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Introduction

The inherent visual nature of dermatology makes it suitable for telemedicine. Several teledermatology projects have recently been initiated in developing countries, and the number is gradually increasing.^1–7 Preliminary results underline a number of potential benefits to patients, remote health care workers and health care systems of host countries. These benefits (Box 12.1) include easy extension of specialized dermatological services to geographically remote areas with few dermatologists, reduction of patients’ waiting time for appointments, faster screening for skin diseases, promotion and coordination of scientific health projects, and education of health workers and lay people.^1–6,8 Local physicians benefit from the mentoring and educational aspects of the consultations, as well as the access to improved research facilities and professional interactions. Consulting experts also get special opportunities to review rare or unusual dermatological cases.

As in other telemedicine systems, teledermatology employs both store-and-forward methods (asynchronous) and real-time approaches (synchronous).⁹ Both modalities have previously been shown to be quite reliable and accurate when compared with traditional face-to-face consultation.^9–13 Store-and-forward systems are more widely used, owing to their lesser technological requirements and affordability. Images are submitted by email or presented on a web-based system. Although the real-time approach represents a reasonable substitute for in-person consultation and has the advantage of enhancing patient–doctor interaction, it is more time-consuming and expensive.

Teledermatology may involve providing assistance, follow-up or teaching. Tele-assistance models aim at teleconsultation, telescreening and/or second opinion.^7,14 The majority of teledermatology projects in developing countries deal with dermatology consultations. Telescreening projects have been used to manage waiting lists for treatment of dermatoses with different healing times or to support prevention programmes such as those surveying skin tumours.¹⁵ Telefollow-up systems deal with transmission of medical information regarding follow-up and treatment progression of patients from remote centres (e.g. to follow up patients treated for certain chronic skin conditions such as leg ulcers and leprosy) and for postoperative evaluation.^5,16 Tele-education is proving to be a versatile model, helpful in staff development such as by tutoring and assessing medical and paramedical workers.⁷ Most teledermatology collaborative projects also involve some degree of tele-education in addition to tele-assistance. Thus, in addition to long-distance consultation, they also provide continuing medical education (CME) for physicians who submit cases. Applications for tele-education mainly integrate text and images (static or dynamic) and/or virtual reality models to achieve health education.

The use of web applications for discussion forums represents another application of teledermatology. The main objective of such applications is to create a quick and easy method for teleconsultation from a pool of expert consultants. The philosophy behind these ‘DermOnline’ communities is open access teleconsultation in dermatology, which means that these platforms are free to all users and that the users themselves generate the content by sending and answering the teleconsultations. These communities have moderators who check both the subscribers and the content of the requests in order to guarantee friendly and orderly virtual interaction.

Teledermatology in developing countries

There are several teledermatology networks and projects in developing countries.

The telederm.org application and networks

The telederm.org application was initiated by the Department of Dermatology of the Medical University of Graz, Austria, in 2002. The primary goal was to develop a software application that would facilitate worldwide exchange of knowledge and expertise in dermatology and dermatopathology. The application is now used by several teledermatology networks, some of which are active in developing countries, including the telederm.org project and the Africa Teledermatology Project.^7,17–19 Versions of the application are available in German, Italian, Chinese, Turkish languages, Serbian and Hebrew.

The program provides the functionality to store and forward medical cases with attached images. Within a particular network, users are categorized as either clients or experts. Clients can only submit cases to selected experts, whereas experts have the right to review cases, write comments and suggest a diagnosis, or further forward cases to other selected experts within the system (Figure 12.1). All users can subscribe for notifications so that they get an automatic email if, for example, a new comment is added to one of their cases or if a new case is entered on the site. Every network has at least one administrator who is able to register users and/or reassign consultations to preferred experts.

Figure 12.1 Africa Teledermatology project data flow

All requests are archived in a database with a personal archive for each user. A client can choose to send a request for consultation only to a selected expert, or he or she can submit a request to an open forum as a ‘discussion case’. In the former situation, the user receives a personal answer and interactions remain private. Cases submitted as ‘discussion cases’ are visible to all users, who can review the cases and submit on-line opinions.

The telederm.org project

This teledermatology network was initiated in April 2002 with the aim of creating an easy-to-use platform for teleconsultation services where physicians could seek diagnostic advice in dermatology from a pool of expert consultants and discuss challenging cases.¹⁸ An online discussion forum was included in October 2003. At present, more than 1300 physicians are subscribed to the telederm.org project from over 90 countries worldwide. Through this application, participants from different medical specialties are matched with dermatologists with a range of experience in diagnosis and management of various skin diseases. By providing a platform for interactive discussion between physicians at the point of care and experts from different countries, the telederm.org project seeks to raise the level of competence of physicians and dermatologists at the point of care on a worldwide level.

The telederm.org project is a non-profit venture under the auspices of the International Society of Teledermatology. The main academic institutions involved are the Department of Dermatology, Medical University of Graz, Graz (Austria) and the Dermatology Group, School of Medicine, University of Queensland, Brisbane (Australia). Moderators of the telederm.org community come from a range of different countries, including Turkey, Croatia, Romania, China, Pakistan, USA and India. The telederm. org project has 1024 users, with an average of 38 new users per month. It handles about 27 new cases per month.

The Africa Teledermatology project

The Africa Teledermatology project²⁰ was initially conceived as the ‘Uganda Tele-Dermatology- and E-Learning-Project’ in February 2007, with sponsorship from the Kommission für Entwicklungsfragen (KEF) der Österreichischen Akademie der Wissenschaften. Its main objective was to facilitate improvement of the treatment of skin diseases in Uganda by establishing an Internet channel for long-distance dermatological consultation between the medical Universities of Makerere and Mbarara in Uganda and the Department of Dermatology, University of Graz. In collaboration with the Department of Dermatology at the University of Pennsylvania, USA, the scope of the project was expanded, with the eventual inclusion of a number of other medical centres in eastern, central and southern Africa, which led to the formation of the Africa Teledermatology project. The main purpose of this work is to support African health workers in the diagnosis and management of patients with skin diseases, especially those having skin conditions related to HIV/AIDS.

The Africa Teledermatology project uses the telederm.org application (Figure 12.2). There are links on the application homepage to educational resources and a dermatology curriculum. An online archive of tropical skin conditions should emerge that will serve as an Internet source of educational material for training and updating of medical specialists and health personnel. A secondary goal of the project is to establish a platform for dermatology research collaboration. The ultimate objective is the integration of the various aspects of teledermatology and teledermatopathology into health care systems of developing countries.

Figure 12.2 Dematologists and medical staff at Mbarara university hospital, Uganda selecting and processing difficult cases of skin diseases for teleconsultation

In the first 12 months, 160 teledermatology-supported patient encounters have been processed. Of these, 35% of cases were children and 25% represented HIV-associated skin conditions. A number of Internet learning facilities for medical personnel have been set up on the project website, including an online case presentation with discussion, dermatology lectures and an international forum of physicians with an interest in tropical dermatology. Through this initiative, scientific cooperation has been established with a number of specialists from well-known medical/dermatology centres worldwide, who have contributed their experience in management of difficult skin conditions submitted by colleagues in Africa.

iPath application and networks

The iPath software was developed by the Department of Pathology of the University Hospital Basel as an open source framework for building web- and email-based tele-medicine applications.^21–23 iPath provides the functionality to store medical cases with attached images and other documents in closed user groups. Within these groups, users can review cases, suggest diagnoses and submit comments. In addition, users can subscribe for notifications so that they receive an automatic email message if, for example, a new comment is added to one of their cases or if a new case is entered in a group. All users are organized into one or more discussion groups. Every discussion group has at least one moderator who can assign other users to the group and who can delete erroneous data.

At present, iPath hosts several telemedicine networks active in developing countries, several of which involve teledermatology. These include the following.

Solomon Islands National Telemedicine Network

This is a joint project of the National Referral Hospital in Honiara, South Pacific Medical Projects and the University of Basel.²⁴ It aims to use telemedicine to improve health care delivery in provincial hospitals in the Solomon Islands. There is special emphasis on the fields of dermatology, radiology, orthopaedics and paediatrics.

LT Telepatologija

This is regional network of pathologists and other medical specialists in the Baltics, based on the iPath platform.²⁵ Its purpose is to support clinicopathological case discussions, consultations and CME.

RAFT-Forum (telemedicine platform of the Réseau de Télé-enseignement et de Télémédecine en Afrique Francophone)

The main activity of this forum is the webcasting of interactive courses for physicians and other health care workers in French-speaking countries of Africa, including Mali, Mauritania, Senegal, Morocco, Tunisia and Madagascar.²⁶ The main goal is to encourage knowledge sharing across medical institutions in the various participating countries. Topics for discussion are proposed by the partners of the network. The technology used for the webcasting works with an Internet connection, a Java-enabled web browser (e.g. Internet Explorer or Mozilla) and the free software RealPlayer.

Telemedicine Sur

This is a telemedicine platform for medical discussions, CME and consultations for medical specialists and health practitioners in Latin America.²⁷ Specialties involved include mainly pathology, dermatology and venereology, as well as paediatrics.

West Africa Doctors and Healthcare Professionals Network

This is a West African telemedicine network, again based on the iPath software.²⁸ Its goal is to enhance the communication capabilities of doctors, particularly in the areas of information access, distance learning (CME), telemedicine- and knowledge-based support of diagnosis, and management of patients in various specialties.

HealthNet Nepal

This is a health information and communication network in Nepal that provides low-cost email, Internet access and a wide range of medical and public health resources to the Nepalese health community.²⁹ The network began in 1994, and is subscribed to by over 230 health institutions and organizations, including hospitals, clinics, university departments, research sites and non-governmental organizations (NGOs) in both urban and rural areas. The network enables health professionals throughout Nepal to communicate and exchange knowledge.

Teledermatology project in Port St Johns, South Africa

This project was initiated in 1999 at Port St Johns, a small and poor provincial town on the east coast of South Africa, with the aim of improving access to dermatological care for patients and family practitioner clinical skills.^30,31 The scope of the project was to connect general practitioners from Port St Johns to a network with dermatology specialists. The project started with email-based store-and-forward teledermatology, but, since 2002, it has been using the iPath software. In the first year, the server in Basel was used, but, since 2003, the project has been connected to a telemedicine network run by the Telemedicine Unit of the University of Transkei (UNITRA) in Umtata.

ITG telemedicine – the Institute of Tropical Medicine website

The project was begun in 2003 by the Department of Clinical Sciences at the Institute of Tropical Medicine, Antwerp, Belgium.³² Its aim was to facilitate the introduction of antiretroviral therapy (ART) for patients affected by HIV/AIDS in developing countries by providing training, distance support and education to health care providers working in these settings. Advice is given through email messages from a server list, and afterwards through a discussion forum on a telemedicine website. Details of the patient’s history, physical examination, images, laboratory findings and questions to be answered have been received from a number of different countries.

Swinfen Charitable Trust

The Swinfen Charitable Trust was set up in 1998 by Lord and Lady Swinfen to ‘assist poor, sick and disabled people in the developing world’ by providing access to expert medical advice from consultants all around the world.³³ It offers provincial hospitals in developing countries the opportunity to submit cases to specialists worldwide. Communication is via a simple email telemedicine system using an automatic email messaging service developed by the Centre for Online Health at the University of Queensland, Brisbane, Australia. The core of the network is an automatic email routing system that directs the messages about each case to the parties concerned (i.e. the referring doctor and the specialists being consulted). The Swinfen Charitable Trust has been able to establish telemedicine links between remote hospitals in the developing world with international medical consultants in order to receive advice free of charge. The remote hospitals and clinics are supplied with high-resolution digital cameras and tripods, and medical staff are taught how to use the equipment. The Swinfen Charitable Trust operates in over 30 countries, including Afghanistan, Cambodia, East Timor, Iraq, Nepal, Papua New Guinea and Sri Lanka, and offers specialist advice in a wide range of fields including dermatology, dentistry, paediatrics, obstetrics and gynaecology, oncology, orthopaedics, ophthalmology, neurology, plastic surgery and trauma (see Chapter 19).

Teledermatology outcomes

There have been few previous studies focusing on teledermatology outcomes, and these have mainly involved projects in industrialized countries.^34–36 Generally, diagnostic accuracy and clinical effectiveness represent the most popular clinical outcome measures. The possible explanation for their repetitive evaluation is the rapidly changing technology, especially that of the digital cameras used in teledermatology.

As far as developing countries are concerned, there have not yet been any large studies focusing on the clinical outcomes of teledermatology, despite general consensus supporting the increased diagnostic accuracy and clinical effectiveness possible using the technique. Problems in assessment of clinical outcomes in projects in developing countries include mainly patient loss to follow up and inadequate medical record systems, although similar problems may also apply to traditional face-to-face consultations in this setting.

The economic value, clinical benefits and sustainability of teledermatology in developing countries remain to be formally proved. This is primarily because evaluations of these economic outcomes require complex analysis of the direct and indirect costs to national health providers and patients, as well as assessment of the impact of teledermatology services on earlier diagnosis and expert management.

Quality

A number of factors may lower diagnostic accuracy in teledermatology. These include poor-quality images, insufficient clinical information supplied, intrinsic difficulties of cases submitted, interference of technology in the perception of three-dimensional images, lack of ability to palpate or physically examine the patient, and lack of proper training of physicians who submit cases or who give opinions, among others. Poor-quality images may be of low resolution or may have a high level of compression. Clinical information may be confusing owing to image files from similar patients being separately sent or inconsistently coded. It is necessary that medical workers be adequately trained to take good images and instructed how to properly send cases before being involved in teledermatology projects. It is also advisable to include a link to working instructions on the homepage of teledermatology web applications; for example, see the Africa Teledermatology project website.²⁰

Legal problems

The increasing availability of health information about individuals in electronic databases and through online networks has offered tremendous benefits to physicians, health care workers and patients. However, it has also created new legal challenges. There are presently extensive discussions concerning the potential risks and complex legal problems associated with telemedicine health care services provided to patients from remote locations using telecommunication. Legal problems relate generally to problems concerning the privacy of identifiable health information, and the reliability and quality of health data, as well as medical liability. Since telemedicine in developing countries is mainly practised across state borders, providers must be aware of the potential risks concerning medical liability in the respective countries where the patients are located. There is a need for developing countries to adopt rules and regulations to address legal aspects involved in the use of telemedicine in order to safeguard the rights of patients. Matters that need to be considered include mainly safeguards about data forwarding, security of the patient’s data (including images), confidentiality and the responsibilities of health workers involved in telemedicine.

Generally speaking, local physicians are directly responsible for treatments deriving from teleconsultations in dermatology. The medico-legal position of remote expert dermatologists is similar to that when the telephone, fax, email or letter is used for consultation, since all these methods amount to the provision of advice from a distance, and normal standards of care and skill should therefore apply. In teledermatology, there is an obligation to practise to a reasonable level of skill. The referring doctor must give accurate clinical information and submit representative images of reasonable quality. Complicated treatment procedures recommended by remote experts need the patient’s permission before being carried out.

Integration and intercultural context

Preliminary studies have confirmed the feasibility and benefits of integrating teledermatology into the medical care systems of developing countries. However, there are major challenges to sustainability, including political, economic, technical as well as cultural barriers. Many governments in developing countries are gradually recognizing the potential of telemedicine to improve health care delivery and reduce national health care budgets. Obviously, dermatology is not a main focus of government and NGO health policies in developing countries, since available resources are normally allocated to medical conditions with more serious consequences, such as malaria, tuberculosis and HIV/AIDS rather than to non-lethal skin disorders.

As a basis for introducing and sustaining teledermatology services in developing countries, it is crucial that the relevant national governments modernize internal communication in hospitals and remote medical centres. Internet services need to be widely accessible, even in rural parts of the developing world. The availability of email services in remote areas has potential benefits for poor countries. It is cheap, requires relatively simple hardware and software, and can easily deliver stored information. The deployment of fixed or mobile telecentres promises to be valuable in bringing telemedicine services to remote areas.

Cultural barriers may play a negative role in the sustainability of teledermatology programmes, and may be based on individual, institutional or societal attitudes. Individual patients may feel uncomfortable or refuse to be involved in teledermatology owing to a lack of trust in the ability of the technology to improve their health. This attitude may be based on inadequate information as a result of political and economic differences, cultural attitudes, language barriers and differences in perceptions of ‘health and wellness’. Studies have shown that patients who are well acquainted with computers and the Internet tend to be more open to the use of telemedicine.³⁷ There is a need for proper explanation in advance, together with information for patients about teledermatology, such as what it is and what its benefits are, before patients are offered teledermatology.

Local physicians and health workers may also adopt a negative attitude to the use of teledermatology services for a number of reasons. They may be uncomfortable about sending consultations in English, feel that teledermatology cannot improve the health of their patients, distrust the safety and privacy of the systems used, prefer the option of transferring patients, or feel that teledermatology services cannot lower their health care costs. Moreover, because of the limited number of doctors in developing countries, local physicians and health workers may be concerned that teledermatology systems will be time-consuming and generate unnecessary extra work. It is therefore crucial that leaders at local hospitals and medical centres be engaged early enough in the process of introducing teledermatology services and be made aware of the potential and relative advantages of the technique. Participating local physicians and health workers should also receive comprehensive education and training packages, as well as support to improve their technical and media skills, prior to their involvement in teledermatology projects. It is an advantage to add formal guidelines and protocols of instructions on the homepages of web applications. In order to facilitate faster adoption, local health workers selected to participate in teledermatology projects should preferably have prior experience in the use of the Internet.

In summary, consideration of a range of economic, political and technical factors in the host country or institution during the planning and early stages of implementation of teledermatology projects should help to ensure the viability and sustainability, as well as the integration, of teledermatology programmes (Box 12.2).

Financial aspects

Most teledermatology activity in developing countries represents pilot projects receiving subsidized funding from external governments and NGOs, or from foreign universities and hospitals. There is very little available information concerning the cost-effectiveness and sustainability of these services. Economic analyses of the viability of teledermatology projects are also complicated owing to the rapidly declining cost of hardware and telecommunications, and the presence of a number of hidden costs and benefits, such as the opportunity cost of a patient’s time and the intangible benefit of an earlier correct diagnosis, which are hard to quantify. Nevertheless, for the adoption of teledermatology services in countries with low resources, it is necessary to obtain reasonable estimates of the financial consequences, including the costs of implementation and subsequent operation. Proper prior financial planning will help to ensure success and sustainability.

Implementation expenses in teledermatology projects mainly comprise the costs for equipment (in a store-and-forward system, these include digital camera and accessories, computers, image editing programs, a back-up system and a printer), equipment maintenance, telecommunication and staff training. Sustainability expenses tend not to depend on the number of users/patients served. They include costs related to the operation and running of the project, acquiring the physical space, supplies and travel.

Future developments

The number of medical centres using teledermatology in developing countries is increasing, and the technique could soon become an integral part of the health care system in some countries. Future technical developments may improve the delivery of teledermatology consultations in developing countries. For instance, the use of mobile phones with built-in cameras represents a potential alternative to bulky digital cameras and computers in more remote areas.^16,38,39 Teledermatopathology, a related field to teledermatology, could refine dermatology teleconsultation by providing a channel for confirming diagnoses as well as for training and supervision and collaborative research. Until now, establishing teledermatopathology services has been mainly hampered by the high implementation costs.

There is an urgent need for physicians and health policy makers in the developing world to establish standards and regulations concerning the practice of telemedicine and teledermatology. Future studies should define the ethical, legal, economic and technical standards required of telemedical referrals in individual countries that would ensure acceptance, economic viability and effectiveness, as well as security, privacy and confidentiality of patients. Studies focusing on teledermatology outcomes should be conducted to confirm its clinical benefits and cost-effectiveness.

Finally, the global increase in the number of teledermatology networks implies a need to establish a common international teledermatology forum. Such a forum could serve to educate and assist users and policy makers in different parts of the developing and industrialized world on how to optimize teledermatology services, especially through identification of proven low-cost technology approaches.

Further reading

FreeMedicalJournals.com. Available at: www.freemedicaljournals.com.

I Do Imaging: Free Medical Imaging Software. Available at: www.idoimaging.com/index.shtml.

Krupinski E, BurdickA, Pak H et al. American Telemedicine Association’s Practice Guidelines for Teledermatology. Available at: www.liebertonline.com/doi/abs/10.1089/tmj.2007.0129.

Pak H, Burg G. Store-and-forward teledermatology. eMedicine. Available at: www.emedicine.com/derm/topic560.htm.

Wootton R, Oakley A, eds. Teledermatology. London: Royal Society of Medicine Press, 2002.

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