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 Table of Contents  
REVIEW ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 5  |  Page : 3-10

Teledermatology practice in the COVID-19 pandemic


Department of Dermatology, Venereology and Leprosy, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, Karnataka, India

Date of Submission01-May-2020
Date of Decision01-May-2020
Date of Acceptance02-May-2020
Date of Web Publication04-Jun-2020

Correspondence Address:
Garehatty Rudrappa Kanthraj
Department of Dermatology, Venereology and Leprosy, JSS Hospital, JSS Academy of Higher Education and Research, Mahatma Gandhi Road, Mysore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijhas.IJHAS_71_20

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  Abstract 


Pandemics like influenza and plague have posed a great threat to humanity in the past. Recent outbreak of COVID-19, a viral pandemic, has motivated the global community for social distancing and enforcement of lockdown. Teledermatology practice (TP) is an effective, safe, and fast medium to reach one who is difficult to reach. It is a medium for a dermatologist to cater the needy patients. Store-and-forward (SAF) teledermatology mobile apps (e.g., WhatsApp) perform to capture, transfer, and store the clinical images. This overview provides an insight to TP. In an Indian scenario, SAF TP meets the technical requirement, economical, and easy to practice. Spotters, pediatric, geriatric, and chronic cases are managed with TP. The Indian Association of Dermatologists, Venereologists, and Leprologists in view of COVID-19 situation encourages its members to perform TP and provide care. The members may practice TP after observing all conditions as in telemedicine guidelines prepared by the National Medical Council with due caution.

Keywords: COVID-19, messenger apps, online discussion forum, teledermatology practice


How to cite this article:
Kanthraj GR, Betkerur JB. Teledermatology practice in the COVID-19 pandemic. Int J Health Allied Sci 2020;9, Suppl S1:3-10

How to cite this URL:
Kanthraj GR, Betkerur JB. Teledermatology practice in the COVID-19 pandemic. Int J Health Allied Sci [serial online] 2020 [cited 2020 Aug 6];9, Suppl S1:3-10. Available from: http://www.ijhas.in/text.asp?2020/9/5/3/285967




  History of Telemedicine Top


In 1906, Wilhelm Einthoven discovered telecardiogram[1] and was successful in the transmission of electrocardiogram using a telephone network. The Nebraska Project,[2] USA, in 1959, used videoconference for psychiatry patients which was conducted between two hospitals within a distance of 150 km. Between 1960 and 1970, research to monitor astronaut's heart rate, blood pressure, and electrocardiogram was conducted.[3] The term teledermatology was introduced by Perednia and Brown.[4] Teledermatology in a nursing home setting was first demonstrated by Zelickson and Homan.[5]

Teledermatology practice (TP) is performed everywhere including as far as South Pole,[6] as remote as Faroe Islands,[7] rural India,[8] USA,[9] Africa,[10] and in austere environments.[11] Teledermatology is a branch of dermatology involving application of electronics, communications, and information technology to transmit the information between the patient and dermatologist and vice versa for research and practice to cater dermatology care.[4],[12]

Similar to radiology, dermatology is a visual specialty; availability of clinical and histopathological images for diagnosis makes it an ideal choice for TP.

A TP consultation is provided without exposing staff to viruses/infections in the times of contagious disease outbreaks like COVID. TP can prevent the transmission of infectious diseases, reducing the risks to both health-care workers and patients. Unnecessary and avoidable exposure of the people involved in delivery of health care can be avoided using TP. COVID-19, a viral pandemic, is a well-suited scenario, in which dermatologists can evaluate and manage patients.

Aim

The aim of TP is to reach the one who is difficult to reach. For dermatology care in remote geographic regions or needy population in situ ations like serious pandemics like COVID-19 where the population is under lockdown, early care is provided and difficult to manage cases that are not neglected.


  Scope and Purpose/indications Top


TP reduces multiple visits for follow-up care and benefits elderly, especially those coming from far-off places. It saves cost and time. A TP applies to diagnosis, treatment, and follow-up of skin disorders and education. Teledermatology was found to be cost-effective and reliable in reducing in-person visits, saves time, and allows for the faster delivery of care. TP provides triage and reduces waiting time. The various indications[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26] are summarized in [Table 1].
Table 1: Summarizes the various indications for teledermatology practice

Click here to view



  Teledermatology for Geriatric Care Top


Store-and-forward teledermatology can improve diagnostic and therapeutic care for skin disease in the elderly who lack easy and/or direct access to dermatologists.[27]


  Teledermatology for Paediatric Care Top


Accurate triage and diagnosis of childhood dermatology cases decrease travel and outpatient clinic visits and provide an avenue for ongoing support and education for primary care physicians.


  Teledermatology for Emergency Conditions Top


The Skin Emergency Telemedicine Service has proved to be a successful, sustainable, and valuable addition to the specialist dermatology services provided across Queensland, Australia.[29] The use of teledermatology within the context of emergency-based care has gained a high degree of patient's acceptance and confidence.[30] New-generation mobile devices reduce the cost of videoconferencing, increase the adaptability of teledermatology, and decrease general practitioner time.[29],[30],[31]


  Teledermatology and Diagnostic Agreement Top


Systematic reviews by Levin and Warshaw[32] showed that there is a good diagnostic agreement when comparing a teledermatology diagnosis and in-person clinical diagnosis or histopathology with traditional face-to-face consultations. The diagnosis concordance between dermatologists and teledermatologists increased from 92% to 98% (95% confidence interval [CI]: 87%–100%) when overlaps between differential diagnoses were considered as partial agreements. The diagnostic accuracy of store-and-forward (SAF) TP was good and comparable to videoconference TP. Health-care providers need to plan for appropriate utility of SAF-TP either alone or in combination with videoconference TP to implement and deliver teledermatology care in India.[33] Messenger apps (e.g. WhatsApp) are a medium for TP.


  Teledermatology and Patient Satisfaction Top


One of the main areas of patient dissatisfaction for both live video and SAF teledermatology revolved around the lack of follow-up.[34] Therefore, the referring physician plays a pivotal role in conveying the dermatologist's recommendations to the patient, which can have a major impact on patient satisfaction in the field.[35] Patient satisfaction will play an integral role in the further growth, development, and implementation of teledermatology. Direct consult may increase patient satisfaction.


  Teledermatology and Cost–-Effectiveness Top


Teledermatology is cost-effective in terms of significantly decreasing the need for in-person visits.[36] Real-time interactive teledermatology has been found to be time-consuming than store-and-forward dermatology.[37] Video call is mostly used to counsel the patient.


  The Organization of Teledermatology Practice Top


The organization of TP for a self-practicing dermatologist is illustrated in [Figure 1]. It comprises a basic model SAF teledermatology where a dermatologist interacts with the patients directly for regular cases (spotters) along with online discussion forum to obtain a second opinion on management of difficult-to-manage cases.[12],[38]
Figure 1: Illustration of the organization and process involved in teledermatology practice for a dermatologist to manage regular case (to use store and forward teledermatology practice) as well as difficult-to-manage cases (to use online discussion forum) and deliver care (modified with permission from Kanthraj GR. J Eur Acad Dermatol Venereol 2010;24:961-6. and Kanthraj GR. Indian J Dermatol Venereol Leprol 2011;77:276-87)

Click here to view



  Prerequisites for Teledermatology Practice Top






  1. A dermatologist should obtain a proper history
  2. Patient should be able to provide electronic images of the skin disorder. Landow[36] summarizes the requirements for a successful TP as: (1) image quality; (2) preselection of patients (tumoral conditions are the simplest; nevi evaluation should not exceed 1–2 lesions at most; multiple nevi patients should be excluded; and hair conditions are difficult to photograph and diagnose);[39] and (3) a dermoscopic image is a requirement for pigmented and tumoral lesions; and good internet connectivity is a necessity.



  Store-And-Forward Teledermatology Top


Static images of clinical and histopathological data are accessed anytime and anywhere. They are transferred from a general practitioner to a specialist to deliver the management. Dermatology cases that can be diagnosed by face-to-face examinations (spotters) have a good diagnostic accuracy by SAF TP. A diagnosis agreement of 89%[40] has been documented. SAF TP is cheap and easy to set up and practice. It is the most common teledermatology tool as most of the cases are dealt and often regarded as a basic model for a TP.[12]


  Videoconference Top


It is a live or interactive teledermatology. General practitioner, patient, and specialist interact with one another using live/motion images. Various feasibility studies[41],[42] have confirmed good diagnostic accuracy when videoconference is compared to face-to-face consultation.


  Hybrid Teledermatology Top


This is a combination of both videoconference and SAF TP to overcome the shortcomings faced when either of them is used individually.[43]


  Store-And-Forward Teledermatology Versus Videoconference Top


Good patient and physician satisfaction along with good diagnostic accuracy is achieved in all. The simultaneous presence of a health-care professional is required in videoconference and hybrid teledermatology and his or her presence may not be required in SAF TP. SAF TP is the most cost-effective and convenient compared to videoconference. The time taken for consultation is least for SAF TP and more in videoconference and hybrid teledermatology. Motion images are used in videoconference, still images are used in SAF TP, and both the types of images are used in hybrid teledermatology. A hybrid system with audio is no better than SAF TP alone.[44] However, in the current context of mobile messenger apps -whatsapp consultation for example, still images and videos can be stored and forwarded. It has emerged as a widely used medium for TP.


  Mobile Teledermatology Top


The term mobile teledermatology represents the transmission of images via mobile phones[45],[46] as well as through personal digital assistants.[47] Motion and still images are transferred. Advanced net-work technology along with the mobile messenger apps has revolutionized TP. Android technology and apps find an application medium to capture, transfer, and store the images.[48],[49]


  Teledermatopathology Top


Transmission of histopathological images of the skin using information technology for expert opinion is called teledermatopathology.[50] Teledermatopathology is achieved by (i) video-image (dynamic) analysis; (ii) SAF (static); and (iii) web-based virtual slide system.[51] A virtual slide system is a recently developed technology where a robotic microscope is used; any field of the specimen is selected for better digitalization at any required magnification at the discretion of the dermatopathologist.


  Teledermoscopy Top


Pigmented skin lesions and melanoma are analyzed based on the dermoscopic criteria[52] that depend on characteristic changes in the epidermis and dermis. Dermoscopy images[25] are transmitted for expert opinion using routine TP tools like SAF TP or tertiary TP for the second opinion. If these images are transferred using mobile technology, it is called mobile teledermoscopy. Pigmentary skin lesions are screened using mobile teledermoscopy.[25],[52],[53],[54],[55]


  Online Discussion Forums Top


Difficult to manage cases is a challenge to the health-care system. An online discussion forum is formed with a group of dermatologists who share constructive suggestions[56],[57],[58] for a submitted case. Feasibility studies have confirmed 81% concordance with face-to-face consultation.[56] Members of academic societies such as the Indian Association of Dermatologists, Venereologists, and Leprologists (IADVL) have formed an online discussion forum at ACAD_IADVL@googlegroups.com (an e-mail group) and participate in regular academic discussions. Telederm.org,[56] Rxderm,[57] Virtual Grand Rounds in Dermatology,[58] and Black Skin Dermatology Online[60] are the examples of online discussion forums. Experts may be unavailable for an instant case or dermatologists and allied research workers who might have carried out research involving an online discussion forum may not have registered at the site and at times consensus may not be reached for a case without these experts are the limitations of online discussion forum.[56],[57],[58],[59],[60]

The various teledermatology tools and health-care professionals involved to provide dermatology care are summarized[61] in [Figure 2].
Figure 2: Summarizes the various teledermatology tools used for patient care (reproduced with permission from Kanthraj GR. Indian J Dermatol Venereol Leprol 2015;81:136-43)

Click here to view


Limitations

Poor net connectivity, poor image quality, and lack of referral pro forma data can limit TP. All cases may not be feasible with an objective of diagnosis in TP. The cases that are not diagnosed by spot examination are summarized in [Table 2].
Table 2: Summarizes the various clinical situations a dermatologist may choose not to offer teledermatology practice for diagnosis purpose

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The requirements for real-time videoconferencing (synchronous encounters) and SAF teledermatology have been specified by the American Telemedicine Association.[62] Monitors for viewing images shall have a minimum of 1024 × 768 pixel resolution, minimum contrast ratio of 500:1, minimum luminance of 250 cd/m[2], and minimum dot pitch of 0.19.[62]

In India, till now, there was no legislation or guidelines on the practice of telemedicine through video-, phone-, and internet-based platforms (web/chat/apps etc.). Recently, the board of governors (BoGs) of the Medical Council of India (MCI) along with NITI Aayog have prepared the guidelines for telemedical practice.[63] The detailed guidelines about the role of patient, health-care provider, and technology platform are highlighted.[63] Each patient will be identified by a unique and universal patient identifier so that one central patient information record can be assimilated, comprehensive medical databases can be built, or if the patient wants, he/she can move across multiple providers without losing data. The same principles apply irrespective of the mode (video, audio, and text) used for a telemedicine consultation.[63]

Guidelines for technology platforms enabling telemedicine prepared by the board of governors of medical council of India along with NITI Aayog[63]

This specifically covers those technology platforms which work across a network of Registered Medical Practitioners (RMPs) and enable patients to consult with RMPs through the platform.





  1. Technology platforms (mobile apps, websites, etc.) providing telemedicine services to consumers shall be obligated to ensure that the consumers are consulting with RMP duly registered with Ntional Medical Councils (NMCs) or respective state medical council and comply with relevant provisions
  2. Technology platforms shall conduct their due diligence before listing any RMP on its online portal. Platform must provide the name, qualification, registration number, and contact details of every RMP listed on the platform
  3. In the event some noncompliance is noted, the technology platform shall be required to report the same to BoGs, in supersession to the MCI who may take appropriate action
  4. Technology platforms based on artificial intelligence/machine learning are not allowed to counsel the patients or prescribe any medicines to a patient. Only a RMP is entitled to counsel or prescribe and has to directly communicate with the patient in this regard. While new technologies such as artificial intelligence, Internet of things, and advanced data science-based decision support systems could assist and support a RMP on patient evaluation, diagnosis, or management, the final prescription or counseling has to be directly delivered by the RMP
  5. Technology platform must ensure that there is a proper mechanism in place to address any queries or grievances that the end-customer may have
  6. In case any specific technology platform is found in violation, BoG, MCI, may designate the technology platform as blacklisted, and no RMP may then use that platform to provide telemedicine.



  Teledermatology and Law Top


There is no definite legislation addressing the TP. One cannot take shelter on the pretext of teledermatology consultation. A medicolegal principle of traditional consultation applies to TP.[64] All prescriptions need to be signed duly by a RMP as per the Drugs and Cosmetic Rules 1945. The physician is responsible for the issues related to security, privacy, and confidentiality of patient data. The American Telemedicine Association Guidelines[62] recommend that each health-care provider and patient should have a unique identifier and the images are stored confidentially in secured data base. Encryption for storage of patient data and for transmitting medical information should be inbuilt.

Use a disclaimer[65] which may read as “the medical opinion is only based on records available without direct contact with the patient and hence, this advice is only to guide the referring doctor and cannot equate face-to-face consultation.”


  Medical Ethics, Data Privacy, and Confidentiality Top


Principles of medical ethics including professional norms for protecting patient privacy and confidentiality as per the Indian Medical Council (IMC) Act shall be binding and must be upheld and practiced. RMP would be required to fully abide by the IMC (Professional conduct, Etiquette, and Ethics) Regulations, 2002, and with the relevant provisions of the IT Act, data protection and privacy laws or any applicable rules notified from time to time for protecting patient privacy and confidentiality and regarding the handling and transfer of such personal information regarding the patient.[66] This shall be binding and must be upheld and practiced.[63]

RMP will not be held responsible for breach of confidentiality if there is a reasonable evidence to believe that patient's privacy and confidentiality has been compromised by a technology breach or by a person other than RMP. The RMPs should ensure that reasonable degree of care is undertaken during hiring such services.


  Teledermatology and Education Top


TP plays a vital role in education. Resident training, exchange of knowledge and opinion between different dermatologists, and learning of dermatological diseases from different parts of the world are the roles of tele-education.[39],[67],[68],[69]

WhatsApp groups make it possible for dermatologists[67] and other specialties to discuss various dermatological diseases and their appropriate management. It is one of the easiest media to exchange knowledge and experience on a one-on-one basis. It is considered to be one of the safest instant messaging media because of encryption technology.[67] Dermatology residents feel more confident at handling various disorders with additional TD learning.[68] TD can reduce the residents' empathetic nature toward patients and reduce the patient–physician relationship and loss of integral approach rather than focusing on single lesions.[68],[69]


  Teledermatology and Reimbursement Top


Reimbursement policies for teledermatology services are rather new and vary significantly from place to place. The Netherlands offers full reimbursement for services and has completely integrated teledermatology into its health-care system.[70] However, in the United States, reimbursement remains a major challenge in telemedicine and continues to evolve in recent years. Currently, all states and the District of Columbia have defined telemedicine law, regulations and Medicaid policies. In USA reimbursement varies from state to state.[71] Reimbursement for live video teledermatology far exceeds the reimbursement for SAF teledermatology. Many states restrict reimbursement coverage to live video teledermatology only and exclude SAF teledermatology.[71]

In the Indian context as per the recent NMC guideline,[63] telemedicine consultations should be treated the same way as in-person consultations from a fee perspective: RMP may charge an appropriate fee for the telemedicine consultation provided.[63] An RMP should also give a receipt/invoice for the fee charged for providing telemedicine-based consultation.


  A Protocol for Teledermatology Practice Top


According to a survey completed by Armstrong et al.,[72] most teledermatology programs have shifted from live interaction video to the SAF modality due to its technological flexibility and lower cost of service delivery. A dermatologist should screen the received clinical image from a general practitioner or self-acquired patient images[73],[74] (selfies) and define the objective/purpose of dermatology care [Figure 3]. If the case suits for diagnostic purpose, a treatment is offered. A clinician should be aware of the dermatological conditions where not to offer consultation for diagnostic purpose [Table 2]. In these cases, a dermatologist can perform face-to-face examination, investigate, analyze the case, offer treatment and provide follow-up care by TP [Figure 3].
Figure 3: Illustrates the protocol for teledermatology practice

Click here to view



  Conclusion Top


In an Indian scenario, mobile teledermatology using messenger apps, for example, WhatsApp, can be used with good diagnostic accuracy and patient satisfaction. Mobile messenger apps provide a dermatologist to capture and transfer the clinical images either in still (SAF) and motion (video) or both. Recently, the BoGs (MCI) have proposed guidelines for telemedical practice. The IADVL in view of COVID-19 situation encourages its members to perform TP and provide care. The members may practice teledermatology after observing all conditions as in telemedicine guidelines prepared by NMC with due caution.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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  In this article
Abstract
History of Telem...
Scope and Purpos...
Teledermatology ...
Teledermatology ...
Teledermatology ...
Teledermatology ...
Teledermatology ...
Teledermatology ...
The Organization...
Prerequisites fo...
Store-And-Forwar...
Videoconference
Hybrid Telederma...
Store-And-Forwar...
Mobile Telederma...
Teledermatopathology
Teledermoscopy
Online Discussio...
Teledermatology ...
Medical Ethics, ...
Teledermatology ...
Teledermatology ...
A Protocol for T...
Conclusion
History of Telem...
Scope and Purpos...
Teledermatology ...
Teledermatology ...
Teledermatology ...
Teledermatology ...
Teledermatology ...
Teledermatology ...
The Organization...
Prerequisites fo...
Store-And-Forwar...
Videoconference
Hybrid Telederma...
Store-And-Forwar...
Mobile Telederma...
Teledermatopathology
Teledermatology ...
Teledermatology ...
A Protocol for T...
Conclusion
Teledermoscopy
Online Discussio...
Medical Ethics, ...
Teledermatology ...
References
Article Figures
Article Tables

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