands, and in outer space. In urban areas, home monitoring, patient management and e-learning are important applications of telemedicine. Home care With remote home care devices enabling transmission of blood sugar rates, blood pressure, and ECGs, individuals who have chronic diseases such as diabetes and cardiac conditions can be monitored. In addition, elderly people and individuals who have special needs can be provided with special alarm systems (eg, in connection with a video telephone). In regard to dermatology, wound care monitoring of patients who have leg ulcers using telemedicine by home care nurses and wound experts represents an exciting approach [35]. It seems possible to use telemedicine to reduce health care costs by reducing the required travel to a wound care center or specialist physician and to improve the quality of life for patients who have leg ulcers [36]. Patient management Two possible types of interaction exist for teledermatologic patient management. The first is a consultation between two health care providers [23] (eg, a general practitioner
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seeking advice from a specialist or the discussion of an equivocal case between two or more experts worldwide). Several Web sites especially designed for this purpose have been launched during the last several years. A recently published study by Lozzi and coworkers [37] focuses on the value of obtaining a second opinion via teledermatology in the diagnosis of challenging skin conditions. Images of these skin conditions were sent from dermatologists in a small institution to a remote expert in a large academic department via a pre-existing Web application (www.telederm.org) using the SAF method. The consulted teledermatologist had the opportunity to request additional information about the patients and to forward cases to another expert chosen because of his/her special area of expertise. The face-to-face diagnosis and telediagnoses then were compared with histopathologic diagnosis as the reference standard. Results of this study demonstrated that teledermatology-aided diagnosis in equivocal skin conditions can increase diagnostic accuracy by as much as to 30%. The model system presented in this study demonstrates a unique advantage of teledermatology; in the future, obtaining a second opinion via teledermatology might become a standard procedure to overcome the geographic inequality in health care caused by the continuing formation of specialized centers. In the second type of interaction, an individual affected with a disease consults an expert directly via a telecommunication network. This approach to telemedicine is complex because it focuses on the direct contact between patient and physician and thus deeply affects present structures in medicine. For primary diagnosis, a visit to the physician might be indispensable, but aftercare of patients could be managed remotely. Mobile applications might be considered especially useful tools for these purposes. Mobile teledermatology holds great potential as a triage system for individuals who have skin lesions, in particular for people who are traveling or who live in underserved areas. Furthermore, mobile teledermatology also has great value for the empowerment of individuals in the industrialized world in accordance with the new formulated concept of ‘‘person-centered health system’’ [24,38]. The eHealth program of the European Commission Information Society and Media focuses on the prevention and management of diseases through research on ‘‘Personal Health Systems.’’ The hallmark of this concept is to ‘‘empower citizens to
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adopt an active role in managing their own health status and, in addition, facilitating early diagnosis of diseases’’ [38]. In this context, mobile teledermatology has the potential to become an easy applicable tool for enhanced self-examination. An individual affected with a skin disease can capture an image of a given lesion with a mobile device and send it to a specialized telemedicine center for triage [39]. E-learning Electronic learning, better known as ‘‘e-learning,’’ avoids limitations of time and location imposed by attending lectures and training programs in person [1]. Again, it can be perfumed in real-time video presentations or with asynchronous systems. E-learning already plays an important role in education of medical students and in the continuing education of physicians and health care workers. Numerous universities such as the Medical University of Graz (Austria), with its Virtual Medical Campus, or the University of Zurich (Switzerland), with Cyberderm-doit, offer students online access to most of their learning material. Online databases and atlases facilitate continuing learning and revision of knowledge. A recent development includes high-level Internet training courses for physicians, such as the International Dermoscopy Diploma, an online dermoscopy course offered by the University Clinic for Dermatology in Graz. E-learning programs go far beyond merely displaying the contents of a textbook on a computer monitor. They provide connections of text with pictures, simulations, and video and audio files. Revisions can be programmed individually, which can accelerate the learning process considerably. Furthermore, learners can interact with their teachers during the learning process. This interaction supplies all participants with fast feedback; the student can control his or her progress, and teachers can adapt their programs in response to frequently asked questions. E-learning, however, is a skill that itself must be learned. For individuals who have been used to textbooks all their lives, it requires flexibility and willingness to adjust to a different system. Elearning never can be a substitute for face-to-face education. It can be seen as a supplement to established learning methods. Even the best learning method is virtually worthless if the content is not presented in a profound, cohesive, and interesting manner. Therefore, a team of medical
et al
and computer experts must spend considerable time and effort to design a good e-learning program [40]. Exchange of expert knowledge Telemedicine also enables the international exchange of expert opinions. Medical professionals can communicate with colleagues all over the world. Online forums designed for teleconsultation (such as www.telederm.org) also offer discussion views where equivocal and interesting cases can be presented [41]. Both diagnostic and treatment issues can be discussed. This exchange has a tremendous educational benefit for all participants, thus enhancing quality assurance in medicine. Through these Web applications an international network of medical experts is in formation. A vivid example is the Consensus Net Meeting of Dermoscopy, a virtual meeting of experts in dermatology from all over the world [42].
Summary The previous sections have emphasized the numerous advantages of telemedicine, but there are some hindrances to the practical implementation of a health care telecommunication network. The practical applicability is improving steadily through technical advances, but there still are restraints arising from unsolved questions of data security, legal issues, reimbursement, and acceptance by patients and physicians. Legal issues with regard to responsibility and liability are complicated because teleconsultations often are performed between participants in two or more countries, each with distinct legal systems [2]. When teleconsultation is used to obtain a second opinion, the physician who has direct contact with the patient always has responsibility. Confidence about the security of personal information is crucial for the practical implementation of a telemedicine network. Opponents of telemedicine point out that it alters the physician–patient relationship, leading to a ‘‘mechanization’’ and a loss of personal contact. These issues must be taken seriously and addressed, but they should not be exaggerated. As outlined previously, a large number of teledermatology consultations occur among physicians themselves and have no direct bearing on the physician–patient relationship. With telemedicine, the doctor–patient relationship is undergoing change, reducing personal contact on the one
A NEW TEACHING AND DIAGNOSTIC ERA
hand but improving access to expert knowledge on the other. These concerns are not relevant for teleeducation, which is probably why it is, so far, the most successful subcategory of telemedicine. Though the implementation of patient management systems is still in development, the era of electronic learning has already begun. Telemedicine holds great potential for revolutionizing the delivery of health care and medical education, if applied with consideration. With its help, in the future medical knowledge could be easily accessible for everyone, independent of geographic and social background. References [1] Wurm EM, Hofmann-Wellenhof R, Wurm R, et al. Telemedicine and teledermatology: past, present and future. J Dtsch Dermatol Ges; [e-pub ahead of print]. [2] Stanberry B. Telemedicine: barriers and opportunities in the 21st century. J Intern Med 2000;247: 615–28. [3] Piccolo D, Smolle J, Argenziano G, et al. Teledermoscopydresults of a multicentre study on 43 pigmented skin lesions. J Telemed Telecare 2000;6: 132–7. [4] Piccolo D, Smolle J, Wolf IH, et al. Face-to-face diagnosis vs telediagnosis of pigmented skin tumors: a teledermoscopic study. Arch Dermatol 1999;135: 1467–71. [5] Norton SA, Burdick AE, Phillips CM, et al. Teledermatology and underserved populations. Arch Dermatol 1997;133:197–200. [6] Eedy DJ, Wootton R. Teledermatology: a review. Br J Dermatol 2001;144:696–707. [7] Oztas MO, Calikoglu E, Baz K, et al. Reliability of Web-based teledermatology consultations. J Telemed Telecare 2004;10:25–8. [8] Wurm E, Hofmann-Wellenhof R, Scholnast R, et al. Mobile teledermatology in a clinical setting. J Dtsch Dermatol Ges 2006;4:1006–7. [9] Massone C, Lozzi GP, Wurm E, et al. Personal digital assistants in teledermatology [see comment]. Br J Dermatol 2006;154:801–2. [10] Massone C, Lozzi GP, Wurm E, et al. Cellular phones in clinical teledermatology. Arch Dermatol 2005;141:1319–20. [11] Braun RP, Vecchietti JL, Thomas L, et al. Telemedical wound care using a new generation of mobile telephones: a feasibility study. Arch Dermatol 2005;141:254–8. [12] Hsieh CH, Tsai HH, Yin JW, et al. Teleconsultation with the mobile camera-phone in digital soft-tissue injury: a feasibility study. Plast Reconstr Surg 2004;114:1776–82.
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[13] Perednia DA, Brown NA. Teledermatology: one application of telemedicine. Bull Med Libr Assoc 1995;83:42–7. [14] Schiener R, Bredlich RO, Pillekamp H, et al. [Evaluation of a telemedicine pilot project]. Hautarzt 2001;52:26–30 [in German]. [15] Chao LW, Cestari TF, Bakos L, et al. Evaluation of an Internet-based teledermatology system. J Telemed Telecare 2003;9(Suppl 1):S9–12. [16] Du Moulin MF, Bullens-Goessens YI, Henquet CJ, et al. The reliability of diagnosis using store-andforward teledermatology. J Telemed Telecare 2003; 9:249–52. [17] High WA, Houston MS, Calobrisi SD, et al. Assessment of the accuracy of low-cost store-and-forward teledermatology consultation. J Am Acad Dermatol 2000;42:776–83. [18] Lim AC, Egerton IB, See A, et al. Accuracy and reliability of store-and-forward teledermatology: preliminary results from the St George Teledermatology Project. Australas J Dermatol 2001;42: 247–51. [19] Nordal EJ, Moseng D, Kvammen B, et al. A comparative study of teleconsultations versus face-to-face consultations. J Telemed Telecare 2001;7:257–65. [20] Taylor P. An assessment of the potential effect of a teledermatology system. J Telemed Telecare 2000;6(Suppl 1):S74–6. [21] Tucker WF, Lewis FM. Digital imaging: a diagnostic screening tool? Int J Dermatol 2005;44:479–81. [22] Duker I, Elsner P. [Dermatology in telemedicine. Possibilities and limits]. Hautarzt 2002;53:11–7 [in German]. [23] Loane M, Wootton R. A review of guidelines and standards for telemedicine. J Telemed Telecare 2002;8:63–71. [24] Shapiro M, James WD, Kessler R, et al. Comparison of skin biopsy triage decisions in 49 patients with pigmented lesions and skin neoplasms: store-andforward teledermatology vs face-to-face dermatology. Arch Dermatol 2004;140:525–8. [25] Morgan MB, Tannenbaum M, Smoller BR. Telepathology in the diagnosis of routine dermatopathologic entities. Arch Dermatol 2003;139:637–40. [26] Pak HS. Teledermatology and teledermatopathology. Semin Cutan Med Surg 2002;21:179–89. [27] Black-Schaffer S, Flotte TJ. Teledermatopathology. Adv Dermatol 2001;17:325–38. [28] Weinstein LJ, Epstein JI, Edlow D, et al. Static image analysis of skin specimens: the application of telepathology to frozen section evaluation. Hum Pathol 1997;28:30–5. [29] Dawson PJ, Johnson JG, Edgemon LJ, et al. Outpatient frozen sections by telepathology in a Veterans Administration medical center. Hum Pathol 2000; 31:786–8. [30] Piccolo D, Soyer HP, Burgdorf W, et al. Concordance between telepathologic diagnosis and conventional histopathologic diagnosis: a multiobserver
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[31]
[32]
[33]
[34]
[35]
[36]
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store-and-forward study on 20 skin specimens [see comment]. Arch Dermatol 2002;138:53–8. Okada DH, Binder SW, Felten CL, et al. ‘‘Virtual microscopy’’ and the Internet as telepathology consultation tools: diagnostic accuracy in evaluating melanocytic skin lesions. Am J Dermatopathol 1999;21:525–31. Berman B, Elgart GW, Burdick AE. Dermatopathology via a still-image telemedicine system: diagnostic concordance with direct microscopy. Telemed J 1997;3:27–32. Ferrara G, Argenziano G, Cerroni L, et al. A pilot study of a combined dermoscopic-pathological approach to the telediagnosis of melanocytic skin neoplasms. J Telemed Telecare 2004;10:34–8. Della Mea V, Puglisi F, Forti S, et al. Expert pathology consultation through the Internet: melanoma versus benign melanocytic tumours. J Telemed Telecare 1997;3(Suppl 1):17–9. Hofmann-Wellenhof R, Salmhofer W, Binder B, et al. Feasibility and acceptance of telemedicine for wound care in patients with chronic leg ulcers. J Telemed Telecare 2006;12(Suppl 1):15–7. Binder B, Hofmann-Wellenhof R, Salmhofer W, et al. Teledermatological monitoring of leg ulcers in cooperation with home care nurses. Arch Dermatol 2007;143:1511–4.
et al [37] Lozzi GP, Soyer HP, Massone C, et al. The additive value of second opinion teleconsulting in the management of patients with challenging inflammatory, neoplastic skin diseases: a best practice model in dermatology? J Eur Acad Dermatol Venereol 2007;21: 30–4. [38] ICT for health and i2010: transforming the European healthcare landscape: towards a strategy for ICT for health. Luxembourg European Commission. Information Society DG; 2006. Available at: http:// europa.eu.int/information_society/activites/health/ docs/publications/ictforhealth-and-i2010-final.pdf. Accessed February 28, 2007. [39] Massone C, Hofmann-Wellenhof R, AhlgrimmSiess V, et al. Melanoma screening with cellular phones. PLoS ONE 2007;2:1–4. [40] Burg G, Soyer HP, Chimenti S. Teledermatology. In: Fritsch P, Burgdorf W, editors. EDF white book: skin diseases in Europe. Berlin: ABW-Wissenschaftsverlag; 2005. p. 130–3. [41] Soyer HP, Hofmann-Wellenhof R, Massone C, et al. telederm.org: freely available online consultations in dermatology. PLoS Med 2005;2:293–5. [42] Argenziano G, Soyer HP, Chimenti S, et al. Dermoscopy of pigmented skin lesions: results of a consensus meeting via the Internet. J Am Acad Dermatol 2003;48:679–93.
Teledermatology: How to Start a New Teaching and Diagnostic Era in Medicine Elisabeth M.T. Wurm, MD, Terri M. Campbell, BBmedSc (Hons), H. Peter Soyer, MD, FACD* Dermatology Group, School of Medicine, Southern Clinical Division, The University of Queensland, Princess Alexandra Hospital, Brisbane, QLD 4102, Australia
Telemedicine or e-health is not as recent a development as it may appear. In fact, telecommunication methods have been used for a long time in medicine, at least dating back to the invention of telephone and radio [1–4]. The rapid technical advances of the last decade, such as the emergence of the World Wide Web, digital imaging, and mobile telecommunication, have led to increased interest in this field. ‘‘Telemedicine’’ is defined as the use of telecommunication technologies for the exchange of medical information across distances. Applications include patient management as well as research and education. Telemedicine provides easy access to expert knowledge for everyone. From the very beginning the central aims of telemedicine have been to provide health care to underserved areas and to individuals to whom no medical service is available for various reasons. Thus, the first telemedicine projects were established on space shuttles, ships, and remote islands [5,6]. Telemedicine, however, also can help to save costs for the health care system and save time and inconvenience for patients in urban centers [6]. Teledermatology is a steadily growing category of telemedicine. General aspects of telemedicine such as modes of data transmission, and practical
H. Peter Soyer is co-founder of e-derm-consult GmbH, a spin-off company of the Medical University of Graz, Graz, Austria, with emphasis on holistic solutions in teledermatology. * Corresponding author. E-mail address: [email protected] (H.P. Soyer).
applications are presented in the following sections, with a special emphasis on their significance for teledermatology. Modes of data transmission Real-time and store-and-forward telemedicine The modes of data transmission in telemedicine include store-and-forward (SAF) and real-time systems and combinations of both [6]. Real-time telemedicine usually is performed as a patient interview via a videoconference. Applications also encompass robotic microscopy and even robotic surgery over distances. Videoconferences are a good substitute for face-to-face evaluation because they allow direct interaction in which participants can ask and answer questions directly. They are, however, time consuming with the prerequisite that all participants be available at the same, predetermined time. In addition, the costs of the technical equipment for real-time systems usually are higher than for SAF systems. In SAF systems, prerecorded medical information and still images are sent to remote experts who can retrieve them time independently. As such, this method is not reliant on participant availability. Furthermore, it is cost effective and easy to perform via e-mail or Web applications especially designed for this purpose, and both methods of data transmission have been found to be accurate and effective [7]. These modes also can be combined, for example in a discussion via e-mail of a previously performed videoconference. In teledermatology, the most commonly used method is the SAF mode
0733-8635/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.det.2007.12.003
derm.theclinics.com
296
WURM
et al
for transmission of images of skin conditions in combination with patient data.
clinical teledermatology, fields with special interest are teledermoscopy and teledermatopathology.
Stationary and mobile telemedicine
Teledermoscopy
‘‘Mobile telemedicine’’ refers to telemedicine applications in which the participants are remotely located with respect to each other and are mobile [1,8–10]. Rather than stationary equipment, small portable telecommunication devices are used for health care delivery. In recent years, the applicability of mobile telecommunication devices such as cellular telephones and personal digital assistants for telemedicine has been examined [9–12]. The increasing quality and power of these and other mobile devices are initiating an era of mobile telemedicine. Mobile telemedicine has practical potential as a screening and triage tool as well as for aftercare of patients. Other benefits are patient management during transport and supply of health care for individuals who are traveling as well as those in disaster areas.
Dermoscopy, dermatoscopy, or epiluminiscence microscopy is a method through which melanomas can be detected in earlier stages and with more diagnostic accuracy than on clinical grounds. In teledermoscopy, digital dermoscopic images combined with macroscopic images of skin lesions and medical data are used for consultation of experts and for educational means. Digital dermoscopic images can be acquired in different ways. A low-cost solution is simply to place a conventional digital camera or even a mobile telephone-camera over a conventional handheld dermatoscope, thus acquiring the images through the lens of the dermatoscope. The best image quality can be acquired with suitable dermoscopic lenses that can be directly attached to a digital camera. An all-in-one but relatively expensive solution is to obtain dermoscopic images via a video camera connected to a computer [11]. Dermoscopy is especially suited for digital imaging, because diagnosis in direct, physical examination is likewise restricted to observation of a two-dimensional image. A disadvantage of teledermoscopy is that the remote expert can analyze only the lesions preselected by someone else. This preselection can cause difficulties in identifying the ‘‘ugly duckling’’ sign, that is, detecting lesions that do not resemble the other nevi in one individual (and could be melanomas) [9]. The first feasibility study concerning teledermoscopy, published by Piccolo and colleagues [4] in 1999, revealed an agreement of 91% between direct dermoscopic diagnoses and telediagnoses. In 2000, Piccolo and colleagues [3] conducted a multicenter study in which telediagnoses in melanocytic lesions by 11 physicians with different degrees of experience in dermoscopy and face-toface diagnosis were compared with histopathologic diagnosis (the reference standard). The diagnostic concordance was 77% to 95%. Remarkably, the diagnostic accuracy of the three most experienced dermoscopists was superior to the accuracy of dermatologists who performed the face-to-face diagnosis (85%). This report underlines the importance of continuous education in this field. A recent development is the availability of online courses, computer-based training, and Web applications for the exchange of expert knowledge in dermoscopy.
Teledermatology Because image transfer is an integral part of telemedicine, dermatology as a visual field of expertise is ideally suited for practical application, especially in SAF systems. The term ‘‘teledermatology’’ was introduced in 1995 by Perednia and Brown [13] who described a teledermatology project in a vast rural area in Oregon (USA) where dermatologic care was supplied by only two local dermatologists. Since then numerous publications have dealt with diagnostic agreement between telediagnoses and face-to-face diagnoses in skin conditions. This agreement was found to be between 54% and 95% (mean, 75%) [7,14–21]. In most teledermatologic studies, the face-to-face diagnosis represented the pragmatic reference standard. The use of face-to-face diagnosis as the reference standard is a limitation to all these studies and probably hides the true potential of telemedicine, because it is based on the unrealistic assumption that face-to-face diagnosis is always correct. Morphology-based diagnosis can be very subjective, especially when it comes to the boundaries of diseases in one category. Generally, terminology problems create an intrinsic difficulty in making dermatologic diagnosis. Still, these studies illustrate that a high number of skin conditions can be diagnosed remotely. In addition to classical
A NEW TEACHING AND DIAGNOSTIC ERA
Teledermatopathology Histopathologic images can be transmitted in real-time via a robotic microscope or as still images. The latter method has been improved recently through the introduction of virtual slide systems in which pathologic images are scanned and digitized, allowing the user to view a specimen at different levels of magnification. The feasibility of both methods of teledermatopathology has been proven mainly on nonmelanoma skin cancer and on melanocytic lesions. with less focus on inflammatory skin disease [15,18–24]. These methods remain diagnostically inferior to common microscopy in detecting the subtle pathologic information of inflammatory skin disease and the delicate cytologic features in dysplastic nevi [25–34]. Applications of telemedicine and teledermatology Telemedicine in underserved areas As mentioned earlier, the first and most obvious benefit of telemedicine is to compensate for infrastructural deficits in rural and disaster areas [5,22]. Several telemedicine pilot projects have been performed in Africa, on remote islands, and in outer space. In urban areas, home monitoring, patient management and e-learning are important applications of telemedicine. Home care With remote home care devices enabling transmission of blood sugar rates, blood pressure, and ECGs, individuals who have chronic diseases such as diabetes and cardiac conditions can be monitored. In addition, elderly people and individuals who have special needs can be provided with special alarm systems (eg, in connection with a video telephone). In regard to dermatology, wound care monitoring of patients who have leg ulcers using telemedicine by home care nurses and wound experts represents an exciting approach [35]. It seems possible to use telemedicine to reduce health care costs by reducing the required travel to a wound care center or specialist physician and to improve the quality of life for patients who have leg ulcers [36]. Patient management Two possible types of interaction exist for teledermatologic patient management. The first is a consultation between two health care providers [23] (eg, a general practitioner
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seeking advice from a specialist or the discussion of an equivocal case between two or more experts worldwide). Several Web sites especially designed for this purpose have been launched during the last several years. A recently published study by Lozzi and coworkers [37] focuses on the value of obtaining a second opinion via teledermatology in the diagnosis of challenging skin conditions. Images of these skin conditions were sent from dermatologists in a small institution to a remote expert in a large academic department via a pre-existing Web application (www.telederm.org) using the SAF method. The consulted teledermatologist had the opportunity to request additional information about the patients and to forward cases to another expert chosen because of his/her special area of expertise. The face-to-face diagnosis and telediagnoses then were compared with histopathologic diagnosis as the reference standard. Results of this study demonstrated that teledermatology-aided diagnosis in equivocal skin conditions can increase diagnostic accuracy by as much as to 30%. The model system presented in this study demonstrates a unique advantage of teledermatology; in the future, obtaining a second opinion via teledermatology might become a standard procedure to overcome the geographic inequality in health care caused by the continuing formation of specialized centers. In the second type of interaction, an individual affected with a disease consults an expert directly via a telecommunication network. This approach to telemedicine is complex because it focuses on the direct contact between patient and physician and thus deeply affects present structures in medicine. For primary diagnosis, a visit to the physician might be indispensable, but aftercare of patients could be managed remotely. Mobile applications might be considered especially useful tools for these purposes. Mobile teledermatology holds great potential as a triage system for individuals who have skin lesions, in particular for people who are traveling or who live in underserved areas. Furthermore, mobile teledermatology also has great value for the empowerment of individuals in the industrialized world in accordance with the new formulated concept of ‘‘person-centered health system’’ [24,38]. The eHealth program of the European Commission Information Society and Media focuses on the prevention and management of diseases through research on ‘‘Personal Health Systems.’’ The hallmark of this concept is to ‘‘empower citizens to
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adopt an active role in managing their own health status and, in addition, facilitating early diagnosis of diseases’’ [38]. In this context, mobile teledermatology has the potential to become an easy applicable tool for enhanced self-examination. An individual affected with a skin disease can capture an image of a given lesion with a mobile device and send it to a specialized telemedicine center for triage [39]. E-learning Electronic learning, better known as ‘‘e-learning,’’ avoids limitations of time and location imposed by attending lectures and training programs in person [1]. Again, it can be perfumed in real-time video presentations or with asynchronous systems. E-learning already plays an important role in education of medical students and in the continuing education of physicians and health care workers. Numerous universities such as the Medical University of Graz (Austria), with its Virtual Medical Campus, or the University of Zurich (Switzerland), with Cyberderm-doit, offer students online access to most of their learning material. Online databases and atlases facilitate continuing learning and revision of knowledge. A recent development includes high-level Internet training courses for physicians, such as the International Dermoscopy Diploma, an online dermoscopy course offered by the University Clinic for Dermatology in Graz. E-learning programs go far beyond merely displaying the contents of a textbook on a computer monitor. They provide connections of text with pictures, simulations, and video and audio files. Revisions can be programmed individually, which can accelerate the learning process considerably. Furthermore, learners can interact with their teachers during the learning process. This interaction supplies all participants with fast feedback; the student can control his or her progress, and teachers can adapt their programs in response to frequently asked questions. E-learning, however, is a skill that itself must be learned. For individuals who have been used to textbooks all their lives, it requires flexibility and willingness to adjust to a different system. Elearning never can be a substitute for face-to-face education. It can be seen as a supplement to established learning methods. Even the best learning method is virtually worthless if the content is not presented in a profound, cohesive, and interesting manner. Therefore, a team of medical
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and computer experts must spend considerable time and effort to design a good e-learning program [40]. Exchange of expert knowledge Telemedicine also enables the international exchange of expert opinions. Medical professionals can communicate with colleagues all over the world. Online forums designed for teleconsultation (such as www.telederm.org) also offer discussion views where equivocal and interesting cases can be presented [41]. Both diagnostic and treatment issues can be discussed. This exchange has a tremendous educational benefit for all participants, thus enhancing quality assurance in medicine. Through these Web applications an international network of medical experts is in formation. A vivid example is the Consensus Net Meeting of Dermoscopy, a virtual meeting of experts in dermatology from all over the world [42].
Summary The previous sections have emphasized the numerous advantages of telemedicine, but there are some hindrances to the practical implementation of a health care telecommunication network. The practical applicability is improving steadily through technical advances, but there still are restraints arising from unsolved questions of data security, legal issues, reimbursement, and acceptance by patients and physicians. Legal issues with regard to responsibility and liability are complicated because teleconsultations often are performed between participants in two or more countries, each with distinct legal systems [2]. When teleconsultation is used to obtain a second opinion, the physician who has direct contact with the patient always has responsibility. Confidence about the security of personal information is crucial for the practical implementation of a telemedicine network. Opponents of telemedicine point out that it alters the physician–patient relationship, leading to a ‘‘mechanization’’ and a loss of personal contact. These issues must be taken seriously and addressed, but they should not be exaggerated. As outlined previously, a large number of teledermatology consultations occur among physicians themselves and have no direct bearing on the physician–patient relationship. With telemedicine, the doctor–patient relationship is undergoing change, reducing personal contact on the one
A NEW TEACHING AND DIAGNOSTIC ERA
hand but improving access to expert knowledge on the other. These concerns are not relevant for teleeducation, which is probably why it is, so far, the most successful subcategory of telemedicine. Though the implementation of patient management systems is still in development, the era of electronic learning has already begun. Telemedicine holds great potential for revolutionizing the delivery of health care and medical education, if applied with consideration. With its help, in the future medical knowledge could be easily accessible for everyone, independent of geographic and social background. References [1] Wurm EM, Hofmann-Wellenhof R, Wurm R, et al. Telemedicine and teledermatology: past, present and future. J Dtsch Dermatol Ges; [e-pub ahead of print]. [2] Stanberry B. Telemedicine: barriers and opportunities in the 21st century. J Intern Med 2000;247: 615–28. [3] Piccolo D, Smolle J, Argenziano G, et al. Teledermoscopydresults of a multicentre study on 43 pigmented skin lesions. J Telemed Telecare 2000;6: 132–7. [4] Piccolo D, Smolle J, Wolf IH, et al. Face-to-face diagnosis vs telediagnosis of pigmented skin tumors: a teledermoscopic study. Arch Dermatol 1999;135: 1467–71. [5] Norton SA, Burdick AE, Phillips CM, et al. Teledermatology and underserved populations. Arch Dermatol 1997;133:197–200. [6] Eedy DJ, Wootton R. Teledermatology: a review. Br J Dermatol 2001;144:696–707. [7] Oztas MO, Calikoglu E, Baz K, et al. Reliability of Web-based teledermatology consultations. J Telemed Telecare 2004;10:25–8. [8] Wurm E, Hofmann-Wellenhof R, Scholnast R, et al. Mobile teledermatology in a clinical setting. J Dtsch Dermatol Ges 2006;4:1006–7. [9] Massone C, Lozzi GP, Wurm E, et al. Personal digital assistants in teledermatology [see comment]. Br J Dermatol 2006;154:801–2. [10] Massone C, Lozzi GP, Wurm E, et al. Cellular phones in clinical teledermatology. Arch Dermatol 2005;141:1319–20. [11] Braun RP, Vecchietti JL, Thomas L, et al. Telemedical wound care using a new generation of mobile telephones: a feasibility study. Arch Dermatol 2005;141:254–8. [12] Hsieh CH, Tsai HH, Yin JW, et al. Teleconsultation with the mobile camera-phone in digital soft-tissue injury: a feasibility study. Plast Reconstr Surg 2004;114:1776–82.
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[13] Perednia DA, Brown NA. Teledermatology: one application of telemedicine. Bull Med Libr Assoc 1995;83:42–7. [14] Schiener R, Bredlich RO, Pillekamp H, et al. [Evaluation of a telemedicine pilot project]. Hautarzt 2001;52:26–30 [in German]. [15] Chao LW, Cestari TF, Bakos L, et al. Evaluation of an Internet-based teledermatology system. J Telemed Telecare 2003;9(Suppl 1):S9–12. [16] Du Moulin MF, Bullens-Goessens YI, Henquet CJ, et al. The reliability of diagnosis using store-andforward teledermatology. J Telemed Telecare 2003; 9:249–52. [17] High WA, Houston MS, Calobrisi SD, et al. Assessment of the accuracy of low-cost store-and-forward teledermatology consultation. J Am Acad Dermatol 2000;42:776–83. [18] Lim AC, Egerton IB, See A, et al. Accuracy and reliability of store-and-forward teledermatology: preliminary results from the St George Teledermatology Project. Australas J Dermatol 2001;42: 247–51. [19] Nordal EJ, Moseng D, Kvammen B, et al. A comparative study of teleconsultations versus face-to-face consultations. J Telemed Telecare 2001;7:257–65. [20] Taylor P. An assessment of the potential effect of a teledermatology system. J Telemed Telecare 2000;6(Suppl 1):S74–6. [21] Tucker WF, Lewis FM. Digital imaging: a diagnostic screening tool? Int J Dermatol 2005;44:479–81. [22] Duker I, Elsner P. [Dermatology in telemedicine. Possibilities and limits]. Hautarzt 2002;53:11–7 [in German]. [23] Loane M, Wootton R. A review of guidelines and standards for telemedicine. J Telemed Telecare 2002;8:63–71. [24] Shapiro M, James WD, Kessler R, et al. Comparison of skin biopsy triage decisions in 49 patients with pigmented lesions and skin neoplasms: store-andforward teledermatology vs face-to-face dermatology. Arch Dermatol 2004;140:525–8. [25] Morgan MB, Tannenbaum M, Smoller BR. Telepathology in the diagnosis of routine dermatopathologic entities. Arch Dermatol 2003;139:637–40. [26] Pak HS. Teledermatology and teledermatopathology. Semin Cutan Med Surg 2002;21:179–89. [27] Black-Schaffer S, Flotte TJ. Teledermatopathology. Adv Dermatol 2001;17:325–38. [28] Weinstein LJ, Epstein JI, Edlow D, et al. Static image analysis of skin specimens: the application of telepathology to frozen section evaluation. Hum Pathol 1997;28:30–5. [29] Dawson PJ, Johnson JG, Edgemon LJ, et al. Outpatient frozen sections by telepathology in a Veterans Administration medical center. Hum Pathol 2000; 31:786–8. [30] Piccolo D, Soyer HP, Burgdorf W, et al. Concordance between telepathologic diagnosis and conventional histopathologic diagnosis: a multiobserver
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