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Teledermatology

European Journal of Dermatology. Volume 19, Number 6, 656-8, November-December 2009, EDF White Book

DOI : 10.1684/ejd.2009.0800

Author(s) : G Burg, HP Soyer, S Chimenti .

ARTICLE

Auteur(s) : G Burg, HP Soyer, S Chimenti

Introduction

The challenge for building a connected world in healthcare is dealing with the mission-critical nature of healthcare transactions, the lack of data standardization, and concerns over security and privacy. Solutions need to address the potential for millions of simultaneous users, they must be available without fail, 24 hours a day, and they must respond quickly to the demands of fast-moving professionals. Most importantly, citizens must feel absolutely confident about the sanctity of their personal data.

The term e-health poorly defines the nearly unlimited number of communication procedures and technologies, ranging from telephone and fax through e-mail and digital data transmission, including telemedicine. Other e-health tools include health information networks, electronic health records, personal wearable and portable communicable systems, and health websites. Thus e-health includes tools for health authorities and professionals as well as personalized health systems for patients. When combined with organizational changes and the development of new skills, e-health can help to deliver better care for less money. Dermatology could serve as a paradigm for how a medical discipline successfully faces the challenges and opportunities of e-health.

Telemedicine, and in particular teledermatology, is just one aspect of e-health. The World Health Organization (WHO) defines telemedicine as “the practice of healthcare using interactive audio, visual and data communication. This includes healthcare delivery, diagnoses, consultation and treatment as well as education and transfer of medical data.” Telemedicine holds great potential to revolutionize medical and paramedical services, not only for primary care physicians in remote areas, but also for teaching students and for continuing medical education.

Telemedicine was first employed by NASA during the Apollo mission. In 1961 the Nebraska Psychiatry Institute reported on their experience in “Two way television group therapy”. The technical advances in the last 40 years opened the window to many possibilities for applied telemedicine. There are still some hindrances: (1) Technical and logistical restraints: high-resolution images need high-speed connections and adequate storage capacities. (2) Organizational resistance: there is a significant lack of infrastructure and willingness to implement telemedicine, which is blocked by endless discussions about the lack of evidence for their return on investment. (3) Psychological barriers: fear of a deterioration in the doctor-patient-relationship results from a lack of awareness of the potential positive impact of telemedicine.

Technology

Principally two methods can be applied.

1) Real-time video transmission is the most interactive approach. World-wide users of this system have to consider time zone differences. All participants have to be available at exactly the same time. The technical effort is extensive with respect to room, illumination and video-camera equipment. Special skills are required for optimal transmission of the images of skin lesions with minimum inconvenience for both patients and doctors.
2) Store-and-forward communication is independent of time zones and complicated schedules. The technical equipment, including digital camera and built-in light source, is less expensive and provides higher quality pictures than a cam camera as used in real-time video transmission. In addition, pictures can be corrected electronically before transmission and can be labeled with annotations.

Fast connections (ISDN) or cable are the prerequisites for high-resolution data-transmission of pictures. A combination of full-motion real-time video and the store-and-forward technology as used in the Dermanet project has proven highly effective. Digital clinical, histopathologic or dermatoscopic images are transferred to the members of a teledermatological network and discussed in a virtual conference room. Similar projects are in use at several dermatology centers worldwide.

Legislation

Data security is a must as in all other areas of clinical medicine. No new laws have to be created, since it makes no difference if patient data are transferred by writing, talking or electronically. Just as in traditional systems, the responsibility for diagnosis and management is always with the physician caring for the patient. Patients usually have no objections to transferring data in order to get a second or expert opinion. For continuing medical education and teaching purposes, the situation is different in that the patient must explicitly agree with the use of their images or data.

Applied teledermatology

The most appropriate application of teledermatology is discussing medical problems between physicians, especially between a general practitioner and a specialist. Associated health care workers, such as nurses or physician assistants working in rural areas may also be able to consult physicians. Teledermatology consulting may be particularly helpful in the transmission of dermatoscopic images of pigmented lesions. Images may be easily obtained and transmitted by non-dermatologists and interpreted by dermatologists who are specially trained in this area.

Continuing medical education

Besides electronic data-bases, some of them comprising thousands of pictures (DOIA – www.dermis.net; Feit’s dermatopathology atlas – www.muni.cz/atlases), transmission of conferences and case presentations in a closed secure network are extremely instructive tools for continuing medical education. Several programs are running worldwide, usually within local or national networks. There is a high potential for training of medical personnel in less developed countries, who may have internet access but no access to a medical library. One of the programs existing for a number of years is DermaNT in Switzerland, connecting between 10 and over 50 specialists in Switzerland once a week.

Another program with worldwide coverage has been launched by the Department of Dermatology, Medical University of Graz, Austria – www.telederm.org. The basic aim of the project is to create a user-friendly platform for a teleconsultation service where physicians can quickly and easily seek diagnostic advice in dermatology from a pool of expert consultants and where they can present and discuss particular dermatological cases with emphasis on diagnostic procedures, diagnosis and therapy. From its inception in April 2002 through May 2004, 348 healthcare professionals from 45 different countries participated – 187 as experts and 161 as clients. Over the first 24 months, telederm.org experts provided 783 consultations.

Teleteaching

E-learning programs provide new didactic possibilities as they can be a unique blend of text, pictures, graphics, animations, audio and video. A significant advantage of e-learning is interactivity, which allows fast bilateral feedbacks between user and provider and is a key to motivation and control of the learner as well as an important help in program development. Interactivity leads to more participation, which results in higher levels of cognitive engagement and better retention.

Nevertheless, e-learning programs can neither completely substitute a good textbook nor a good lecture. Since it is much easier to put a simple collection of pictures or lecture slides on the web than to create an interactive program, providers are easily seduced into overemphasizing the visual aspect of dermatology. Only carefully constructed e-learning programs will lead to more effective and faster teaching and learning. E-learning programs have to be designed by a team of experts in dermatology, education and computer skills; these programs need continuous refining.

The role of the teacher should move towards support for the learner and not the delivery of knowledge. In the future, teachers will spend more time on instructional design of e-learning programs, which should open ways for national and international networking between faculties and medical disciplines.

Among the 16 dermatology e-learning programs offered on the web, only one (cyberderm-doit, www.cyberderm.net) fulfills most of the requirements of a complete, interactive, well-interlinked and didactically elaborate multi-language program.

Future prospects

In the future, consulting and asking for second opinion will be the gold standard of medical care, which will be beneficial especially for patients and medical or paramedical services in remote areas. Quality of healthcare will be improved while reducing indirect costs such as travel time and effort for the patient. While there is still some resistance to this approach from physicians, other healthcare providers, patients, the general public, politicians, insurance companies, there is no way back and it is our duty to help develop a responsive widely accepted system. Easy access to expert medical information for all regardless of their social, economic, ethnic and geographic status should remain a major aspect of medical policy today; this goal can only be realized by the implementation of e-health tools – dermatology will meet this challenge.